Pseudonormalisation of the T wave: old wine?: A fresh look at a 25-year-old observation.

A 74-year-old woman with documented coronary artery disease presented with symptoms of angina at rest. During these episodes of angina, the initial abnormal terminal negative T waves converted to normal positive T waves. In this article the significance of pseudonormalisation as a sign of ischaemia is reviewed. The underlying electropathological basis of this phenomenon is discussed as well. (Neth Heart J 2007;15:257-9.).

Abortion of acute ST segment elevation myocardial infarction after reperfusion: incidence, patients' characteristics, and prognosis.

OBJECTIVES: To study the incidence and patient characteristics of aborted myocardial infarction in both prehospital and in-hospital thrombolysis. DESIGN: Retrospective, controlled, observational study. SETTING: Two cities in the Netherlands, one with prehospital thrombolysis, one with in-hospital treatment. PATIENTS: 475 patients with suspected acute ST elevation myocardial infarction treated before admission to hospital, 269 patients treated in hospital. MAIN OUTCOME MEASURES: Aborted myocardial infarction, defined as the combination of subsiding of cumulative ST segment elevation and depression to < 50% of the level at presentation, together with a rise of creatine kinase of less than twice the upper normal concentration. A stepwise regression analysis was used to test independent predictors for aborted myocardial infarction. RESULTS: After correction for "unjustified" thrombolysis, 17.1% of the 468 prehospital treated patients and 4.5% of the 264 in-hospital treated patients fulfilled the criteria for aborted myocardial infarction. There was no difference in age, sex, risk factors, haemodynamic status, and infarct location of aborted myocardial infarction compared with established myocardial infarction. Time to treatment was shorter in the patients with aborted myocardial infarction (86 versus 123 minutes, p = 0.05). A shorter time to treatment, lower ST elevation at presentation, and higher incidence of preinfarction angina were independent predictors for aborted myocardial infarction. Aborted myocardial infarction had a 12 month mortality of 2.2%, significantly less than the 11.6% of established myocardial infarction. CONCLUSION: Prehospital thrombolysis is associated with a fourfold increase of aborted myocardial infarction compared with in-hospital treatment. A shorter time to treatment, a lower ST elevation, and a higher incidence of preinfarction angina were predictors of aborted myocardial infarction.

Clinical significance of reverse redistribution on technetium-99m tetrofosmin single-photon emission computed tomography: an 18-month follow-up study.

BACKGROUND: The clinical and prognostic significance of reverse redistribution on technetium-99m (99mTc) single-photon emission computed tomography (SPECT) is unclear. OBJECTIVES: To determine outcomes of chest pain patients showing reverse redistribution after 99mTc tetrofosmin SPECT versus SPECT showing no reverse redistribution. METHODS: Patient outcomes (death, nonfatal myocardial infarction, coronary artery bypass grafting and percutaneous transluminal coronary angioplasty) within 18 months after 99mTc tetrofosmin SPECT were determined in two populations of ambulatory patients, most of whom had been evaluated because of chest pain: a population of 57 patients whose SPECT images showed reverse redistribution without reversible or fixed defects, versus a control population of 98 patients whose SPECT images were normal (no reverse redistribution, no reversible defects, no fixed defects). RESULTS: Stepwise logistic regression analysis showed that the population of patients with reverse redistribution did not have a worse 18-month outcome in comparison with the control population of patients without reverse redistribution (3.5% versus 9.2%, respectively; p=0.15 corrected for age and gender). CONCLUSION: Reverse redistribution on 99mTc tetrofosmin SPECT does not appear to be an unfavourable prognostic factor in ambulatory chest pain patients.

Time from symptom onset to treatment and outcome in prehospital thrombolysis for acute ST-elevation myocardial infarction.

BACKGROUND: Prehospital thrombolysis for acute ST-elevation myocardial infarction shortened treatment by 60 minutes, and created a large patient group who were treated within two hours. OBJECTIVES: We analysed our database of patients undergoing prehospital treatment for acute ST-elevation myocardial infarction in search of characteristics for a better outcome in the early treatment group. METHODS: From 1994 to 2000 a total of 475 patients were treated using prehospital administration of anistreplase (in 407 patients) or reteplase (in 68 patients) after diagnosis was confirmed with transtelephonic transmission of the ECG. There was no age limit. The patient data were divided into two groups: one treated within two hours after onset of pain (291 patients, 62%), and one treated later (171 patients, 37%). Thirty-day mortality, symptoms and clinical signs of heart failure were used as parameters of outcome. Both univariate and stepwise logistic regression analyses were used to test 30-day mortality against age, actual time to treatment, prior myocardial infarction, hypertension, diabetes, anterior myocardial infarction, Killip class, systolic blood pressure and heart rate at presentation. RESULTS: Overall 30-day mortality was 9.1%. Overall heart failure was in 16.6% of patients. Both mortality (5.5% vs. 15.5%, p<0.02) and heart failure (12.7% vs. 23.2%, p<0.02) were significantly lower in the early treatment group compared with the group treated late. Independent parameters showing a relation with 30-day mortality were age, time to treatment, hypertension and prior myocardial infarction. Age, time to treatment, hypertension and hyperlipidaemia were identified as predicting heart failure within the first 30 days. CONCLUSION: With prehospital thrombolysis, both 30-day mortality and heart failure were lower in an early treatment group with acute ST-elevation myocardial infarction. Independent variables for 30-day mortality were age, hypertension, prior myocardial infarction and time to treatment, and age, hypertension, hyperlipidaemia and time to treatment were independent predictors for heart failure.

