Exercise-electrocardiography and/or pharmacological stress echocardiography for non-invasive risk stratification early after uncomplicated myocardial infarction. A prospective international large scale multicentre study.

AIMS: The aim of the present study was to assess the relative prognostic value of clinical variables, the exercise electrocardiography test and the pharmacological stress echocardiography test either with dipyridamole or dobutamine early after a first uncomplicated acute myocardial infarction in a large, multicentre, prospective study. METHODS AND RESULTS: Seven hundred and fifty-nine in-hospital patients (age=56+/-10 years) with a recent and first clinical uncomplicated myocardial infarction, with baseline echocardiographic findings of satisfactory quality, an interpretable ECG and able to exercise underwent a resting 2D echocardiogram, a pharmacological stress test with either dipyridamole or dobutamine and an exercise electrocardiography test at a mean of 10 days from the infarction; they were followed-up for a median of 10 months. During the follow-up, there were 13 deaths, 23 non-fatal myocardial infarctions and 59 re-hospitalizations for unstable angina. When all spontaneous events were considered, with multivariate analysis, the difference between the wall motion score index at rest and peak stress (delta wall motion score index), and exercise duration were independent predictors of future spontaneous events (relative risk 7.2; 95% CI=2.73-19.1; P=0.000; relative risk 1.1, 95% CI=1.02-1.18; P=0.008, respectively). Kaplan-Meier survival estimates showed a better outcome for those patients with a negative pharmacological stress echocardiography test compared to patients with low dose positivity (94.7 vs 74.8%, P=0.000). CONCLUSION: Stress echocardiography tests provide stronger information than historical and exercise electrocardiography test variables. Pharmacological echocardiography as well as the exercise ECG is able to predict all spontaneously occurring events when the presence as well as the timing, severity, and extension of stress-induced wall motion abnormalities are considered.

[Primary angioplasty in acute inferior myocardial infarct with anterior ST-segment depression: the long-term follow-up]. / Angioplastica primaria nell'infarto miocardico acuto inferiore con sottoslivellamento anteriore del tratto ST: follow-up a lungo termine.

BACKGROUND: Concomitant anterior ST-segment depression is a marker of severe prognosis in inferior myocardial infarction. PATIENTS AND METHODS: Prospective observational study in patients with inferior acute myocardial infarction and ST-segment depression > or = 4 mm in the anterior leads, who were treated with primary angioplasty. Angiography was performed at hospital discharge and at six months, and a clinical follow-up was obtained at one year after the infarction. RESULTS: Sixty-three patients were included in the study. Pre-hospital and in-hospital delay were 147 +/- 70 minutes (20-355) and 54 +/- 11 minutes (18-80), respectively. Angioplasty was successful in all patients and 48 stents were implanted in 36 patients (57%). Angiography was performed at hospital discharge in 55 patients (87%) and showed a TIMI grade 3 coronary flow in the infarct-related artery in all cases. The left ventricular ejection fraction was 0.55 +/- 0.09 (0.4-0.8). One patient (1.6%) died before discharge, two (3.2%) had ischemic complications (one had non-fatal reinfarction, another had recurrent angina at rest), and three (4.9%) had local vascular complications. At the six-month follow-up, none of the patients had died. One had suffered reinfarction (1.6%) and another had been readmitted for recurrence of angina at rest (1.6%); none had symptoms of stable angina. The ejection fraction was 0.56 +/- 0.12 and eight patients (14%) showed angiographic restenosis. At twelve months, two patients had died (1.6%) and five (8%) had required readmission to hospital. CONCLUSIONS: Primary angioplasty yielded favorable results in this group of patients. Our data confirm the efficacy of primary angioplasty for the treatment of acute myocardial infarction, with a low rate of clinical (3.2%) and angiographic (14%) restenosis at six months, and a high rate (87%) of event-free survival at one year follow-up.

Role of stress echocardiography in risk stratification early after an acute myocardial infarction. EPIC (Echo Persantin International Cooperative) and EDIC (Echo Dobutamine International Cooperative) Study Groups.

Resting and stress echocardiography is a 'one-stop shop', which enables a wide range of information to be collected on resting function, myocardial viability, and induced ischaemia, all of which are useful for prognostic stratification. Large scale, multicentre, prospectively collected data show the prognostic failure of resting function and inducible ischaemia, both independently and combined, which are especially effective in predicting cardiac death. The GISSI data show that the increment of risk as a result of reduction in ventricular function has a hyperbolic trend, with a relatively moderate increase in mortality for ejection fraction values between 50 and 30%, but with marked increases below 30%. The EPIC data show that the 1-year risk of cardiac death is as low as 2% in patients with negative dipyridamole stress echocardiography: it doubles if the test is positive at a high dose, and is almost four times higher if it is positive at a low dose. In the field of prognostic stratification, in the absence of carefully controlled studies, the choice between coronary angiography as the only essential study, or use of a non-invasive test to discriminate access to catheterization currently reflect alternate philosophical approaches rather than scientifically based decisions. In the invasive approach, stress echocardiography offers relief from the vicious circle of chest pain-coronary angiography revascularization. In the non-invasive and physiological approach, stress echo is capable of offering, in one sitting, an insight into the main determinants of survival: function, viability, and ischaemia.

