[Short- and long-term effects of intensified versus conventional antilipidemic therapy in patients with coronary heart disease. Results from the Lipid-Coronary Artery Disease (L-CAD) Study]. / Kurz- und Langzeiteinfluss einer frühzeitigen Pravastatin-Kombinationstherapie im Vergleich zu konventioneller Behandlung auf Koronarstenosen und klinische Ereignisse bei Patienten mit Hypercholesterinämie und koronarer Herzerkrankung: Ergebnisse der Lipid-Coronary Artery Disease (L-CAD)-Studie.

In a prospective, randomized study of patients with acute manifestation of coronary heart disease and hypercholesterolemia (LDL cholesterol >/= 130

Estimation of enzymatic infarct size: direct comparison of the marker enzymes creatine kinase and alpha-hydroxybutyrate dehydrogenase.

BACKGROUND: Estimation of infarct size with serum-time activity curves of creatine kinase (CK) (or CKMB) or alpha-hydroxybutyrate dehydrogenase (HBDH) is widely used in clinical trials. However, an independent variable such as left ventricular function has not been directly compared with CK and HBDH infarct size measurements in the same group of patients. METHODS AND RESULTS: Infarct size was calculated by the CK area under the curve (AUC) and by the cumulative release of HBDH in 90 patients with acute myocardial infarction undergoing early thrombolysis. Infarct size estimates by CK AUC and HBDH release were closely correlated (r = 0.88, p < 0.0001). HBDH release was significantly better (p < 0.001) correlated to angiographically assessed ejection fraction 8 days after infarction (r = 0.74) than to CK AUC (r = 0.60), as was maximum HBDH (r = 0.71) compared with CK maximum (r = 0.59). In contrast to CK, maximum levels of HBDH only slightly overestimate myocardial damage in patients with early reperfusion. Data reanalyzed from the former placebo-controlled Intravenous Streptokinase in Acute Myocardial Infarction (ISAM) study revealed significant differences in favor of streptokinase for CK and CKMB AUC and for HBDH maximum, but no difference for CK and CKMB maximums. CONCLUSIONS: For comparative clinical trials HBDH appears to be the preferable marker enzyme for estimates of infarct size and measure of reperfusion effectiveness. In clinical practice one routine measure of HBDH serum activity on the second day after infarction may be a useful approximate value of infarct size.

Comparative in-vitro validation of eight first- and second-generation quantitative coronary angiography systems.

BACKGROUND: It is known that first-generation quantitative coronary angiography (QCA) systems overestimate small vessel sizes owing to the point-spread function of the respective X-ray imaging chain. With second-generation systems new algorithms were introduced to correct for this source of error. OBJECTIVE: To evaluate the efficiency of the modified contour detection algorithms. METHODS: Six second-generation QCA systems (CMS, QANSAD, AWOS, CAAS II, Cardio 500, and Angioimage) were validated and compared with first-generation systems (CAAS and ARTREK). By using an arterial phantom consisting of stenotic and nonstenotic glass tubes (of diameters 0.5-5.0 mm) the accuracy and precision of each analysis system, as well as their additional accuracy and precision values for phantom diameters < or = 1.0 mm were determined. RESULTS: All systems had high accuracy and precision values, but first-generation systems overestimated small vessel diameters. With second-generation systems a significantly improved accuracy in the submillimeter range (an accuracy within +/-0.028 mm) was obtained. This improvement was accompanied by a moderate reduction in precision in the submillimeter range. CONCLUSION: The new algorithms of the second-generation QCA systems allow accurate and reliable measurements of small coronary dimensions and, therefore, precise analysis of coronary stenoses of moderate-to-high grade seems feasible with the improved accuracy of the new systems.

Comparison of the diagnostic potential of four echocardiographic stress tests shortly after acute myocardial infarction: submaximal exercise, transesophageal atrial pacing, dipyridamole, and dobutamine-atropine.

