TAPSE/SPAP ratio stratifies mortality risk in mild-to-moderate idiopathic pulmonary fibrosis.

BACKGROUND: Due to paucity of literature data, we aimed at evaluating the prognostic role of the ratio of tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (SPAP) in idiopathic pulmonary fibrosis (IPF) patients without severe pulmonary hypertension and at assessing its correlation with effective arterial elastance index (EaI). METHODS: Multi-instrumental data obtained in 60 IPF patients (73.2 ± 6.8 years) and 60 matched controls were retrospectively analysed. Primary endpoint was all-cause mortality, while secondary endpoint was the composite of all-cause mortality and re-hospitalisations for all-causes over medium-term follow-up. RESULTS: ;At baseline, TAPSE/SPAP was significantly lower in patients with IPF than in controls (0.36 ± 0.25 vs. 0.77 ± 0.18 mm/mmHg; P < 0.001). TAPSE/SPAP was inversely correlated with EaI (r = -0.96) in IPF patients. During follow-up (3.5 ± 1.5 years), 21 patients died and 25 were re-hospitalised due to cardiopulmonary causes. TAPSE/SPAP was independently associated with both primary (HR 0.79, 95%CI 0.65-0.97) and secondary (HR 0.94, 95%CI 0.92-0.97) endpoints. A TAPSE/SPAP ratio of <0.20 and <0.44 mm/mmHg showed the greatest sensitivity and specificity for predicting primary (AUC 0.98) and secondary (AUC 0.99) endpoints, respectively. CONCLUSIONS: TAPSE/SPAP is a strong predictor of adverse outcomes in mild-to-moderate IPF. The strong correlation between TAPSE/SPAP and EaI might be an expression of a systemic fibrotic process which involves the heart, lungs and circulation.

Left atrial remodelling early after mitral valve repair for degenerative mitral regurgitation.

OBJECTIVE: Left atrial (LA) size is an important predictor of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation (MR). Data on LA remodelling after mitral valve repair (MVr) for chronic non-ischaemic MR are scarce. The aim of this study was to assess changes in LA size early after MVr for chronic severe degenerative MR and to identify clinical and echocardiographic correlates of those changes. METHODS: The study analysed 225 consecutive patients who underwent MVr and were echocardiographically evaluated in our hospital within 1 month before and 1-6 months after surgery. Patients with MR aetiology other than degenerative, associated aortic valve replacement, or congenital heart disease were excluded. The remaining 79 patients (aged 60 (SD 12) years, 55 men) with isolated chronic severe degenerative MR formed the study group. LA reverse remodelling was defined as a decrease in LA volume index (LAVi) > or = 15%. RESULTS: LA dimensions significantly decreased after MVr (p<0.001). Mean LAVi reduction was 29% (SD 18%). LA reverse remodelling was observed in 63 patients (80%). Correlates of LAVi reduction were preoperative LAVi (p = 0.008), systolic and diastolic blood pressure (p = 0.032, p = 0.009), postoperative transmitral mean pressure gradient (p = 0.001) and residual MR (p = 0.043). LAVi reduction was lower in patients > 45 years (p = 0.008) and in hypertensive patients (p = 0.031). CONCLUSION: LA reverse remodelling is common early after MVr for chronic severe degenerative MR. Preoperative LAVi, blood pressure, postoperative transmitral mean pressure gradient, residual MR and age > 45 are related to LAVi reduction. The prognostic value of LA reduction in this setting needs further study.

Right ventricular functional recovery after acute myocardial infarction: relation with left ventricular function and interventricular septum motion. GISSI-3 echo substudy.

