Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment.

UNLABELLED: Acute myocardial infarction (AMI) is one of many causes of ST-segment elevation (STE) in emergency department (ED) chest pain (CP) patients. The morphology of STE may assist in the correct determination of its cause, with concave patterns in non-AMI syndromes and non-concave waveforms in AMI. OBJECTIVES: To determine the impact of STE morphologic analysis on AMI diagnosis and the ability of this technique to separate AMI from non-infarction causes of STE. METHODS: The electrocardiograms (ECGs) of consecutive ED adult CP patients (with three serial troponin I determinations) were interpreted in two-step fashion by six attending emergency physicians (EPs): 1) the determination of STE by three EPs followed by 2) STE morphologic analysis (either concave or non-concave) in those patients with STE. The impact of STE morphology analysis was investigated in the identification of AMI and non-AMI causes of STE. Acute myocardial infarction was diagnosed by abnormal serum troponin I values (>0.1 mg/dL) followed by a rise and fall of the serum marker; STE diagnoses of non-AMI causes were determined by medical record review. Interobserver reliability concerning STE morphology was determined. Study inclusion criteria included at least three troponin values performed in serial fashion no more frequently than every three hours, initial ED ECG, ED diagnosis, and final hospital diagnosis. RESULTS: Five hundred ninety-nine CP patients were entered in the study, with 171 (29%) individuals having STE on their ECGs. Of the 171 patients who had STE, 56 had AMI, 50 had unstable angina pectoris (USAP), and 65 had non-coronary final diagnoses. Forty-nine patients had non-concave STE, 46 with AMI and three with USAP; no patient with a non-coronary diagnosis had a non-concave STE morphology. The sensitivity and specificity of the non-concave STE morphology for AMI diagnoses were 77% and 97%, respectively; the positive and negative predictive values for non-concave morphology in AMI diagnoses were 94% and 88%, respectively. Interobserver reliability in the STE morphology determination revealed a kappa coefficient of 0.87. CONCLUSIONS: A non-concave STE morphology is frequently encountered in AMI patients. While the sensitivity of this pattern for AMI diagnosis is not particularly helpful, the presence of this finding in adult ED chest pain patients with STE strongly suggests AMI. This technique produces consistent results among these EPs.

Strain differences in adrenalectomy-induced alterations in nicotine sensitivity in the mouse.

Adult mice of four inbred strains (A, BUB, C57BL, DBA) and two selectively bred lines [Long-Sleep (LS) and Short-Sleep (SS)] were tested for differences in glucocorticoid regulation of nicotine sensitivity. One week following adrenalectomy (ADX), animals were tested for nicotine sensitivity in a battery of tests that included acoustic startle response, Y-maze activity (line crosses and rearings), heart rate and body temperature. Although each type of animal tested had increased nicotine sensitivity in at least one of the test battery measurements, there was clear evidence for a genetic influence on the scope of ADX-induced changes in sensitivity. LS animals had the largest increase in sensitivity with altered responses in four of five tests following ADX. The sensitivity of DBA animals was increased in two tests while for A, BUB, C57BL and SS animals, only one test was affected. ADX-induced alterations in nicotine sensitivity could not be explained on the basis of changes in nicotinic receptor number since changes were consistent across strains. The mechanism by which ADX causes increased nicotine sensitivity is not known. However, these data support the hypothesis that nicotine sensitivity is modulated by adrenal glucocorticoid secretion and also suggest that this phenomenon is under strict genetic control.

Genetic differences in plasma corticosterone levels in response to nicotine injection.

Changes in plasma corticosterone (CCS) levels following intraperitoneal injections of nicotine were measured in four inbred mouse strains: DBA/2Ibg, C57BL/6Ibg, C3H/2Ibg, and A/J. In all four strains, nicotine produced a dose-dependent (0.5-2.0 mg/kg nicotine) increase in plasma CCS levels which peaked 10-30 min after injection. Saline increased plasma CCS levels in C57BL, A, and C3H, but not in DBA mice. After correcting for plasma CCS levels produced by saline injection, the nicotine-induced rise in plasma CCS was significantly lower for the C57BL strain than for the other three strains tested. These mouse strains also varied in their responses to saline injection with the rank order: C57BL greater than A = C3H greater than DBA. However, the two most divergent strains (C57BL and DBA) did not differ in the effects of a cold water stress. The response to nicotine was completely inhibited by mecamylamine in two strains tested (C3H and C57BL) whereas the response to saline injection was unaffected, suggesting that only the response to nicotine was mediated by nicotinic receptors. It is clear that elevations in plasma CCS induced either by saline injection or by nicotine are influenced by genetic factors.