This study assessed and compared the diagnostic potential of submaximal exercise, transesophageal atrial pacing, dipyridamole, and dobutamine-atropine stress echocardiography tests shortly after acute myocardial infarction. In 121 study patients, 325 digital echocardiographic stress tests were attempted 10 to 11 days after acute myocardial infarction: 83 submaximal exercise tests, 121 high-dose dipyridamole echocardiography tests (DET), 69 transesophageal atrial pacing tests (< 150 beats/min), and 52 dobutamine tests, starting at 10 microgram/kg per minute, increasing stepwise to 40 microgram kg/min, and coadministering atropine in 12 patients (dobutamine-atropine stress echocardiography [DASE]). Results were correlated to a coronary artery diameter stenosis > or = 50% as determined by quantitative angiography. Feasibility to perform submaximal exercise echocardiography, atrial pacing echocardiography, DET, and DASE was 89%, 52%, 98%, and 88%, respectively. Atrial pacing was not tolerated by 18 patients and refused by 6 (9%). Severe but not life-threatening side effects were hypotension in DET (2%) and tachyarrhythmias in DASE (6%). Test positivity in multivessel disease with submaximal exercise, DET, and DASE was 55%, 93%, and 90%, respectively, and in 1-vessel disease 47%, 65%, 71%, and for atrial pacing, 82%, respectively. We conclude that submaximal exercise has limited sensitivity and atrial pacing limited feasibility. The pharmacologic stressors provide a useful, safe diagnostic approach: DET with slightly lower sensitivity in 1-vessel disease and DASE with insignificantly less feasibility.

Analytic isocenter calibration. A new approach for accurate x-ray gantries.

Isocenter calibration transforms cardiac structures in digitized biplane angiograms to absolute dimensions, calculating their radiological magnification and video transformation. Since a scaling device is not required, isocenter calibration yields to more accurate measurements than the widely used reference object calibration. Both isocenter methods reported so far, regarding geometrically inaccurate x-ray gantries, yield to different and complex computational formulas. Since these formulas are hard to understand, isocenter calibration is less widely used. To facilitate the implementation of the isocenter calibration, the basic formulas for accurate x-ray gantries are derived. Shifting virtually one x-ray system onto the other, basic isocenter calibration is derived geometrically in three simple steps. The radiological magnification of an object is illustrated as a ratio of planes. The calculation of all parameters entering the computations is demonstrated geometrically, by use of the isocenter of the x-ray gantry. The derivation gives a clear idea of isocenter calibration. It is simple to derive and facilitates the understanding of the error regarding developments. When geometrical inaccuracies vanish, all formulas become equivalent. However, even if the inaccuracies increase, all methods provide nearly identical results, indicating the robustness of isocenter calibration.

Quantitative coronary arteriography: efficient correction of catheter calibrated vessel measurement.

1. BACKGROUND. To quantify coronary dimensions from digitized angiograms, the coronary catheter is commonly used as a scaling device. However, significant errors may result due to different angiographic magnification (DM) of the vessel and of the catheter resulting from deviating locations in the X-ray field. These errors can be corrected by biplane angiography. Since this correction needs a gantry measurement system, DM correction is less widely used. We analyzed the magnitude of DM that affects the accuracy of catheter calibrated vessel dimensions and developed DM corrections requiring low computational and measurement effort. 2. MATERIAL AND METHODS. We filmed biplane a perspex bloc of vessel phantoms (0.3 - 4.5 mm) in the isocenter of the x-ray system to get the true pixel sizes before any calibration. The phantoms were detected in the digitized images using a cardiac workstation (Kontron Cardio 500) and calibrated with differently located catheters. The calibration error was then calculated for increasing distances phantom-catheter. For DM correction, we developed procedures decreasing: (i) the computational effort (E) by approximated (A) formulas, as well as (ii) the measurement effort; this decrease approximates measured gantry settings (M) through fixed pre-settings for distances (D) and videochain (V). The several DM corrections were applied on the phantom images to analyze their correction performance and remaining calibration error. 3. RESULTS. The calibration of correctly detected pixel dimensions by a differentially magnified catheter causes a deviation of the absolute vessel dimensions, increasing with the vessel size. However, as shown in Table 1, DM correction reduces this calibration error substantially. Table 1: Calibration errors of catheter calibration and performance of DM corrections with decreasing effort (50 mm location distance phantom-catheter) 4. CONCLUSIONS. DM causes errors of vessel diameters of up to 15%. Even a measurement-free procedure (fixed presettings) corrects 71% of DM. Thus, the only additional effort of selecting an angiogram from the opposite view and marking the vessel and catheter locations in both images should be accepted.

