Autonomic Responses During Acute Anterior Versus Inferior Myocardial Infarction: A Systematic Review and Meta-Analysis.

Autonomic responses elicited by myocardial infarction vary depending on the site of injury, but accurate assessment using heart rate variability during the acute phase is limited. We systematically searched PubMed without language restrictions throughout July 2023. We reviewed studies reporting autonomic indices separately for anterior and inferior infarcts, followed by a meta-analysis of those reporting the standard deviation of the inter-beat interval between normal sinus beats during the initial 24 hours after the onset of symptoms. Six studies were included, comprising 341 patients (165 anterior, 176 inferior infarcts), all with satisfactory scores on the Newcastle-Ottawa quality scale. The estimated average of the standardized mean difference (based on the random-effects model) was -0.722 (95% confidence intervals: -0.943 to -0.501), which differed from zero (z=-6.416, p<0.0001). This finding indicates sympathetic and vagal dominance during acute anterior and inferior infarcts, respectively, with excessive responses likely contributing to early arrhythmogenesis. Despite the amelioration of autonomic dysfunction by revascularization, infarct location should be considered when commencing ß-adrenergic receptor blockade, especially after delayed procedures.

Effects of Compound Danshen Dripping Pills on Ventricular Remodeling and Cardiac Function after Acute Anterior Wall ST-Segment Elevation Myocardial Infarction (CODE-AAMI): Protocol for a Randomized Placebo-Controlled Trial.

BACKGROUND: Ventricular remodeling after acute anterior wall ST-segment elevation myocardial infarction (AAMI) is an important factor in occurrence of heart failure which additionally results in poor prognosis. Therefore, the treatment of ventricular remodeling needs to be further optimized. Compound Danshen Dripping Pills (CDDP), a traditional Chinese medicine, exerts a protective effect on microcirculatory disturbance caused by ischemia-reperfusion injury and attenuates ventricular remodeling after myocardial infarction. OBJECTIVE: This study is designed to evaluate the efficacy and safety of CDDP in improving ventricular remodeling and cardiac function after AAMI on a larger scale. METHODS: This study is a multi-center, randomized, double-blind, placebo-controlled, parallel-group clinical trial. The total of 268 patients with AAMI after primary percutaneous coronary intervention (pPCI) will be randomly assigned 1:1 to the CDDP group (n=134) and control group (n=134) with a follow-up of 48 weeks. Both groups will be treated with standard therapy of ST-segment elevation myocardial infarction (STEMI), with the CDDP group administrating 20 tablets of CDDP before pPCI and 10 tablets 3 times daily after pPCI, and the control group treated with a placebo simultaneously. The primary endpoint is 48-week echocardiographic outcomes including left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume index (LVEDVI), and left ventricular end-systolic volume index (LVESVI). The secondary endpoint includes the change in N terminal pro-B-type natriuretic peptide (NT-proBNP) level, arrhythmias, and cardiovascular events (death, cardiac arrest, or cardiopulmonary resuscitation, rehospitalization due to heart failure or angina pectoris, deterioration of cardiac function, and stroke). Investigators and patients are both blinded to the allocated treatment. DISCUSSION: This prospective study will investigate the efficacy and safety of CDDP in improving ventricular remodeling and cardiac function in patients undergoing pPCI for a first AAMI. Patients in the CDDP group will be compared with those in the control group. If certified to be effective, CDDP treatment in AAMI will probably be advised on a larger scale. (Trial registration No. NCT05000411).

Usefulness of the four-variable formula on serial electrocardiograms in detecting subtle anterior myocardial infarction.