OBJECTIVE: To evaluate the pattern of right ventricular (RV) functional recovery and its relation with left ventricular (LV) function and interventricular septal (IVS) motion in low risk patients after acute myocardial infarction (AMI). DESIGN AND SETTING: Multicentre clinical trial carried out in 47 Italian coronary care units. PATIENTS: 500 patients from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico) -3 echo substudy, who underwent serial echocardiograms 24-48 hours after symptom onset and at discharge, six weeks, and six months after AMI. RESULTS: Tricuspid annular plane systolic excursion (TAPSE) increased significantly during follow up (mean (SD) 1.79 (0.46) cm at 24-48 hours to 1.92 (0.46) cm at six months, p < 0.001) and the increase was already significant at discharge (1.88 (0.47) cm, p < 0.001). LV ejection fraction (LVEF) was the best correlate of TAPSE at 24-48 hours (r = 0.15, p = 0.001). TAPSE increased significantly in patients both with reduced (< 45%) and with preserved (> or = 45%) LVEF, but the magnitude of increase was higher in patients with lower initial LVEF (p = 0.001). Improvement in IVS wall motion score index (IVS-WMSI) was the only independent predictor of TAPSE changes during follow up (r = -0.12, p = 0.007). CONCLUSIONS: In low risk patients after AMI, RV function recovered throughout six months of follow up and was already significant at discharge. TAPSE was significantly related to LVEF at 24-48 hours. The magnitude of RV functional recovery was higher in patients with lower initial LVEF. RV functional recovery is best related to IVS-WMSI improvement, suggesting that IVS motion has an important role in RV functional improvement in this setting.

Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy.

OBJECTIVE: To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus. DESIGN AND SETTING: Multicentre clinical trial carried out in 47 Italian coronary care units. PATIENTS AND METHODS: 757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views. RESULTS: In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m(2), p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m(2), p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction. CONCLUSIONS: Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent determinant of left ventricular thrombosis is the extent of the akinetic-dyskinetic area detected on echocardiography between 24-48 hours from symptom onset.

Prediction of 6 months left ventricular dilatation after myocardial infarction in relation to cardiac morbidity and mortality. Application of a new dilatation model to GISSI-3 data.

AIMS: To predict the long-term left ventricular volume index early after myocardial infarction and to investigate the relationship between long-term left ventricular dilatation risk and clinical outcome. METHODS AND RESULTS: By applying a previously developed dilatation model, we predicted the 6-month left ventricular volume index early after myocardial infarction (median 9 days) in 13,679 GISSI-3 patients, to identify patients at high risk of long-term left ventricular dilatation. The left ventricular systolic and diastolic volume indexes at 6 months were predicted with r=0.72 and r=0.68, respectively, in the subgroup of patients in whom a pre-discharge echo was available (n=7842). Patients predicted to be at risk for long-term left ventricular dilatation had an increased risk of mortality (RR 1.87, 95% CI: 1.48 to 2.36) and heart failure at 6 months (RR 2.59, 95% CI:2.04 to 3.28), but no increased risk of reinfarction at 6 months (RR 1.12, 95% CI: 0.87 to 1.45) or of angina pectoris (RR 1.07, 95% CI: 0.95 to 1.20). CONCLUSION: Our prediction of long-term left ventricular dilatation, obtained by applying our new dilatation model in over 13,000 GISSI-3 patients, correlated well with mortality and heart failure after myocardial infarction. Therefore, our new dilatation model may contribute to more efficient risk stratification early after myocardial infarction.

Assessment of absolute risk of death after myocardial infarction by use of multiple-risk-factor assessment equations: GISSI-Prevenzione mortality risk chart.

AIMS: To present and discuss a comprehensive and ready to use prediction model of risk of death after myocardial infarction based on the very recently concluded follow-up of the large GISSI-Prevenzione cohort and on the integrated evaluation of different categories of risk factors: those that are non-modifiable, and those related to lifestyles, co-morbidity, background, and other conventional clinical complications produced by the index myocardial infarction. METHODS: The 11-324 men and women recruited in the study within 3 months from their index myocardial infarction have been followed-up to 4 years. The following risk factors have been used in a Cox proportional hazards model: non-modifiable risk factors: age and sex; complications after myocardial infarction: indicators of left ventricular dysfunction (signs or symptoms of acute left ventricular failure during hospitalization, ejection fraction, NYHA class and extent of ventricular asynergy at echocardiography), indicators of electrical instability (number of premature ventricular beats per hour, sustained or repetitive arrhythmias during 24-h Holter monitoring), indicators of residual ischaemia (spontaneous angina pectoris after myocardial infarction, Canadian Angina Classification class, and exercise testing results); cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, systolic and diastolic blood pressure, blood total and HDL cholesterol, triglycerides, fibrinogen, leukocytes count, intermittent claudication, and heart rate. Multiple regression modelling was assessed by receiver operating characteristic (ROC) analysis. Generalizability of the models was assessed through cross validation and bootstrapping techniques. POPULATION AND RESULTS: During the 4 years of follow-up, a total of 1071 patients died. Age and left ventricular dysfunction were the most relevant predictors of death. Because of pharmacological treatments, total blood cholesterol, triglycerides, and blood pressure values were not significantly associated with prognosis. Sex-specific prediction equations were formulated to predict risk of death according to age, simple indicators of left ventricular dysfunction, electrical instability, and residual ischaemia along with the following cardiovascular risk factors: smoking habits, history of diabetes mellitus and arterial hypertension, blood HDL cholesterol, fibrinogen, leukocyte count, intermittent claudication, and heart rate. The predictive models produced on the basis of information available in the routine conditions of clinical care after myocardial infarction provide ready to use and highly discriminant criteria to guide secondary prevention strategies. CONCLUSIONS AND IMPLICATIONS: Besides documenting what should be the preferred and practicable focus of clinical attention for today's patients, the experience of GISSI-Prevenzione suggests that periodically and prospectively collected databases on naturalistic' cohorts could be an important option for updating and verifying the impact of guidelines, which should incorporate the different components of the complex profile of cardiovascular risk. The GISSI Prevenzione risk function is a simple tool to predict risk of death and to improve clinical management of subjects with recent myocardial infarction. The use of predictive risk algorithms can favour the shift from medical logic, based on the treatment of single risk factors, to one centred on the patient as a whole as well as the tailoring of medical interventions according to patients' overall risk.