Adrenocortical hormone regulation of nicotine sensitivity in mice.

The possibility that nicotine-induced corticosterone (CCS) release regulates nicotine sensitivity was investigated in female mice of the C3H strain. Adrenalectomy (ADX) resulted in an increase in nicotine sensitivity as measured in a number of physiological and behavioral tests. In ADX animals, chronic CCS (100 micrograms/ml) administered in the drinking solution normalized nicotine sensitivity. Dexamethasone (DEX), a potent synthetic glucocorticoid which interacts with a distinct population of CNS steroid receptors, did not reverse the effects of ADX. Unoperated animals administered CCS (200 micrograms/ml) were protected from the effects of nicotine for several test battery parameters. ADX had no effect on the number of brain nicotinic cholinergic receptors and also did not alter nicotine metabolism. These data support the hypothesis that CCS secretion modulates nicotine sensitivity in the mouse; however, the mechanisms by which this regulation occurs are unknown.

An analysis of cocaine effects on locomotor activities and heart rate in four inbred mouse strains.

The effects of cocaine on Y-maze activity and heart rate have been examined in four inbred strains of mouse (BALB, C57BL, C3H and DBA). In addition, brain [3H]-cocaine concentrations were measured at the time of maximal response to cocaine. Cocaine produced a dose-related increase in Y-maze cross activity in C3H, DBA and C57BL, with C3H mice being considerably more sensitive than DBA or C57BL. Cocaine was without effect on Y-maze cross activity in BALB mice. Cocaine produced a biphasic effect on rearing activity in C3H mice, a dose related depression in BALB mice, and was without effect on C57BL and DBA mice. At the highest dose studied (15 mg/kg), cocaine produced a small decrease in heart rate in C3H mice. Strain differences in behavior were maximal 15 minutes after a dose of 5 mg/kg, IP. At this dose and time interval, brain [3H]-cocaine concentrations were not significantly different among the four strains of mice. The results suggest a genetically-determined difference in CNS sensitivity to cocaine.

3H-5-hydroxytryptamine accumulation by rat brain synaptic vesicles in a membrane-impermeant medium, and selective reduction by 5,7-dihydroxytryptamine.

In order to examine possible selectivity of amine uptake by synaptic vesicles, the ATP-stimulated accumulation of 3H-5-hydroxytryptamine (5HT) by synaptic vesicles from rat whole brain was examined in a medium comprised largely of membrane-impermeant anions (d-tartrate). Such media have previously been shown to stabilize vesicular accumulation of several neurotransmitters. Accumulation of 3H-5HT did not occur in tartrate medium alone, but was increased biphasically with increasing concentrations of both potassium phosphate and potassium bicarbonate. At optimal concentrations of each anion (10 mM), stable accumulation of 3H-5HT was observed at 37 degrees (26.1 +/- 1.2 pmol/mg protein; Km 6 X 10(-7) M), which was reduced by greater than 95% in the absence of K2ATP, at 4 degrees C, in the presence of 10(-6) M reserpine, or in the presence of the proton ionophore carbonyl cyanide p-trifluoromethoxyphenylhydrazone (FCCP). Uptake was significantly antagonized by millimolar concentrations of Na+, Mg++ or Cl-, but was unaffected by ouabain (10(-5) M). Pretreatment of animals with 5,7-dihydroxytryptamine (5,7-DHT) (200 micrograms, intraventricular) 10 days prior to sacrifice reduced endogenous 5HT levels by 70%, while levels of endogenous norepinephrine (NE) and dopamine (DA) were unaffected. Accumulation of 3H-5HT, examined in the presence of 10(-6) M NE to block 3H-5HT accumulation by vesicles from noradrenergic nerve endings, was reduced by 40% in vesicles from treated animals. Vesicular accumulation of 3H-(-)-NE and 3H-DA was unaffected by 5,7-DHT treatment. The data suggest the possibility of preferential accumulation of 3H-5HT by vesicles arising from serotonergic nerve endings.