Identification of the culprit artery in inferior myocardial infarction through the 12-lead ECG.

BACKGROUND: Identification of the culprit artery can be helpful in the management of inferior infarction with ST-segment elevation myocardial infarction. Some studies suggest that previously published algorithms intended to help identify the infarct-related artery are suboptimal. Our aim is to develop a better method to localise the culprit artery on the basis of the 12-lead ECG. PATIENTS AND METHODS: We analysed the ECG and coronary angiograms of two different cohorts of patients with inferior ST-segment elevation myocardial infarction. Patients from the first cohort were labelled the derivative cohort (group A), whereas patients in the second cohort were labelled the validation cohort (group B). ST-segment elevation was measured in each lead, and a multiple logistic regression analysis was carried out to determine the best equation to predict the culprit artery. A derived algorithm was then applied to the validation cohort. Next, our algorithm was applied to the total cohort of both groups and compared with four different previously published algorithms. We analysed differences in sensitivity, specificity and area under the curve (AUC). RESULTS: We included 252 patients in the derivative group and 90 in the validation group. The multiple models analysis concluded that the best model should include five leads. This model was validated by internal bootstrapping with 1000 repetitions in group A and externally in group B. The resultant algorithm was as follows: (ST-elevation in III + aVF + V3) - (ST-elevation in II + V6) less than 0.75 mm means that the culprit artery is the left circumflex artery (Cx). If the result is at least 0.75, the culprit artery is the right coronary artery. The total group of both cohorts comprised 342 patients, aged 61.2 ± 12.4 years, of whom 19.6% were female and 80.4% were male. The Cx was the culprit artery in 67 (19.6%) patients. Our algorithm had a sensitivity of 72.3, a specificity of 80.9 and an AUC of 0.766. The AUC value was better compared with the other algorithms. CONCLUSION: The best algorithm to localise the culprit artery includes ST-elevation in leads II and V6 related to Cx, and ST-elevation in leads III, aVF and V3 related to right coronary artery. Our algorithm has been validated internally and externally, and works better than other previously published algorithms.

Elevation of ST-segment in aVR is predictive of cardiogenic shock but not of multivessel disease in inferior myocardial infarction.

INTRODUCTION: Some studies suggest that ST elevation in aVR (aVR-STE) can predict the presence of left main or multivessel disease (MVD) and relates to prognosis. Our purpose was to analyze the relationship of aVR-STE to MVD disease or cardiogenic shock (CS) in patients with inferior myocardial infarction (inferior STEMI). METHODS: We analyzed two cohorts of consecutive patients admitted for inferior STEMI in the Coronary Unit of two university hospitals. ST elevation and ST depression in each derivation were compared between patients with and without MVD and with and without CS. RESULTS: We included 342 patients-19.6% women and 80.4% men-with a median age of 60 (52, 70); 18 patients (5.2%) had MVD, and 25 (7.3%) patients presented CS. There was no relationship between ST elevation or ST depression in either derivation and MVD. In contrast, CS was associated with aVR-STE, ST-segment depression in lead aVL, and the sum of ST-segment depression. aVR-STE of 0.25 mm had a sensitivity of 24.0% and a specificity of 95.9% for CS. After multivariate analysis including clinical variables, aVR-STE was independently associated with CS. CONCLUSIONS: In patients with inferior STEMI, ST-segment analysis was not useful in predicting multivessel disease. aVR-STE was an independent predictor of CS, with high specificity but low sensitivity.

Localization of the culprit artery in inferior myocardial infarction: Influence of the point of measurement of ST segment.

BACKGROUND: There are several approaches widely used in the localization of the responsible artery in inferior myocardial infarction. However, the existing papers show differences in the point where the ST segment is measured. The purpose of our investigation is to analyse the influence of the point at which elevation of the ST segment is measured on the results of these algorithms. METHODS: We analysed the 12­lead electrocardiograms of 90 consecutive patients with inferior myocardial infarction. The ST segment elevation or depression was measured at the J-point and at 80 ms, and three algorithms were applied to predict the culprit artery with both measurements. Sensitivity, specificity, the area under the curve, and the kappa index of agreement were analysed to compare each algorithm at the J-point and at 80 ms. RESULTS: The area under the curve was better at the J-point than at 80 ms in two algorithms (0.696 vs. 0.635, p < 0.043, and 0.754 vs. 0.661, p < 0.045) and did not change in one. Agreement between the J-point and 80 ms was suboptimal in all three algorithms (0.71, 0.65, and 0.58). CONCLUSIONS: The result of different algorithms to detect the culprit artery in inferior STEMI patients can change significantly depending on the point where ST elevation or depression is measured.

A 70-Year-Old Woman With a Prosthetic Mitral Valve and Sudden Chest Pain.

CASE PRESENTATION: A 70-year-old woman presented to the ED with oppressive ongoing chest pain that had lasted for 1 hour and was accompanied by intense sweating. The patient had a previous history of bronchial asthma, severe degenerative mitral regurgitation, and an ostium secundum atrial septal defect that had been treated 6 years ago with a prosthetic mechanical mitral valve, Bicarbon 25, and an atrial septal defect closure. She was being treated with ciclesonide, tiotropium bromide, olodaterol, theophylline, and warfarin, adjusted according to the international normalized ratio. Two weeks before the current event, because of trauma suffered in her leg, her primary care physician changed her treatment to subcutaneous enoxaparin, 80 mg once daily. Considering that her weight was 80 kg and her renal function was normal, the dose of enoxaparin prescribed was subtherapeutic for a mechanical prosthetic valve.

Antibiotic treatment in native valve infective endocarditis.