Can short-term verapamil therapy reduce the recurrence of atrial fibrillation after successful low energy intracardiac cardioversion?

BACKGROUND: Calcium-lowering drugs seem to be able to reduce the recurrences of atrial fibrillation (AF) after cardioversion by preventing electrical remodeling of atrial cells. The aim of our study was to prospectively evaluate the efficacy of short-term verapamil therapy associated with propafenone or amiodarone in reducing recurrences of AF after low energy intracardiac cardioversion. METHODS: Eighty-two patients with chronic AF (mean duration 6.1 months, range 1-96 months) underwent low energy intracardiac cardioversion. Forty-one patients (Group A) were instructed to suspend antiarrhythmic therapy 48 hours before the procedure (only chronic amiodarone was allowed). The subsequent 41 patients (Group B), in addition to previous prescriptions, had to take verapamil (120 mg twice daily) for 3 days before low energy intracardiac cardioversion and for 7 days after cardioversion. A right atrium-coronary sinus or right atrium-left pulmonary artery electrode configuration was indifferently utilized. Propafenone (450-900 mg daily) or amiodarone (200 mg daily) was prescribed to all patients after cardioversion. RESULTS: Sinus rhythm was acutely restored in 80 patients (97.6%): the mean number of shocks delivered was 2.3 (range 1-5); the mean energy required was 10.5 J (range 7.2-19.8 J). No statistically significant differences were found between the right atrium-coronary sinus vs right atrium-left pulmonary artery electrode configuration regarding the energy required and the number of shocks delivered. Group A and Group B showed the same number of AF recurrences at the first month of follow-up. CONCLUSIONS: In our study, short-term verapamil treatment associated with propafenone or amiodarone seems to be useless for the prevention of recurrent AF after low energy intracardiac cardioversion.

[Digital signature: new prospects for the information of the cardiologic clinical card]. / Firma digitale: nuove prospettive per l'informatizzazione della cartella clinica cardiologica.

In the last few years, remarkable improvements have been made in computerized database systems used in cardiology. However, they will not easily lead to further relevant improvements unless the weaknesses and the gaps deriving from the obligation of forming and storing case sheets, according to law, are faced and resolved in an original way. This article covers the topic of the digital signature and how it could form the basis for a new powerful impulse to the process of informatization of cardiology records. The proposal of elaborating a totally computerized case sheet involves the need of rationalizing the flow of clinical information and of implementing a management system integrated with the hospital information system. The elimination of paper support will probably lead to an advantageous cycle that will involve the entire hospital, both clinically as well as administratively.

Heterogeneity of left ventricular remodeling after acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-3 Echo Substudy.