[Benefit of prehospital thrombolysis in the treatment of acute myocardial infarction]. / Winst van prehospitale trombolyse bij de behandeling van het acute myocardinfarct.

Randomized studies comparing early and late thrombolysis in the treatment of acute myocardial infarction show that mortality is lower if therapy is administered at an early stage, and especially if it is administered during the first hour of symptoms. Since only few patients can actually be treated within one or two hours, a search was made for time gaining strategies, including prehospital thrombolysis. In the region of Nijmegen, the Netherlands, it proved possible with prehospital treatment to treat 25% of the patients in the first hour after onset of ischaemic symptoms. The group given prehospital treatment included almost three times as many aborted infarctions as the group treated in hospital. In clinical practice, the proportion of aborted infarctions and more pronounced ECG abnormalities, namely, increase the probability of early prehospital treatment as well as the risk of death. Conditions of the organization of prehospital thrombolysis in a region are equipment for ECG transmission by telephone, good co-operation between cardiologists and cardiologic care units and special training of paramedics and general practitioners.

Effect of prehospital thrombolysis on aborting acute myocardial infarction.

On administering thrombolysis in a prehospital setting, we found a threefold increase in the incidence of abortion of myocardial infarction, compared with the in-hospital program of a nearby hospital. Assessment of aborted myocardial infarction may be a better criterion for the efficacy of early thrombolysis than mortality data.

Atrial natriuretic peptide after myocardial infarction.

Plasma concentrations of atrial natriuretic peptide (ANP) after acute myocardial infarction were measured at fixed times during 48 hours in 38 patients admitted to the hospital within 4.4 hours after the onset of symptoms. Three hours after admission, the mean concentration of ANP was significantly lower than that at the time of admission. Thereafter it rose steadily until 15 hours after admission. ANP concentrations measured in each patient at the time of admission and the individual mean ANP concentrations during the first 48 hours after admission correlated weakly but significantly with the size of the infarct and the left ventricular function. Neither the site of the infarct, the occurrence of reperfusion, nor the number of coronary vessels affected influenced the ANP concentration. In 24 patients in whom cardiac catheterization was performed, no relationship between ANP concentrations and left ventricular pressures was observed. Determination of ANP concentrations seems to be of little value in assessing cardiac function after acute myocardial infarction.

Quantitative assessment of regional left ventricular motion using endocardial landmarks.

In this study the hypothesis is tested that the motion pattern of small anatomic landmarks, recognizable at the left ventricular endocardial border in the contrast angiocardiogram, reflects the motion of the endocardial wall. To verify this, minute metal markers were inserted in the endocardium of eight pigs with a novel retrograde transvascular approach. Marker motion was subsequently recorded with roentgen cinematography and compared with the motion of the landmarks on the endocardial contours detected from the contrast ventriculogram with an automated contour detection system. Linear regression analysis of the directions of the systolic metal marker and endocardial landmark pathways yielded a correlation coefficient of 0.86 and a standard error of the estimate of 10.3 degrees. Landmark pathways were also measured in 23 normal human left ventriculograms. Normal left ventricular endocardial wall motion during systole, as observed in the 30 degrees right anterior oblique view, is characterized by a dominant inward transverse motion of the opposite anterior and inferoposterior walls and a descent of the base toward the apex. The apex itself is almost stationary. On the basis of these observations, a widely applicable model for the assessment of left ventricular wall motion is described in mathematical terms.

Influence of intracoronary nifedipine on left ventricular function, coronary vasomotility, and myocardial oxygen consumption.

The effect of intracoronary nifedipine on regional and global left ventricular performance, coronary vasomotility, and myocardial oxygen consumption is reported. Left ventricular pressures and volume indices of contractility and relaxation were simultaneously recorded in five patients without coronary artery disease. In these patients, nifedipine in the left main coronary artery not only delayed (+115 ms) anterior wall contraction but also slowed (3.5 vs 1.9 cm/s) and depressed it (-26%), resulting in a depression of global left ventricular ejection. This asynchrony and depression of regional contraction is considered to be responsible for the slowed isovolumic contraction and relaxation of the whole ventricle. In 10 other patients with coronary artery disease, coronary sinus blood flow and myocardial oxygen consumption were measured before and after intracoronary nifedipine. The observed decrease in myocardial oxygen consumption (-28%) depended primarily on a decrease in contractility and left ventricular performance. In a third study group of 12 patients with coronary artery disease, the effects of intracoronary nifedipine on the coronary vasomotility of 40 coronary segments (normal, prestenotic, stenotic, poststenotic) were quantitatively determined. Left ventricular haemodynamics and coronary sinus saturation were monitored while the cineangiograms were recorded before and after nifedipine. Nifedipine provoked vasodilatation of the normal (+10.3%), prestenotic, stenotic (+4 to 30%), and poststenotic (+16.4%) coronary segments, which persisted after the disappearance of its direct effects on the myocardium. This transient regional "cardioplegic" effect of nifedipine, associated with an increase in coronary blood flow, a reduction in myocardial oxygen consumption, and a vasodilatation of the epicardial vessels is likely to be beneficial during temporary coronary occlusion such as occurs in spasm or transluminal angioplasty.