Previous to the availability of antimicrobial therapy, infective endocarditis (IE) was habitually lethal. Although approximately 80 percent of patients with endocarditis currently survive their infections, one of every six patients with IE does not survive the initial hospitalization, and up to one-third of patients infected with highly virulent organisms (such as Staphylococcus aureus) may die as a direct or indirect result of their valvular infection. An unfavourable outcome in these patients can occur despite having received appropriate antimicrobial therapy in a suitable approach, and despite the expert use of modern diagnostic techniques. Our purpose is to review the main issues related to the antimicrobial therapy.

Distortion of the QRS in elderly patients with myocardial infarction.

BACKGROUND: Distortion of the terminal portion of the QRS in the initial electrocardiogram (ECG) is a strong predictor of adverse outcome in myocardial infarction. Our purpose is to assess the relationship of distortion of QRS and other ECG characteristics with older age. METHODS AND RESULTS: We analysed 634 consecutive patients (age 62.6 +/- 13.7, 77% male) admitted in the first 12 hours of ST-elevation myocardial infarction. Two groups of age were defined: < 75 years-old and >or= 75 years-old. Additionally, we defined two ECG groups according to the presence of ST segment elevation with distortion of the terminal portion of the QRS in two or more adjacent leads (QRS+) or the absence of this pattern (QRS-). Older people had more often QRS+ (30% vs. 20%, p = 0.023). The older group with QRS+ had an in-hospital mortality of 18%, vs. 7% with QRS- (p = 0.04), and an incidence of major adverse events of 40% vs. 14% (p = 0.002). In the multivariate analysis, age >or= 75 years was an independent predictor of distortion of the QRS (odds ratio 2.1, 1.2-4.9, p = 0.016). CONCLUSIONS: The distortion of the terminal portion of the QRS in myocardial infarction is more frequent in elderly people, and is significantly related to adverse prognosis. This ECG finding can be helpful to promptly stratify the risk in elderly patients.

Distortion of the terminal portion of the QRS is associated with poor collateral flow before and poor myocardial perfusion after percutaneous revascularization for myocardial infarction.

AIMS: The distortion of the terminal portion of the QRS has been related to adverse outcome in patients with ST-segment elevation myocardial infarction. METHODS: We studied the relationship of this electrocardiographic pattern with the angiographic findings in patients treated with percutaneous revascularization for ST-segment elevation myocardial infarction. We included 349 patients, 318 treated with primary angioplasty and 31 with rescue angioplasty after failed thrombolysis. RESULTS: Eighty-five patients were found with distortion of the terminal portion of the QRS complex (group 1) and 264 without it (group 2). Collateral flow was absent in 30 patients (35%) from group 1, versus 52 patients (20%) from group 2 [odds ratio (OR) 1.806, 1.097-2.974, P 0.019]. No-reflow occurred in 12 (14%) patients in group 1 versus 17 (6.4%) in group 2 (OR 2.388, 1.091-5.230, P 0.016). Myocardial perfusion was graded 2-3 in 28 patients (58%) of group 1 versus 98 (76%) in group 2 (OR 0.443, 0.220-0.893, P 0.021). CONCLUSION: Patients with ST-segment elevation myocardial infraction showing distortion of the terminal portion of the QRS have worse collateral flow, and present more often no-reflow or poor myocardial perfusion after percutaneous revascularization. These data contribute to explain the worse clinical outcome of these patients.

Distortion of the terminal portion of the QRS is predictor of shock after primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: Although invasive management of ST segment elevation myocardial infarction has improved the clinical outcome, cardiogenic shock (CS) remains an important issue. Our purpose was to asses the utility of the initial electrocardiogram in detecting patients who are at increased risk of CS after percutaneous coronary intervention for acute myocardial infarction. METHODS: We evaluated 508 consecutive patients admitted in our Coronary Unit and treated by primary angioplasty within 12 h of an ST segment elevation myocardial infarction. Patients with cardiogenic shock at admission were excluded. Two groups were defined according to the presence of distortion of the terminal portion of the QRS in two or more adjacent leads (group 1) or the absence of this pattern (group 2). RESULTS: There were 99 patients (20%) in group 1 and 409 (80%) in group 2. CS developed in 38 patients, 18 in group 1 (18%) and 20 in group 2 (5%), p<0.001. Seventeen patients died in hospital, 6 in group 1 (6%) and 11 in group 2 (3%), p 0.094. Multivariate analysis including clinical, electrocardiographic and angiographic variables showed distortion of the QRS as an independent predictor of cardiogenic shock (odds ratio 3.17, 95% confidence interval 1.44 to 6.96, p 0.004), together with Killip class at admission and TIMI 3 flow after revascularization. CONCLUSIONS: Distortion of the terminal portion of the QRS complex is a strong predictor of cardiogenic shock in STEMI patients. Close hemodynamic monitoring should be warranted in patients showing this electrocardiographic pattern.

Ventricular tachycardia in a man with spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute ischemic coronary events. It is more prevalent in young women, particularly in the peripartum period. In men it is an extremely rare cause. We described the clinical course of a patient, man, presenting pain chest and ventricular malignant arrhythmias. Four days after admission the patient underwent coronary angiography, showing a large SCAD. After this, he had undergone coronary artery bypass surgery. He presented an angiography and clinical resolution and he was still asymptomatic at a 6-month clinical follow up. Pathophysiologic aspects and treatment options of spontaneous coronary artery dissection are discussed.

Taquicardia ventricular inducida por prueba de esfuerzo en paciente con síndrome de Brugada / Ventricular tachycardia induced by exercise testing in a patient with Brugada syndrome

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