OBJECTIVE: To perform serial electrocardiogram (ECG) analyses in patients with subtle ECG changes in the anterior leads and evaluate the performance of the four-variable formula in detecting left anterior descending (LAD) coronary artery occlusion. METHODS: This prospective study included patients admitted to the emergency department with acute chest pain between April 2021 and January 2023, whose initial ECG was not diagnostic but indicated suspicion of myocardial infarction (MI) and who underwent percutaneous coronary intervention in their follow-up. The control group consisted of patients who were diagnosed with benign variant ST-segment elevation (BV-STE) due to ST-segment elevation (STE) of at least 1 mm in the anterior lead, who had normal cardiac troponin levels, and who presented with non-cardiac chest pain. Following admission, six ECGs were taken at 10-min intervals. The scores of all patients were calculated with the four-variable formula on serial ECGs and compared between the groups. RESULTS: A total of 232 patients, including 116 with anterior MI and 116 with BV-STE, were included in the study. When the cut-off value for the four-variable formula was taken as ≥18.2, the sensitivity, specificity, and diagnostic accuracy of the first ECG were determined to be 82.7%, 85.3%, and 83.6%, respectively. We found that the four-variable formula had the highest sensitivity, specificity, and diagnostic accuracy in detecting LAD occlusion for the ECG taken at the 20th minute (83.6%, 89.6%, and 86.2%, respectively). CONCLUSION: The four-variable formula was found to be a valid method for the differentiation of STEMI and BV-STE in patients with subtle ECG changes. While managing this patient group, using serial ECGs rather than a single ECG to evaluate the clinical status of patients can help clinicians make more accurate decisions.

The relationship between CHA2DS2VASc score and left ventricular apical thrombus formation in patients with acute anterior ST segment elevation myocardial infarction.

BACKGROUND: Left ventricular apical thrombus (LVAT) formation is a well-known complication of acute anterior myocardial infarction (AMI). The CHA2DS2VASc is a scoring system that has been used to estimate the risk of thromboembolism in patients with nonvalvular atrial fibrillation. This score has also been used for other clinical conditions. The aim of this study was to investigate the relationship between CHA2DS2VASc score and development of LVAT in patients with AMI. METHOD: The study population included 378 patients (mean age: 56.5 ± 12.3 years, male: 318) presenting with AMI between January 2016 and January 2020. Primary percutaneous coronary intervention procedure was performed in all patients. Initial echocardiogram was performed within 7 days of admission. All patients were evaluated with echocardiography at 3rd, 6th and 12th months. Patients were divided into two groups according to the presence of LVAT on echocardiography. RESULTS: The incidence of the LVAT was 8.5% (n = 32) during a mean follow-up time of 233.1 ± 66.7 days. The mean CHA2DS2VASc score was notably higher in patients with LVAT compared to patients in the control group (3.1 ± 1.9 vs. 1.9 ± 1.2, p < 0.001). In Cox regression analysis, high CHA2DS2VASc score, low left ventricular ejection fraction (LVEF) and the presence of LV apical akinesis/aneurysm were the independent predictors for LVAT formation. All of these parameters were associated with higher cumulative incidence of LVAT formation in Kaplan-Meier analyses (p < 0.001 for all). CONCLUSION: High CHA2DS2VASc score, low LVEF and the presence of LV apical akinesis/aneurysm may be used for LVAT risk prediction among patients presenting with AMI.

Machine learning of microvolt-level 12-lead electrocardiogram can help distinguish takotsubo syndrome and acute anterior myocardial infarction.