BACKGROUND: Left ventricular (LV) remodeling after acute myocardial infarction has still to be clarified in the thrombolytic era. METHODS: To evaluate timing and the magnitude and pattern of postinfarct LV remodeling, a subset of 614 patients enrolled in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-3 Echo Substudy underwent serial 2-dimensional echocardiograms at 24 to 48 hours from symptom onset (S1), at hospital discharge (S2), at 6 weeks (S3), and at 6 months (S4) after acute myocardial infarction. RESULTS: During the study period the end-diastolic volume index (EDVi) increased (P <.001) and wall motion abnormalities (%WMA) decreased (P <.001), whereas ejection fraction (EF) remained unchanged. Nineteen percent of patients showed a > 20% increase in EDVi at S2 compared with S1 (severe early dilation), and 16% of patients showed a > 20% dilation at S4 compared with S2 (severe late dilation). Independent predictors of severe in-hospital LV dilation were relatively small EDVi (odds ratio [OR] 0.961, 95% confidence interval [CI] 0.947-0.974, P =.0001) and relatively large %WMA (OR 1.030, 95% CI 1.013-1.048, P =.0005). Similarly, smaller predischarge EDVi (OR 0.975, 95% CI 0. 963-0.987, P =.0001), greater %WMA (OR 1.026, 95% CI 1.008-1.045, P =.0042), and moderate to severe mitral regurgitation (OR 2.261, 95% CI 1.031-4.958, P = 0.0417) independently predicted severe late dilation. Importantly, 92% of the patients with severe early dilation did not have further dilation at S4, and 91% of patients with severe late dilation did not have in-hospital dilation. EF was unchanged over time in patients with early dilation, whereas it significantly decreased in those with late dilation. CONCLUSIONS: Although in-hospital LV enlargement is not predictive of subsequent dilation and dysfunction, late remodeling is associated with progressive deterioration of global ventricular function over time: patients with extensive %WMA and not significantly enlarged ventricular volume before discharge are at higher risk for progressive dilation and dysfunction.

[Open access echocardiography in patients with suspected or confirmed heart failure]. / Open access echocardiography per i pazienti con scompenso cardiaco sospetto o accertato.

Cardiac failure is a disease still characterized by high morbidity and mortality. The use of clinical criteria is not yet considered sufficient for the diagnosis of this disease by main scientific associations. Echocardiography can give important information not only for diagnosis, but also for prognosis and management of the disease. As a growing demand for echocardiography is expected in the near future scientific community should be ready to face this difficult challenge. In fact it will be necessary to implement and organize structures in which this technique will be readily and easily available, in order to facilitate the diagnosis and allow "personalized" management and follow-up in these patients.

[Echocardiographic evaluation of the volumes and global systolic function of the left ventricle]. / Valutazione ecocardiografica dei volumi e della funzione sistolica globale del ventricolo sinistro.

The qualitative and quantitative evaluation of left ventricular systolic function is one of the most important applications of echocardiography in clinical practice. In this review the most commonly employed echocardiographic Doppler indexes of left ventricular systolic function are described, with particular emphasis on the practical clinical relevance of each index. Linear measurements, volumes and derived M-mode and two-dimensional indexes are discussed, i.e. endocardial and midwall fractional shortening, ejection fraction, velocity of circumferential fiber shortening, sphericity indexes, relative wall thickness, mitral-septal separation). Furthermore, other less load-dependent indexes are analyzed such as wall stress, end-systolic stress-shortening relations, and left ventricular dP/dt. Finally the clinical application of new interesting echocardiographic techniques is described: harmonic imaging, contrast echocardiography, acoustic quantification, three-dimensional echocardiography and intracardiac echocardiography.

Validation of the ejection fraction-velocity ratio: a new simplified "function-corrected" index for assessing aortic stenosis severity.

A new echocardiographic method for the evaluation of aortic stenosis (AS) severity has recently been introduced: the fractional shortening-velocity ratio (FSVR = fractional shortening/4 Vmax(2)). An important advantage of the method is the possibility of avoiding the difficulties related to the measurement of left ventricular outflow tract in calcific AS for assessing the continuity equation. FSVR, however, also shows some significant limitations especially in patients with regional wall motion abnormalities and conduction defects. To overcome this problem, we developed a new index: the ejection fraction-velocity ratio (EFVR = ejection fraction/4 Vmax(2)), where percent ejection fraction and Vmax have been obtained with an apical echocardiographic approach. In 343 consecutive patients with AS, aortic valve area was measured by cardiac catheterization (Gorlin), whereas FSVR and EFVR were calculated by echo-Doppler examination performed within 24 hours. Mean valve area was 0.70 +/- 0.30 cm(2), mean EFVR was 0.78 +/- 0.41, and mean FSVR was 0.45 +/- 0.26. The linear correlation area-EFVR was highly significant (r = 0.88). Correlation valve area-FSVR was also significant (r = 0.82). EFVR allowed identification of patients with severe AS (area

[Right ventricular thrombosis in arrhythmogenic cardiomyopathy. A case report]. / Trombosi ventricolare destra nella cardiomiopatia aritmogena. Descrizione di un caso clinico.