Early assessment of outcome by ST-segment analysis after thrombolytic therapy in acute myocardial infarction.

As an early marker of outcome, the sum of ST-segment elevation resolution between the electrocardiogram before and 3 hours after initiation of thrombolysis was investigated in 77 patients with acute myocardial infarction. Prospectively, three groups were defined according to complete (> or = 70%, n = 34), partial (< 70% to > or = 30%, n = 26), or no (< 30%, n = 17) ST resolution. There were considerable differences in the enzyme-determined infarct size (alpha-hydroxybutyrate dehydrogenase release for complete, partial, and no ST resolution: 529 +/- 397 IU/L, 689 +/- 484 IU/L, and 1293 +/- 742 IU/L, respectively; p = 0.0001) and the angiographic left ventricular function 1 week later (ejection fraction 58% +/- 10%, 53% +/- 13%, and 43% +/- 12%, respectively, p < 0.01; regional dyssynergic area 24 +/- 19, 39 +/- 23, and 50 +/- 21 U2, respectively, p < 0.01). Early reperfusion as assessed by creatine kinase release measured in 15-minute intervals was 90%, 65%, and 18%, respectively (p = 0.0001). Differences in degrees of ST-elevation resolution at 3 hours may help facilitate timely screening of patients for appropriate therapeutic intervention. Patients with complete ST resolution may be considered for early discharge, and patients with no ST resolution may be candidates for an early invasive approach or additional thrombolytic therapy.

Early recurrence of ST-segment elevation in patients with initial reperfusion during thrombolytic therapy: impact on in-hospital reinfarction and long-term vessel patency.

AIM: To investigate the frequency and prognostic impact of early recurrent ST-segment elevation after initial ST-segment resolution in patients with acute myocardial infarction who had been treated with intravenous thrombolysis. METHODS: Eighty-one patients with acute myocardial infarction underwent 24 h Holter monitoring of the infarct-related ST-segment elevation, at the initiation of thrombolytic therapy. Angiography was performed in 88% of the patients 9 +/- 4 days after infarction. RESULTS: Resolution of the ST-segment elevation during the first 4 h, suggestive of early reperfusion, occurred in 67 (83%) patients (group 1). Of these, 31 (46%) had subsequent re-elevations (group 1a), 26 during the first 4 h, and 20 later. Thirty-six (54%) patients had no recurrence of the ST-segment elevation (group 1b). During follow-up, patients in group 1a experienced more in-hospital reinfarctions (26 versus 6%, P = 0.04) and had a higher rate of occluded infarct-related vessels at angiography than patients in group 1b (40 versus 17%, P = 0.01). CONCLUSION: During the first 24 h after initiation of thrombolytic therapy, recurrences of ST-segment elevation are frequent in myocardial infarction patients with ECG signs of an initially reperfused infarct-related artery. Recurrence of ST-segment elevation indicates a higher risk of reinfarction during hospitalization and of long-term occlusion of the infarct artery.

Extent of early ST segment elevation resolution: a simple but strong predictor of outcome in patients with acute myocardial infarction.