Background: Qualitative differences in 12-lead electrocardiograms (ECG) at onset have been reported in patients with takotsubo syndrome (TTS) and acute anterior myocardial infarction (Ant-AMI). We aimed to distinguish these diseases by machine learning (ML) approach of microvolt-level quantitative measurements. Methods: We enrolled 56 consecutive patients with sinus rhythm TTS (median age, 77 years; 16 men), and 1-to-1 random matching was performed based on age and sex of the patients. The ECG in the emergency room was evaluated using an automated system (ECAPs12c; Nihon-Koden). Statistical and ML predictive models for TTS were constructed using clinical features and ECG parameters. Results: Statistically significant differences were observed in 25 parameters; the V1 ST level at the J point (V1 STJ) showed the lowest P value (P < .001). V1 STJ ≤+18 µV showed the highest accuracy for TTS (0.773). The highest area under the receiver operating characteristic curve (AUROC) was shown in the aVR ST level at 1/16th of the preceding R-R interval after the J point (aVR STmid: 0.727). Conversely, the light gradient boosting machine (model_LGBM) and extra tree classifier (model_ET) indicated higher accuracy (model_LGBM: 0.842, model_ET: 0.831) and AUROC (model_LGBM: 0.868, model_ET 0.896) than other statistical models. V1 STJ had high feature importance and Shapley additive explanation values in the 2 ML models. Conclusion: ML applied to automated microvolt-level ECG measurements showed the possibility of distinguishing between TTS and Ant-AMI, which may be a clinically useful ECG-based discriminator.

Giant Left Ventricular (Pseudo?) Aneurysm Complicating Anterior Myocardial Infarction.

The differential diagnosis of true aneurysms and pseudoaneurysms is challenging, and multimodality cardiac imaging is often necessary. We report a case in which the limitations of these techniques are exposed, showing that post-operative evaluation of tissue layers remains the gold standard in establishing this diagnosis. (Level of Difficulty: Beginner.).

Predictors and long-term prognosis of left ventricular aneurysm in patients with acute anterior myocardial infarction treated with primary percutaneous coronary intervention in the contemporary era.

BACKGROUND: Primary percutaneous coronary intervention (PCI) has been the standard reperfusion strategy for patients with acute myocardial infarction (AMI) in the contemporary era. Meanwhile, the incidence and prognosis of left ventricular aneurysm (LVA) in AMI patients remain ambiguous. The aim of the current study is to identify the predictor and long-term prognosis of LVA in patients with acute anterior myocardial infarction. METHODS: We prospectively enrolled 942 consecutive patients with acute anterior myocardial infarction who were treated by primary PCI. The baseline characteristics, procedural features, and one-year clinical outcomes were compared between the patients with and without LVA. The primary endpoint of major adverse cardiovascular and cerebrovascular events (MACCEs) was defined as a composite of cardiac death, target vessel revascularization, and ischemic stroke. Multiple logistic regression was applied to predict LVA formation and the receiver operating characteristic (ROC) curves were plotted to evaluate the accuracy of the multivariate analysis model. RESULTS: The general incidence of LVA was 15.92%. At one-year clinical follow-up, patients in the LVA group had significantly higher incidence of MACCEs (15.33% vs. 6.44%, P<0.01), mainly driven by an increased incidence of cardiac death (8.00% vs. 2.78%, P<0.01), target vessel revascularization (5.33% vs. 2.27%, P=0.03), and ischemic stroke (4.00% vs. 1.39%, P=0.03). Multivariate analysis found that longer symptom-to-balloon time (S2B) [odds ratio (OR): 1.16, 95% confidence interval (CI): 1.11-1.21, P<0.01], higher initial and residual SYNTAX score (iSS, OR: 1.19, 95% CI: 1.14-1.24, P<0.01; rSS, OR: 1.33, 95% CI: 1.22-1.45, P<0.01), lower left ventricular ejection fraction (LVEF) (OR: 1.15, 95% CI: 1.11-1.18, P<0.01), and persistent ST segment elevation (OR: 1.89, 95% CI: 1.06-3.38, P=0.03) were independent predictors of LVA formation. CONCLUSIONS: LVA is still common in patients with acute anterior myocardial infarction in the contemporary PCI era, and the prognosis of these patients was significantly worse during the one-year clinical follow-up. Strategies of prompt reperfusion and complete revascularization may be helpful in preventing LVA formation and improving clinical outcomes.