The relative value of exercise-electrocardiography and dipyridamole stress echocardiography for risk stratification early after uncomplicated myocardial infarction. The EPIC (Echo Persantine International Cooperative) Study Group.

BACKGROUND: Rational prognostic algorithm should be developed considering the logical progression of the information as it becomes available to the physician, with clinical data first, ECG data second and stress imaging data last. The aim of the present study was to assess in a clinically realistic fashion the relative prognostic value of exercise electrocardiography test (EET) and dipyridamole-echocardiography test (DET) early after first acute uncomplicated myocardial infarction. METHODS AND RESULTS: Five hundred and forty-seven in-hospital patients (age = 56 +/- 9 years) with recent clinically uncomplicated first myocardial infarction, baseline echocardiographic findings of satisfactory quality, interpretable ECG and capability to exercise underwent a resting 2D echocardiogram, a DET and an EET at a mean of 10 days from the infarction and were followed up for 16.2 +/- 11 months. During the follow-up, there were 17 cardiac deaths, 19 non-fatal myocardial infarctions and 49 unstable angina. When cardiac death was considered as the only significant event, with multivariate analysis, peak dipyridamole Wall Motion Score Index was the only significant predictor (chi 2 = 5.66; p = 0.013; relative risk estimate = 4.7; confidence intervals = 1.35-16.08). In presence of a negative exercise electrocardiography test for both chest pain and electrocardiographic criteria, the death rate was 2%. CONCLUSION: DET provides stronger information in comparison with historical and EET variables. However, a negative maximal EET is sufficient to identify a very low risk subset in whom additional testing may not be warranted.

Does stress echocardiography predict the site of future myocardial infarction? A large-scale multicenter study. EPIC (Echo Persantine International Cooperative) and EDIC (Echo Dobutamine International Cooperative) study groups.

OBJECTIVES: We sought to assess whether the site of future myocardial infarction can be predicted on the basis of induced dyssynergy ("area at risk") recognized by stress echocardiography. BACKGROUND: The severity and extent of stress-induced dyssynergy are strong predictors of subsequent major cardiac events. However, high grade stenotic lesions are not strictly associated with the site of future coronary occlusions. METHODS: From the stress echocardiography multicenter trials data bank, we selected 70 patients (56 men; mean age +/- SD 58 +/- 11 years) meeting the following inclusion criteria: 1) dipyridamole (n = 53) or dobutamine (n = 17) stress echocardiography; 2) a spontaneously occurring infarction, with no intercurrent revascularization procedure between the initial study and the infarction; and 3) a follow-up rest echocardiogram obtained 41 +/- 90 days after the infarction. RESULTS: A complete ischemia-infarction mismatch (infarct-related dysfunction in a patient with negative stress test results) occurred in 29 patients (41%). A partial mismatch (ischemic dysfunction in a territory different from the infarct area) occurred in nine patients (13%). A match (ischemia-related and infarction-related dyssynergy involving the same region) occurred in 32 patients (46%). The average time interval between the stress examination and the occurrence of infarction or reinfarction was 144 +/- 160 days in patients with a match and 439 +/- 622 days in patients with a mismatch (p < 0.05). CONCLUSIONS: Induced ischemia (imaged as transient dyssynergy by pharmacologic stress echocardiography) inconsistently identifies the site of future infarction. The majority of spontaneous coronary occlusions leading to infarction are unheralded by induced ischemia. However, most infarctions occurring within 1 year of stress testing are in the area identified as ischemic during testing.

[Risk stratification after uncomplicated myocardial infarct: the usefulness of the echocardiographic-dipyridamole test]. / Stratificazione del rischio dopo infarto miocardico non complicato: utilità del test eco-dipiridamolo.

To assess the value and safety of echo-dipyridamole test in risk stratification soon after an uncomplicated acute myocardial infarction, 56 consecutive patients were enrolled in a prospective study with a 1-year follow-up period for new coronary events. Echo-dipyridamole and symptom-limited ECG stress test were performed respectively 14 to 20 days and 4 to 5 weeks after acute event. Echo-dipyridamole test was performed administering 0.84 mg/kg iv of the drug in 10 min: any worsening of left ventricular regional wall motion was considered as a positive test. Up to December 1989, 43 out of 56 patients had their follow-up period completed: the infarction was anterior in 13 (30%), inferior in 22 (51%), non-Q wave in 8 (19%); mean age was 55 +/- 10; basal echocardiographic ejection fraction was 52 +/- 6%. There were no major complications during echo-dipyridamole test. Coronary events occurred in 7 patients (16%): reinfarction in 3, angina in 4; there were no cardiac deaths. A positive echo-dypiridamole test was observed in 12/43 patients (28%); sensitivity versus coronary events was 43%, specificity 75%, negative predictive value 87%. Ten out of 43 patients (23%) had positive and 9/43 (21%) non valuable ECG stress test: sensitivity versus coronary events was 50%, specificity 75%, predictive negative value 88%. The 2 tests showed no significant difference in detecting patients at risk of future coronary events.(ABSTRACT TRUNCATED AT 250 WORDS)