OBJECTIVES: This study proposed to verify the prognostic power of early ST segment elevation resolution in patients with acute myocardial infarction from the Intravenous Streptokinase in Acute Myocardial Infarction study data base. BACKGROUND: Data from a small prospective study suggested that use of two cutoff points for three different levels of ST segment resolution 3 h after the start of thrombolysis may be an efficient way to predict outcome in an individual patient. METHODS: The three groups of ST segment resolution were defined as 1) complete resolution (> or = 70% [552 patients]) or only slight ST segment elevation (127 patients); 2) partial resolution (< 70% to 30% [475 patients]); 3) no resolution (< 30% to > 0% [362 patients]). Infarct size was measured from creatine kinase isoenzyme, MB fraction, release and from the number of Q waves. Left ventricular function was assessed in 818 patients 1 month after infarction. RESULTS: For complete, partial and no ST segment resolution 3 h after the start of streptokinase or placebo infusion, enzyme release was 1.2, 1.8 and 2.1 IU/ml x h; number of Q waves 1.7, 2.5 and 3.0; and ejection fraction 60%, 53% and 49%, respectively (all adjusted p = 0.0000). Mortality rate at 21 days was 2.2%, 3.4% and 8.6%, respectively. No ST segment resolution was the most powerful independent predictor of early mortality (p = 0.0001). Survival rate curves at 6-year follow-up showed significant mortality differences with increasing divergence (p = 0.0003 anterior infarction; p = 0.005 inferior infarction). In subgroups with an overall higher risk of dying, mortality was strongly determined by the extent of early ST segment resolution. CONCLUSIONS: The extent of ST segment elevation resolution conveys useful early information about outcome in an individual patient after acute myocardial infarction.

[Recurrent ST segment elevations in continuous ECG analysis in the acute phase of myocardial infarct treated with thrombolytic therapy]. / Auftreten erneuter ST-Strecken-Hebungen bei der kontinuierlichen EKG-Analyse in der akuten Phase des Myokardinfarkts mit thrombolytischer Behandlung.

Early fluctuations of the ST-segment elevation indicating intermittent opening and reocclusion of the infarct artery has been well documented by angiographic monitoring in individual acute myocardial infarction patients undergoing thrombolytic therapy. However, the frequency of such episodes has not been studied in a consecutive patient group. Furthermore, it is not known what impact this finding has on the reinfarction risk during hospitalization and on left ventricular healing. The present investigation included 79 patients with acute myocardial infarction (pain < or = 6 h). Continuous Holter monitoring of the infarct-related ST elevation was initiated before or directly after starting thrombolytic therapy. During the 24-h observation period, 34 patients (43%) showed episodes of recurrent ST elevation after an initial resolution (group 1). Among those without episodes, ST elevation resolved within 4 h in 34 (43%, group 2) and persisted > or = 4 h in 11 (14%, group 3). Episodes of re-elevation were more frequent during the first 4 h (0.25 episodes per hour) than in the late part of the observation period (0.04 episodes per hour). Most episodes were transient and short lasting; only nine patients showed persistent re-elevations longer than 60 min. During hospitalization, group 1 patients had a higher incidence of reinfarctions and severe ischemic events than those without episodes (group 1 12/34 (35%) vs. group 2 4/34 (12%) vs. group 3 1/11 (9%), p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

[Endocardial fibrosis in neuroendocrine tumors of the gastroenteropancreatic system]. / Endokardfibrose bei neuroendokrinen Tumoren des gastroenteropankreatischen Systems.

Clinical characteristics, echocardiographic and Doppler echocardiographic findings, as well as serum levels of chromogranin A were recorded on 62 patients (27 women, 35 men; mean age 55 [11-83] years) with histologically confirmed tumours of the gastroenteropancreatic (GEP) system. Changes in the right heart were found in 14 patients (22%), club-like thickening of tricuspid leaflets in 13, tricuspid regurgitation in 14, stenosis in 2 and right atrial or right ventricular dilatation in 11 and 5, respectively. There was no difference between the patients with or without right-heart changes in regard to age, presence of carcinoid syndrome, duration of symptoms, primary tumour site, pattern of metastases, treatment or chromogranin A level. Two patients with nonfunctioning tumours had right-heart changes. While clinical and biochemical parameters did not identify patients with right-heart changes, echocardiography demonstrated all haemodynamically significant endocardial changes. Even patients with nonfunctioning GEP tumours should be regularly monitored by echocardiography.