Early application of esmolol in young and middle-aged patients with acute anterior myocardial infarction / 中华急诊医学杂志

Objective:To investigate the clinical effect of esmolol on young and middle-aged patients with acute anterior myocardial infarction.Methods:Patients with acute anterior myocardial infarction from January 2008 to August 2020 were collected to obtain the basic information and clinical indicators. According to the clinical medication, the patients were divided into metoprolol group and esmolol group. The metoprolol group ( n=189) received routine esmolol, and the esmolol group ( n=104) received esmolol, intravenous injection, and then metoprolol sustained-release tablets. The clinical indexes, Gensini score, Killip grade, esmolol status and cardiac function after 7 d and 3 months of treatment were compared between the two groups. Results:Compared with the metoprolol group, the triglyceride (TG) was significantly higher, and the alanine aminotransferase (ALT) and aspartate aminotransferase (AST were significantly lower in the esmolol group (all P<0.05). The C-reactive protein (CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and Gensini scores of culprit vessels in the esmolol group were lower than those in the metoprolol group ( P<0.05). There was no significant difference in cardiac function between the two groups within 7 d after treatment ( P>0.05). After 3 months of treatment, the left ventricular ejection fraction (LVEF) was higher and left ventricular end diastolic diameter (LVDD) was lower than those in the metoprolol group ( P<0.05). The number of postperative, ventricular tachycardia, shock and death in the esmolol group were lower than those in the metoprolol group, but the difference was not statistically significant ( P>0.05). Conclusions:Intravenous infusion of esmolol in young and middle-aged patients with acute anterior myocardial infarction can significantly improve the myocardial injury, liver function and cardiac function in prognosis.

Effects of Sacubitril Valsartan Sodium on Short-term Prognosis of Patients with Acute Anterior Myocardial Infarction Complicated with Acute Cardiac Insufficiency / 中国药房

OBJECTIVE：To investigate the effec ts of angiotensin receptor neprilysin inhibitor （ARNI）sacubitril valsartan sodium（SVS）on the short-term prognosis of patients with acute anterior myocardial infarction （AAMI）complicated with acute cardiac insufficiency. METHODS ：A total of 80 patients with AAMI and Killip grade Ⅱ-Ⅳ of cardiac function ，who met the inclusion criteria ，were randomly divided into ARNI group and control group ，with 40 patients in each group. Both groups were given the same basic standardized drug treatment ，vital signs support treatment and percutaneous coronary intervention treatment at the same time. On this basis ，ARNI group was given SVS tablet orally ，with initial dose of 25 mg each time ，twice a day ； thereafter，gradually adjust the dose to 200 mg each time ，twice a day. Control group was given Enalapril maleate tablets orally ， with an initial dose of 5 mg each time ，twice a day ；thereafter，gradually adjust the dose to 10 mg each time ，twice a day. Both groups took medicine for a long time ，and were followed up after 1，3 and 6 months of medication to the clinic. The levels of N-terminal pro-B-type natriuretic peptide （NT-proBNP）， soluble growth stimulation expressed gene 2 protein （sST2） and echocardiography indexes were compared between 2 groups before and after medication. The 6-minute walking test （6MWT）and the incidence of cardiogenic readmission events were recorded in 2 groups after medication. RESULTS ：Compared with before treatment，the indexes of the two groups were significantly improved at 1，3 and 6 months after treatment （P＜0.05）. Compared with control group ，the levels of NT-proBNP and sST 2 in ARNI group decreased significantly （P＜0.05），the levels of left ventricular ejection fraction and 6MWT increased significantly（P＜0.05），and the left ventricular end systolic diameter and left ventricular end diastolic diameter decreased significantly，after 3 and 6 months of treatm ent（P＜0.05）. However ，there was no significant difference in the velocity ratio of peak E to peak A ，pulmonary artery pressure ，right ventricular end diastolic diameter and the incidence of cardiogenic readmission events between 2 groups（P＞0.05）. CONCLUSIONS ：For patients with AAMI complicated with acute cardiac insufficiency ， compared with enalapril ，SVS can significantly improve the cardiac function （especially the left ventricular systolic function ）， reduce the inflammatory reaction of cardiomyocytes ，protect cardiomyocytes ，so as to improve the short-term prognosis of patients.

