Early right ventricular dysfunction after primary percutaneous coronary intervention in anterior versus isolated inferior myocardial infarction assessed by tissue Doppler imaging and speckle tracking echocardiography.

This study hypothesized that imaging provides information indicating the right ventricular (RV) involvement after anterior or inferior ST-elevation myocardial infarction (STEMI), beyond standard electrocardiogram (ECG) due to the increasing interest in RV function and assessment techniques. This study aimed to compare RV function between anterior and inferior MI without RV involvement using different echocardiographic modalities. This study included 100 patients with anterior (50 patients) and inferior (50 patients) STEMI, who underwent primary percutaneous coronary intervention (PPCI) and two-dimensional echocardiographic imaging within 24 h after PPCI with RV function analysis by left ventricular (LV) infarct size, LV filling pressure, and RV strain rate. Our primary endpoint was the subclinical RV dysfunction in anterior or inferior MI using tissue Doppler and speckle tracking (STE). The study population included 80 (80%) males and 20 (20%) females. Patients with the anterior STEMI had higher mean creatine kinase-MB (CKMB) and troponin than those with inferior STEMI. This study revealed worse RV dysfunction in patients with anterior than those with inferior STEMI, as reflected by significantly lower RV systolic function, tricuspid annular plane systolic excursion (p ≤ 0.0001), tissue Doppler-derived velocity (p ≤ 0.0001), and STE-derived strain magnitude and rate (p ≤ 0.0001). RV dysfunction occurs in patients without ECG evidence of RV STEMI. RV dysfunction is worse in anterior than inferior MI. Moreover, RV systolic functions were affected by declined LV ejection fraction irrespective of the infarction site, which clinically implies prognostic, treatment, survival rate, and outcome improvement between both conditions. (Trial registration ZU-IRB#:4142/26-12-2017 Registered 26 December 2017, email: IRB_123@medicine.zu.edu.eg).

Novel predictors and adverse long-term outcomes of No-reflow phenomenon in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: The no-reflow phenomenon occurs in 25% of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may be associated with adverse outcomes. The aim of our study was to detect novel predictors of no-reflow phenomenon and the resulting adverse long term outcomes. METHODS: We enrolled 400 STEMI patients undergoing primary PCI; 228 patients had TIMI flow 3 after PCI (57%) and the remaining 172 patients had TIMI flow <3 (43%). Fibrinogen to albumin ratio (FAR), high sensitive C-reactive protein to albumin ratio (CAR), and atherogenic index of plasma (AIP) were calculated. Long term mortality and morbidity during 6 months follow up were recorded. These data were compared among both groups. RESULTS: In multivariate regression analysis, old age (OR = 1.115, 95% CI: 1.032-1.205, P = 0.006), higher troponin level >5.6 ng/mL (OR = 1.040, 95% CI: 1.001-1.080, P = 0.04), diabetes mellitus (OR = 4.401, 95% CI: 1.081-17.923, P = 0.04) and heavy thrombus burden (OR = 16.915, 95% CI: 5.055-56.602, P < 0.001) could be considered as predictors for the development of no-reflow. Interestingly, CAR >0.21, FAR >11.56, and AIP >0.52 could be considered as novel powerful independent predictors (OR = 3.357, 95% CI: 2.288-4.927, P < 0.001, OR = 4.187, 95% CI: 2.761-6.349, P < 0.001, OR = 16.794, 95% CI: 1.018-277.01, P = 0.04, respectively). Higher long term mortality (P < 0.001) and heart failure (P < 0.001) was also strongly related to incidence of no-reflow. CONCLUSION: No-reflow could be attributed to novel predictors as CAR, FAR, and AIP. This phenomenon was associated with long term adverse events as higher mortality and pump failure.

Short- and long-term prognostic value of right ventricular function in patients with first acute ST elevation myocardial infarction treated by primary angioplasty.

INTRODUCTION: Limited data are known about the prognostic value of right ventricle (RV) function in patients with first acute ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the prognostic value of RV dysfunction in predicting both in-hospital and long-term outcomes in these patients, irrespective of the site of necrosis. METHODS: We enrolled 502 consecutive patients with first acute STEMI treated with primary angioplasty and underwent echocardiography within 48 hours of admission. RV function was evaluated by RV myocardial performance index (RVMPI), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler S' wave velocity, and RV global longitudinal strain (RVGLS) of the free wall. The occurrence of in-hospital major adverse cardiac events (MACE) and 1-year survival rate were recorded. RESULTS: In MACE group, RVFAC, TAPSE, and RV S' wave velocity were lower. However, RVMPI, RVGLS, and TR Vmax. were higher than MACE free group (P < .001). In multivariable analysis adjusted for other variables that predicted adverse outcomes, RVFAC < 35% (P < .001), TAPSE < 17 mm (P < .001), RVGLS > -17% (P < .001), RV S' wave velocity < 9.5 cm/s (P = .02), RVMPI > 0.43 (P < .001), and TR Vmax. > 2.8 m/s (P = .01) were strong independent predictors of in-hospital MACE. Lower 1-year survival was noted in patients with RV dysfunction, documented by these cutoffs values. CONCLUSION: RV dysfunction, evidenced by multiparametric echocardiography, is predictive for adverse in-hospital outcomes, and lower 1-year survival rate in first acute STEMI regardless of the site of necrosis.