Echocardiographic demonstration of right ventricular thrombosis is relatively common in pulmonary embolism. There are also reports of right ventricular thrombi in patients affected by right myocardial infarction or dilated cardiomyopathy. In arrhythmogenic right ventricular cardiomyopathy single or multiple aneurysms are often present in the right ventricular free wall. These hypoakinetic areas represent a site for potential development of thrombi especially in advanced disease states. In the literature a single case of a patient affected by arrhythmogenic right ventricular cardiomyopathy with right heart failure and atrial and ventricular thrombi is reported. We report a case of arrhythmogenic right ventricular cardiomyopathy with a right ventricular thrombus located inside a single apical aneurysm in the presence of normal right ventricular systolic function.

Low energy intracardiac cardioversion of chronic atrial fibrillation by single femoral approach: safety and effectiveness of the procedure.

BACKGROUND: Low energy intracardiac cardioversion has recently been introduced into clinical practice to treat both acute and chronic atrial fibrillation. It has also been suggested that low energy intracardiac cardioversion has a higher efficacy rate in restoring sinus rhythm than conventional external cardioversion. METHODS: A prospective study was started in 41 patients (mean age 64.5 years) with chronic atrial fibrillation (mean duration 6.5 months), in order to obtain more data on low energy intracardiac cardioversion concerning: 1) time required to perform low energy intracardiac cardioversion by single venous femoral approach; 2) acute efficacy; 3) incidence of complications; 4) persistence of sinus rhythm after 1 month. RESULTS: Twenty patients had right atrium-coronary sinus (Group A) and 20 right atrium-left pulmonary artery (Group B) electrode configuration for defibrillation. In 1 patient the configuration was not available. In all patients (100%) sinus rhythm was acutely restored. No statistically significant differences were found between the two groups concerning mean energy and impedance required to obtain cardioversion. With mild sedation the discomfort induced by the electrical shock was minimal or mild. Only 44% of patients were in sinus rhythm 1 month after low energy intracardiac cardioversion, in spite of adequate pharmacological therapy. CONCLUSIONS: Low energy intracardiac cardioversion by single venous femoral approach may be considered a very effective and not time consuming procedure in acutely restoring sinus rhythm, with low complication rate; in addition the procedure was well accepted by all patients.

[Is a more efficient operative strategy feasible for the emergency management of the patient with acute chest pain?]. / E realizzabile una strategia operativa più efficace per la gestione in urgenza del paziente con dolore toracico acuto?

Patients with acute chest pain are a common problem and a difficult challenge for clinicians. In the United States more than 5 million patients are examined in the emergency department on a yearly basis, at a cost of 6 billion dollars. In the CHEPER registry the prevalence of patients with chest pain in the Emergency Department was 5.3%. Similarly, in 1997 at our institution the prevalence was 4.8%. Only 50% of the patients are subsequently found to have cardiac ischemia as the cause of their symptoms and 50-60% of them showed a non-diagnostic electrocardiogram (ECG). Twenty-five-50% of chest pain patients are not appropriately admitted to the hospital and despite this conservative approach, acute myocardial infarction is misdiagnosed up to 8% of patients with acute chest pain who are released from the emergency department without further evaluation, accounting for approximately 20% of emergency department malpractice in the United States. Important diagnostic information is covered by the patient's medical history, physical examination, and ECG, but often this approach is inadequate for a definitive diagnosis. Creatine kinase (CK) and CK isoenzyme--cardiac muscle subunit (CK-MB)--are traditionally obtained in the emergency department in patients admitted for suspected acute coronary syndrome. Mass measurements of CK-MB have improved sensitivity and specificity, and to date this is the gold standard test for diagnosis of acute myocardial infarction. CK-MB, however, is not a perfect marker because it is not totally cardiac specific and does not identify patients with unstable angina and minimal myocardial damage. There are no controlled clinical impact trials showing that these tests are effective in deciding whether to discharge or to appropriately admit the patient with suspected acute coronary syndrome. Relevant investigative interest has recently been focused on new markers for myocardial injury, including myoglobin, cardiac troponins T and I. Myoglobin, a sensitive but not specific marker for cardiac damage, increases earlier than CK-MB and cardiac troponins. It should be used early after symptom onset and in conjunction with a more specific marker of myocardial damage. Cardiac troponins T and I are highly specific markers for cardiac damage, rise parallel to CK-MB and remain elevated longer, up to 5 to 9 days. They are useful for detection of less severe degrees of myocardial injury, which may occur in several patients with unstable angina who are at higher risk of cardiac events. Recent studies suggest that cardiac troponins have good diagnostic performance and prognostic value in the heterogeneous population of patients seen in the Emergency Department with acute chest pain. Despite these promising data, several analytical and interpretative problems in the routine use of cardiac troponins must be solved. Incremental value of echocardiography in acute chest pain patients is still uncertain. Echocardiography can be recommended as an adjunctive test if readily available during acute chest pain or prolonged pain, especially in patients without previous myocardial infarction. Rest myocardial radionuclide imaging has been studied in the emergency department setting and although the overall diagnostic performance and prognostic value of sestamibi has been found to be promising, it is not suitable, in our country, for extensive clinical use. ECG exercise stress test in the emergency department population has been shown to be safe and it has a good negative predictive value for cardiac events. It should be recommended that any institution identify specific and shared protocol and strategies for management of patients with chest pain. These should include basal clinical evaluation, serial ECG and the use of specific and sensitive myocardial markers. Adjunctive tests, such as echocardiography, nuclear studies and stress tests should be employed when indicated taking into account local facilities.