Guidezilla-Assisted Tracking of Guide Catheter for Tortuous and Angulated Subclavian-Brachiocephalic Artery During Transradial Intervention.

This case highlights the novel use of the Guidezilla catheter to facilitate guide catheter use during transradial intervention by overcoming a tortuous and angulated SB artery.

Serum biomarker analysis at the protein level on pulmonary hypertension secondary to old anterior myocardial infarction.

Pulmonary hypertension (PH) related to old anterior myocardial infarction (OAMI) always accompanies a bad prognosis, and thus, we aimed to screen serum biomarkers related to PH in OAMI patients. According to right ventricular systolic pressure, we divided mice into sham, OAMI, and PH-OAMI groups and evaluated body, heart and lung weight, heart function, pulmonary blood flow velocity, cardiac fibrotic area, and pulmonary arteriole condition. Lung and serum were under the proteomic analysis. Levels of three identified proteins were measured. Compared with sham and OAMI mice, PH-OAMI mice showed heart dysfunction, low pulmonary blood flow, high right ventricular systolic pressure, heavy heart and lung weight, large cardiac fibrotic area, and pathological pulmonary arteriole remodeling (P<0.05 or P<0.01). Haptoglobin, annexin A5, and Ig mu chain C region of lung and serum were changed significantly in PH-OAMI mice (P<0.01). Then, we collected serum and clinical data, measured three serum protein levels, and performed multivariate regression and receiver operating characteristic curve in patients (normal, OAMI, and PH-OAMI groups). Compared with normal and OAMI patients, serum levels of three proteins in PH-OAMI patients were also altered notably (P<0.01). These three proteins can predict PH in OAMI patients (P<0.01). Receiver operating characteristic curve analysis revealed haptoglobin (cut-off value: 78.295, sensitivity: 62.8%, specificity: 94.4%), annexin A5 (cut-off value: 151.925, sensitivity: 41.9%, specificity: 82.4%), and Ig mu chain C region (cut-off value: 168.885, sensitivity: 86.0%, specificity: 79.6%) (P<0.01). Three circulating serum proteins can be useful for the categorization of OAMI patients with and without PH.

Apical longitudinal strain can help predict the development of left ventricular thrombus after anterior myocardial infarction

Abstract Background: Left ventricular (LV) thrombus formation is a common complication of anterior myocardial infarction (ANT-MI). The aim of this study was to investigate the relationship between apical longitudinal strain (ALS) and LV apical thrombus after ANT-MI. Methods: The cross-sectional study included a total of 235 patients who were followed up after primary percutaneous coronary intervention performed for ANT-MI and had a reduced LV ejection fraction (LVEF) (≤40%). Of these patients, 24 were excluded from the study, and the remaining 211 patients were included in the analysis. Patients were divided into two groups based on the presence (n = 42) or absence (n = 169) of LV thrombus detected by echocardiography. ALS was measured using speckle-tracking echocardiography. Results: Thrombus was detected in 42 of 211 patients. There was no significant difference between the groups regarding age or gender. Apical strain (AS), global longitudinal strain (GLS), apical wall thickness (AWT), and EF were significantly lower in patients with LV apical thrombus when compared to those without LV apical thrombus (AS, –5.00 ± 2.30% vs. −8.54 ± 2.48%, p < 0.001; GLS, −10.6 ± 3.54% vs. −12.1 ± 2.84%, p = 0.013; AWT, 4.71 ± 1.11 vs. 6.33 ± 1.78 mm, p < 0.001; EF, 31.40 ± 4.10% vs. 37.75 ± 3.17%, p < 0.001). On univariate and multivariate analyses, aneurysm (AA), AS, and AWT were found to be independent predictors of LV apical thrombus (AA, odds ratio [OR] 4.649, p = 0.010; AS, OR 1.749, p < 0.001; AWT, OR 0.729, p = 0.042). Conclusion: ALS is highly sensitive and specific for predicting LV thrombus after ANT-MI. An early and accurate evaluation of LV thrombus may prevent embolic complications, particularly cerebrovascular events.