Circadian variation of cardiopulmonary disease onset in the general population: an emergency care system perspective from Berlin.

STUDY HYPOTHESIS: The objective of the present study was to determine the circadian pattern of onset of acute pulmonary emergencies in the general population and to analyze the influence of age and sex on these patterns. METHODS: Analysis of all 47,082 emergency calls during the years 1987 and 1988 of the Berlin emergency medical system. Analysis of circadian variation in incidence of subgroups with the leading symptom of respiratory distress, chest pain, or sudden unconsciousness. All cases of nontraumatic sudden death were analyzed. All missions were evaluated with regard to sex and age dependence. RESULTS: There is a circadian variation in acute cardiopulmonary emergencies with the highest incidence between 6 AM and noon. This applies to subpopulations of chest pain (9,068), respiratory distress (13,732), sudden unconsciousness (7,829), resuscitation attempts (4,787), and persons found dead without resuscitation attempts (4,780). Cases of chest pain, respiratory distress, and resuscitations show a second evening peak. Patients 65 years old or less have the highest rates in the afternoon, whereas those aged over 65 show a single morning peak (P < .0001). These relations are independent of sex and presenting complaint. CONCLUSION: Unselected populations show circadian variations in the incidence of cardiopulmonary emergencies. Age-related differences suggest different pathophysiological age-dependent mechanisms, eg, hormonal factors or lifestyle-dependent trigger mechanisms. Emergency medical systems should adjust the availability of emergency services to the distinct circadian differences of life-threatening cardiovascular and pulmonary diseases.

[Early diagnosis of left ventricular dysfunction following acute myocardial infarct. Doppler echocardiography in a study of its course]. / Frühzeitiges Erkennen einer linksventrikulären Dysfunktion nach akutem Myokardinfarkt. Verlaufsuntersuchung mit der Dopplerechokardiographie.

The prognosis of acute myocardial infarction depends on the development of left-ventricular dilatation and chronic heart failure. Serial echocardiography was performed on admission and on days 2, 4 and 6, to discover the temporal course of any early myocardial adaptation. There were 78 patients (20 women, 58 men; mean age 59 [49-69] years) with acute myocardial infarction and systemic thrombolysis, first studied up to 4 hours after onset of symptoms. The patients were divided into two groups according to infarct size as measured by creatine kinase ("area under the curve"--AUC); group 1: CK AUC < 12 IU/ml.h; group 2: CK AUC > 12 IU/ml.h. While there was no difference between the two groups on admission and on day 2, filling patterns differed significantly at the end of the first postinfarction week in that maximal early diastolic flow velocity (E) in group 1 was 0.65 m/s, but 0.73 m/s in group 2 (P < 0.05); maximal late diastolic flow velocity (A), group 1: 0.71, group 2: 0.58 m/s (P < 0.01); E/A ratio: 0.89 vs 1.22 (P < 0.001); integrated E/A ratio 1.37 vs 1.77 (P < 0.001), and the atrial component of left-ventricular filling 42 vs 36% (P < 0.001). It is concluded that the serial measurement of left-ventricular filling by Doppler echocardiography in the first post-infarction week can identify patients with impaired left-ventricular function through differences in flow pattern. Drug or interventional treatment can then be started early to prevent further left-ventricular dilatation and in this way improve prognosis.

Quantitative assessment of peripheral and coronary artery lesions before and after balloon angioplasty: a comparison of intravascular ultrasound and angiography.