Relation of collateral circulation with reciprocal changes in patients with acute ST-elevation myocardial infarction.

OBJECTIVE: Acute STEMI is often accompanied by reciprocal ST-segment depression (RC) occurring in opposite leads, whose significance has been debated for decades. The possible role of collateral circulation in promoting RC in acute STEMI has not been identified. So our aim to find the relationship between collateral circulation and RC in STEMI patients treated with primary percutaneous intervention (PPCI). METHODS: The study included 112 pts. with acute STEMI underwent PPCI. The patients divided in to 2 groups: Group (A):66 pts. with RC, Group (B):46 pts without RC. All patients subjected to history taking, ECG [localization of infarction & RC], CKMB level, transthoracic echo [LVEF%], coronary angiography &PPCI to culprit artery and assess number of diseased vessels, site of occlusion, collaterals, TIMI flow pre and post PCI. RESULTS: Patients in group A with RC had shorter time to door, P < 0.001; more frequent inferior infarctions, P < 0.001; had higher CKMB level, P < 0.001; higher LVEDD, P < 0.001; LVESD, P < 0.001and lower LVEF, P = 0.004; had multi vessel diseases P = 0.02, increase incidence of RCA as a culprit artery <0.001 compared to patients with no RC. Patients with RC had significantly higher incidence of proximal LAD occlusion, distal RCA and distal LCX compared to patients without RC. The percentage of change was 61.2 ± 12.35% for ST elevation and 50.5 ± 10.87% for reciprocal ST depression post PCI with significance difference between them, t = 3.035P = 0.0023.There was no significant correlation between collateral circulation and RC. We found four significant independent predictors of RC. They were inferior infarction (P = 0.024), RCA as a culprit vessel, (P = 0.034), low EF, (P = 0.007) and multi-vessel disease, (P = 0.022). CONCLUSION: There is no correlation between concomitant RC and presence of collateral vessels in acute STEMI patients. So the pathogenesis of reciprocal ST-segment changes result from an interplay of ischemia at distance due to multi-vessel CAD and benign mirror electrical changes not caused by collateral circulation diverting blood to ischemic area from non-diseased artery.

Transmural Extent in Relation to Clinical Scoring in Non-ST Elevation Myocardial Infarction Patients: Speckle-Tracking Echocardiographic Study.

BACKGROUND: To assess the extent of transmurality in non-ST elevation myocardial infarction (NSTEMI) patients using speckle-tracking echocardiography (STE) in relation to their risk categorization to improve the risk stratification of NSTEMI patients through detecting the presence of transmural infarction. PATIENTS AND METHODS: It included 96 patients with NSTEMI. All patients were subjected to GRACE score (GS) calculation, transthoracic and speckle-tracking echocardiography (STE): To detect left ventricular ejection fraction and myocardial global longitudinal strain [GLS] and circumferential strain [CS]. RESULTS: As compared to low-GS group; high-risk group was older with the increased prevalence of hypertension (HTN), diabetes, and smoking. There was no significant difference between both groups regarding LS and CS of all 17 segments except for apex where longitudinal strain (LS) was significantly decreased in low-risk group (-17.2 ± 1.1) as compared to high-risk group (-18.6 ± 1.4). GLS was significantly decreased in high-risk group (15.4 ± 0.6) as compared to low-risk group (16 ± 0.8), P = 0.02 with no significant difference in the global CS (P = 0.8). Transmural infarction constitutes 37.5% of all patients. The prevalence of transmural infarction was increased in the low-risk group without significant difference. GS showed a positive correlation with age, male, HTN, diabetes, and smoking and negative correlation with GLS. There was no significant correlation between GS and global CS. Age, GS, and LS were significantly related to transmural infarction. None was found to predict the occurrence of transmural infarction. CONCLUSION: Transmural extent as detected by STE had been found in a relatively substantial number of patients with NSTEMI, and it may serve as a tool in conjunction with risk stratification scores for the selection of high-risk patients.

Factors influencing postoperative atrial fibrillation in patients undergoing on-pump coronary artery bypass grafting, single center experience.