Association Between C-Reactive Protein to Albumin Ratio and Left Ventricular Thrombus Formation Following Acute Anterior Myocardial Infarction.

Left ventricular thrombus (LVT) is associated with inflammatory response in survivors with anterior ST-elevation myocardial infarction (STEMI). The C-reactive protein to albumin ratio (CAR) has been proposed as a marker of inflammation. However, there is a lack of data with respect to the role of CAR in LVT development. We investigated the relationship between CAR and LVT development in patients with anterior STEMI treated percutaneously; 955 consecutive patients were enrolled and LVT was observed in 126 (13.2%) patients. Clinical, demographic, and laboratory parameters were recorded. The CAR was significantly higher in patients with LVT (12.6 [8.6-16.1] vs 18.1 [11.5-23], P < .001). Other independent predictors for LVT development were lower ejection fraction, the presence of left ventricular apical aneurysm, proximal left anterior descending lesion location, glycoprotein IIb/IIIa inhibitors treatment, >1 diseased arteries, higher total protein level, neutrophil count, and peak creatine kinase myocardial band activity. In conclusion, the CAR may be useful as a simple tool for predicting LVT development among survivors of anterior STEMI.

[Giant left ventricular false aneurysme revealing a silent myocardial infarction]. / Volumineux faux anévrisme de la pointe du ventricule gauche révélant un infarctus du myocarde silencieux.

Left ventricular false aneurysms are rare. They are secondary to a myocardial rupture which is contained by adherent pericardium and scar tissue. LV pseudoaneurysm contains no endocardium or myocardium unlike left ventricular true aneurysm. Most cases of LV pseudoaneurysm are related to acute myocardial infarction in inferior or posterior wall. We report a case of a 56-year-old man with a medical history of chronic cigarette smoking, dyslipidemia, and obesity. The patient had no myocardial infarction before. He was admitted for evaluation of important shortness of breath at effort without chest pain for 5 months. Physical exam find an enlarged left ventricular. The electrocardiogram revealed Q waves and ST segment elevation in leads V1 to V6. Transthoracic echocardiogram showed a large thrombosed apical left ventricular false aneurysm, severe left ventricular dysfunction, which were confirmed by cardiac magnetic resonance imaging, this exam also showed no viability in the mid left anterior descending coronary artery territory. The coronary angiography showed an occlusion of the mid left anterior descending coronary artery and a stenosis of the first diagonal artery. The patient was offered a surgical aneurysectomy with coronary artery bypass. The surgery was successful with amelioration of symptoms. We present a rare case of a giant false left ventricular aneurysm complicating a silent myocardial infarction in the anterior wall. The diagnosis is made by cardiac echocardiogram and cardiac magnetic resonance imaging. Because of the important risk of rupture, the surgical treatment is required.

Machine Learning to Predict the 1-Year Mortality Rate After Acute Anterior Myocardial Infarction in Chinese Patients.

A formal risk assessment for identifying high-risk patients is essential in clinical practice and promoted in guidelines for the management of anterior acute myocardial infarction. In this study, we sought to evaluate the performance of different machine learning models in predicting the 1-year mortality rate of anterior ST-segment elevation myocardial infarction (STEMI) patients and to compare the utility of these models to the conventional Global Registry of Acute Coronary Events (GRACE) risk scores. We enrolled all of the patients aged >18 years with discharge diagnoses of anterior STEMI in the Western China Hospital, Sichuan University, from January 2011 to January 2017. A total of 1244 patients were included in this study. The mean patient age was 63.8±12.9 years, and the proportion of males was 78.4%. The majority (75.18%) received revascularization therapy. In the prediction of the 1-year mortality rate, the areas under the curve (AUCs) of the receiver operating characteristic curves (ROCs) of the six models ranged from 0.709 to 0.942. Among all models, XGBoost achieved the highest accuracy (92%), specificity (99%) and f1 score (0.72) for predictions with the full variable model. After feature selection, XGBoost still obtained the highest accuracy (93%), specificity (99%) and f1 score (0.73). In conclusion, machine learning algorithms can accurately predict the rate of death after a 1-year follow-up of anterior STEMI, especially the XGBoost model.