Intravascular ultrasound and conventional angiography were used to determine the degree of stenosis before and after angioplasty in 25 consecutive patients with peripheral arterial occlusive disease and 15 selected patients with coronary artery disease. Angiographic determinations of the luminal area and percent stenosis were made with the help of an automatic detection system, and the same parameters were evaluated planimetrically in the ultrasound studies. Following angioplasty of peripheral lesions, angiography demonstrated a significantly greater increase in mean luminal area (10.8 +/- 7.8 mm2 vs 5.8 +/- 4.0 mm2; P < 0.05) and a greater reduction in degree of stenosis (26% +/- 16% vs 14% +/- 11%; P < 0.05) than did the ultrasonic investigation. There was a significant but moderate correlation between values for the luminal area determined by angiography and ultrasound before angioplasty (r = 0.75; SEE = 4.8 mm2) and in normal proximal segments of coronary arteries (r = 0.79; SEE 4.1 mm2). Following angioplasty there was no significant correlation between angiographic findings and those determined by intravascular ultrasound in peripheral or coronary lesions. These results suggest that angiography and intravascular ultrasound are fundamentally different imaging and analysis techniques. Following angioplasty, conventional angiography rarely demonstrated dissection or intraluminal filling defects, while intravascular ultrasound detected plaque rupture and the presence of intraluminal atheroma in almost all cases. Quantitative determinations of luminal area and degree of stenosis rely on indirect measures with conventional angiography, while these parameters are determined directly by intravascular ultrasound.(ABSTRACT TRUNCATED AT 250 WORDS)

Prehospital thrombolysis: beneficial effects of very early treatment on infarct size and left ventricular function.

OBJECTIVES: The purpose of this study was to compare the effects of very early (< or = 1.5 h after symptom onset) and later (> 1.5 up to 4 h) thrombolytic therapy on infarct size, left ventricular function and early mortality in patients with acute myocardial infarction. To start thrombolysis at the earliest possible moment, it was performed in the prehospital setting. A cutoff time of 1.5 h was prospectively stipulated. BACKGROUND: Shortening of ischemic time is crucial within the 1st 2 h. Prehospital thrombolysis can reduce time to treatment and enables very early initiation of therapy for many patients. METHODS: One hundred seventy patients received 30 mg of anistreplase up to 4 h from symptom onset by a mobile intensive care unit physician. Infarct size was measured from cumulative release of alpha-hydroxybutyrate dehydrogenase, and left ventricular function was assessed by contrast angiograms 10 days after the infarction. RESULTS: The decision to treat on scene was correct in 98% of patients. There were no bleeding complications or deaths outside the hospital setting. In 28 patients (17%) the ischemic process was interrupted. Findings with thrombolytic therapy initiated < or = 1.5 (96 patients) versus > 1.5 h (74 patients) were the following: initial extent of epicardial injury, 1.6 +/- 0.9 versus 1.4 +/- 0.7 mV, p = NS; infarct size by cardiac enzyme release 646 +/- 634 versus 886 +/- 712 IU/liter, p < 0.05; ejection fraction 57 +/- 14% versus 51 +/- 13%, p < 0.05; regional dyssynergic area 24 +/- 22 versus 33 +/- 24 U, p < 0.05; 21-day mortality 1 of 96 versus 5 of 74 patients (1% vs. 7%, p < 0.05). CONCLUSIONS: The data suggest that in evolving myocardial infarction up to 4 h in duration, the start of thrombolytic therapy at < or = 1.5 h compared with > 1.5 h limits infarct size, preserves left ventricular function and may save lives.

Sudden increase of the ST segment elevation at time of reperfusion predicts extensive infarcts in patients with intravenous thrombolysis.

Within 4 hours from the onset of symptoms in 61 patients with myocardial infarction and intravenous thrombolysis, ST segment elevation and creatine phosphokinase (CK) were measured every 15 minutes. Because of a premature enzyme rise, 42 patients (69%) were reperfused early (group 1). Immediately following reperfusion, eight of them (13%, group 1a) showed a marked increase of the ST elevation, in six of whom it was associated with clearly intensified chest pain. These patients exhibited a much steeper enzyme release and developed a larger enzymatic infarct size than patients (group 1b) without an additional transient ST elevation at reperfusion (CK peak 5.1 +/- 1.6 vs 9.8 +/- 4.2 hours after the start of thrombolysis; CK release 48 +/- 22 vs 19 +/- 18 IU/ml x hours, both p < 0.005). At angiography 11 days later, left ventricular function was significantly worse in group 1a than in group 1b (regional dyssynergic area 51 +/- 24 vs 21 +/- 18, global ejection fraction 39 +/- 14 vs 58 +/- 11; both p < 0.0005). During intravenous thrombolysis in acute myocardial infarction, some patients show a marked transient increase of the ST segment elevation at reperfusion. Their enzyme rise is very rapid and suggests a special reperfusion pattern. Most of these patients suffered large infarcts.