Electrocardiographic evolutionary changes and left ventricular remodeling after acute myocardial infarction: results of the GISSI-3 Echo substudy.

OBJECTIVES: The aim of this study was to describe the electrocardiographic (ECG) evolutionary changes after an acute myocardial infarction (AMI) and to evaluate their correlation with left ventricular function and remodeling. BACKGROUND: The QRS complex changes after AMI have been correlated with infarct size and left ventricular function. By contrast, the significance of T wave changes is controversial. METHODS: We studied 536 patients enrolled in the GISSI-3-Echo substudy who underwent ECG and echocardiographic studies at 24 to 48 h (S1), at hospital discharge (S2), at six weeks (S3) and six months (S4) after AMI. RESULTS: The number of Qwaves (nQ) and QRS quantitative score (QRSs) did not change over time. From S2 to S4, the number of negative T waves (nT NEG) decreased (p < 0.0001), wall motion abnormalities (%WMA) improved (p < 0.001), ventricular volumes increased (p < 0.0001) while ejection fraction remained stable. According to the T wave changes after hospital discharge, patients were divided into four groups: stable positive T waves (group 1, n = 35), patients who showed a decrease > or =1 in nT NEG (group 2, n = 361), patients with no change in nT NEG (group 3, n = 64) and those with an increase > or =1 in nT NEG (group 4, n = 76). The QRSs and nQ remained stable in all groups. Groups 3 and 4 showed less recovery in %WMA, more pronounced ventricular enlargement and progressive decline in ejection fraction than groups 1 and 2 (interaction time x groups p < 0.0001). CONCLUSIONS: The analysis of serial ECG can predict postinfarct left ventricular remodeling. Normalization of negative T waves during the follow-up appears more strictly related to recovery of regional dysfunction than QRS changes. Lack of resolution and late appearance of new negative T predict unfavorable remodeling with progressive deterioration of ventricular function.

Echocardiography to understand remodeling and to assess prognosis after acute myocardial infarction.

Ventricular remodeling indicates a dynamic process, starting with and after acute myocardial infarction, as a result of structural and functional modifications which involve acutely and chronically both the infarcted and noninfarcted zones of the left ventricle. The most effective way to prevent or minimize post-MI cardiac remodeling is to limit the extent of the initial insult. This can be partly achieved by early myocardial reperfusion obtained by different strategies including thrombolysis. In 6405 patients of the GISSI-3 trial, 2D echocardiographic studies were available at predischarge, at 6 weeks and at 6 months after the infarction. The increase in left ventricular volumes over time was reduced by 6-week lisinopril treatment. Patients randomized to lisinopril had smaller volume also at 6 months, after withdrawal of treatment at 6 weeks. Important prognostic indications can also be derived from predischarge echocardiography, since larger quartiles of left ventricular volumes and lower quartile of ejection fraction indicates higher risk of mortality and non-fatal congestive heart failure in the 6 months after the index event, even in the relatively low risk general population of infarcts of the GISSI-3.