Relationship between apical thrombus formation and blood viscosity in acute anterior myocardial infarction patients.

Aim: This study sought to investigate the predictive value of whole blood viscosity (WBV) to identify high-risk patients who will develop an apical thrombus during the acute phase of anterior transmural infarction. Materials & methods: Consecutive 1726 patients with first acute anterior myocardial infarction were evaluated. WBV was calculated according to the Simone's formula. Results: Patients with an apical thrombus had prolonged pain to balloon time, higher rate of post-PCI thrombolysis in myocardial infarction flow ≤1 and significantly higher mean WBV values at both shear rates than those without an apical thrombus. Conclusion: WBV values at both shear rates were found to be significant and independent predictors for early LV apical thrombus formation complicating a first-ever anterior wall myocardial infarction.

Acute Anterior Myocardial Infarction in a Patient With Dextrocardia and Situs Inversus: An Unusual Coexistence.

Situs inversus totalis is a rare disorder. In addition, acute coronary syndromes, especially ST-segment elevation myocardial infarctions, are rarely detected in this group. We demonstrate the electrocardiographic features and discuss the interventional challenges of acute anterior myocardial infarction in a patient with dextrocardia. (Level of Difficulty: Beginner.).

Acute anterior myocardial infarction with pectus carinatum.

We presented a case of acute anterior myocardial infarction caused by left anterior descending artery occlusion in a patient with pectus carinatum. The electrocardiogram (ECG) on admission showed counterclockwise rotation and T wave inversion only in leads V1-V2. Computed tomography revealed that this patient with pectus carinatum had greater septal angle. Electrocardiographic counterclockwise rotation due to greater septal angle in pectus carinatum led to atypical ECG findings of acute myocardial infraction.

Electrocardiographic criteria of epicardial ventricular tachycardia with anterior origin.

BACKGROUND: ECG criteria for identifying an epicardial origin of ventricular tachycardia (VT) have mainly been described for VTs with basal-superior and lateral origin. OBJECTIVE: The aim of this study was to determine ECG criteria for epicardial VTs with anterior origin as a guide for trans-pericardial ablation. RESULTS: Among 22 patients undergoing successful ablation of VTs from the anterior myocardial wall, 14 patients underwent endocardial ablation and 8 patients underwent epicardial ablation. VTs with anterior origin ablated epicardially had widened QS complexes in precordial leads with staircase-shaped notching and slowing of the descent to the nadir of S. In comparison, endocardial VTs with anterior origin usually had narrower QS complexes with a smooth and fast downstroke to the nadir of S. The duration of the negative pseudodelta wave was longer in epicardial VTs (55 ± 12 ms) compared to endocardial VTs (22 ± 12 ms). The interval "time to the nadir of S" in patients with anterior VT origin was longer in epicardial VTs (121 ± 16 ms) than in endocardial VTs (80 ± 22 ms). The QRS duration was also longer in patients with epicardial origin (212 ± 19 ms) than with endocardial VT origin (166 ± 30 ms). CONCLUSIONS: Epicardial origin of VTs arising from the anterior myocardial wall produces a slowing, widening and staircase-shaped notching in the initial VT-QS complex. Thus, the morphology of the initial part of the QS complex in precordial leads can be used as a guide for trans-pericardial ablation of VTs with anterior origin.