[Detection of early reperfusion and prediction of left ventricular damage from the course of increased ST values in acute myocardial infarct with thrombolysis]. / Erkennung der frühen Reperfusion und Vorhersage der linksventrikulären Schädigung aus dem Verlauf der ST-Strecken-Hebung beim akuten Myokardinfarkt mit Thrombolyse.

In 60 patients with acute myocardial infarction (pain < or = 4 h), we examined the value of ST segment monitoring in predicting early reperfusion, resulting left ventricular damage, and complications during hospitalization. Two criteria were determined by observation of the ST segment elevation during the first 4 h following initiation of thrombolysis. Early reperfusion was assessed by an early increase of the creatine phosphokinase (CK) with measurements taken in 15-min intervals. Cardiac catheterization was performed on days 11 +/- 5. According to the CK measurements, a reduction of the ST elevation > or = 50% within 1 h of serial ECG follow-up (ST criterion A) was the best indicator of early reperfusion (sensitivity 84%, specificity 80%, positive predictive value 93%, negative predictive value 67%). Simple comparison of the ST segment in the initial ECG and an ECG recorded 3 h later (ST criterion B) was less accurate according to the detection of early reperfusion (sensitivity 68%, specitivity 93%, positive predictive value 97%, negative predictive value 50%). However, contrary to ST criterion A, criterion B was useful in predicting subsequent left ventricular damage. Patients with a resolution of the initial ST elevation > or = 70%/3 h showed smaller regional wall motion abnormalities (dyssynergic area 21.3 +/- 20.3 vs 33.8 +/- 18.4, p < 0.01) and a better left ventricular ejection fraction (57.7 +/- 11.6 vs 50.2 +/- 12.6, p < 0.05). Patients with early reduction of the ST elevation following either criterion experienced fewer critical events (reinfarction, reischemia, death). In conclusion, the investigated criteria are useful in assessing reperfusion of the infarcted artery following thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficiency of a physician-operated mobile intensive care unit for prehospital thrombolysis in acute myocardial infarction.

The efficiency of an emergency medical system for routinely performed prehospital thrombolysis is evaluated for 1 of the 7 physician-staffed mobile intensive care units (MICU) in former West Berlin. During 19 consecutive months the MICU had 4,920 missions, and 1,226 patients had chest pain of presumed cardiac origin. The diagnosis at hospital discharge was acute myocardial infarction (AMI) in 406 patients and "interrupted" infarction in 11 patients (total 417). Correct on-scene electrocardiographic diagnosis of acute injury was made in 268 patients (64%) and was false-positive in 4 patients (1%). In 8%, present ST elevations were not recognized. In 27%, the electrocardiogram on scene was nondiagnostic (16% with no ST elevation, 11% with bundle branch block). Of all 417 patients with later hospital evidence of AMI, 317 (76%) were seen by the MICU physician within 4 hours, and 173 (41%) within the first hour from symptom onset. Two hundred three patients seen within 4 hours had diagnostic ST elevation on the scene, of whom 124 (61%) received prehospital thrombolysis (74 patients [36%] within the first hour). There was no prehospital death; hospital mortality was 6.3%. Because greater than 50% of all patients in the community, hospitalized because of AMI, made use of the MICU and 3/4 of them had called within 4 hours from symptom onset, a large proportion of all patients with AMI were candidates for the actually received prehospital thrombolysis.