BACKGROUND: The reported incidence of AF after CABG surgery varies from 20 to 40%, with the arrhythmia usually occurring between second and fourth postoperative days. Postoperative AF after CABG was associated with greater in-hospital mortality and worse survival at long-term follow-up. Therefore, intensive attention has focused on the prevention of AF in high-risk patients. Many perioperative factors have been suggested to increase the incidence of postoperative AF after conventional CABG. In this study we are trying to examine some of these risk factors as predictors for Post-operative AF in our patients. In this study, our aim was to identify the perioperative predictors of AF in our patients who underwent Coronary Artery Bypass Grafting. METHODS: Our Patients were divided into two groups; Group A included patients who did not develop PO AF (168 patients) and Group B patients who developed PO AF (84 patients). Perioperative Data, including gender, age, demographic variables and postoperative morbidity and mortality were extracted from the medical records. RESULTS: This retrospective cohort study was conducted on 252 consecutive adult patients underwent CABG, in King Faisal Specialist Hospital and Research Center in Jeddah, Saudi Arabia. The mean age for patients with PO AF was 65 years (P = .0001). Eight-three patients (49.4%) were diabetics in group A and 56 patients (66.7%) in group B (P = .0001). Patients who developed POAF had a lower ejection fraction (44.8 ± 5.7%) (P = .0001), diastolic dysfunction (P = .0001), Larger Left atrial volume (P = .0001). Bleeding requiring re-opening for exploration and Postoperative shock were identified as significant predictors for POAF. Multivariate logistic regression (odds ratio, ±95% CI, P value) was performed to identify the effect of age, preoperative heart rate, ejection fraction, postoperative bleeding, Shock, ventilator time, Sensitivity was 89.5%, specificity was 94.6%, positive predictive value was 89.5%, and negative predictive value was 94.6%. CONCLUSION: In our study, advanced age, enlarged LA volume, low ejection fraction, combined surgeries and prolonged ventilation time were found to be predictors of atrial fibrillations after coronary artery bypass grafting.

Relation between left atrial measurements and thromboembolic risk markers assessed by echocardiography in patients with nonvalvular atrial fibrillation: A cross-sectional study.

BACKGROUND: Left atrium (LA) dilatation has been associated with adverse cardiovascular outcomes in patients with sinus rhythm and atrial fibrillation (AF). AIM OF THE STUDY: We aimed to evaluate the accuracy of left atrial (LA) size to predict transesophageal echocardiographic (TEE) markers of increased thromboembolic risk left atrial appendage (LAA) thrombus, low LAA velocities and dense spontaneous echocardiographic contrast (SEC), and also to assess the best method to evaluate LA size. PATIENTS AND METHODS: Cross-sectional study included 64 patients with nonvalvular AF undergoing transthoracic and transesophageal echocardiographic (TTE and TEE) evaluation. LA size was measured on TTE by several methods including the following: anteroposterior diameter (AP), LA area in four and two apical chamber views and volumes by ellipsoid, single plane (1P) and biplane area-length (2P) formulas. All these measures were indexed to the body surface area (BSA). Thromboembolic markers including LAA thrombus, low LAA velocities, dense SEC and LA abnormality (LA ABN) which means the presence of one or more of the previous three parameters were evaluated by TEE. RESULTS: There was statistically significant increase in indexed and non-indexed LA parameters in patients with LA ABN compared to patients without LA ABN. According to ROC curve, the study found that all indexed LA parameters were predictive for LAA thrombus with the highest AUC was indexed LA 1P area length volume (AUC 0.91, CI 95% 0.81-1.01, p < 0.000), for LAA low flow velocity were indexed and non-indexed LA AP diameters with the highest AUC was indexed LA AP diameter (AUC 0.89, CI 95% 0.80-0.98, p < 0.000), for LA dense SEC were indexed LA ellipsoid volume (AUC 0.78, CI 95% 0.66-0.96, p = 0.002) and indexed LA 1P area length volume (AUC 0.78, CI 95% 0.66-0.90, p = 0.002) and for LA ABN were all LA parameters with the highest AUC was indexed LA 1P area length volume (AUC 0.87, CI 95% 0.79-0.96, p < 0.000). On multivariate logistic regression analysis of TEE parameters, the study found that the most predictive LA measurement for LAA thrombus was indexed LA AP diameter with cutoff 3 cm/m2 (OR 7.5, 95% CI 1.24-45.2, p = 0.02), for LAA low flow velocity was LA AP diameter with cutoff 6 cm (OR 17.6, 95% CI 3.23-95.84, p = 0.001), for LA dense SEC was indexed LA ellipsoid volume with cutoff 42 cm3/m2 (OR 6.5, 95% CI 1.32-32.07, p = 0.02), and for LA ABN was indexed LA ellipsoid volume with cutoff 42 cm3/m2 (OR 10.45, 95% CI 2.18-51.9, p = 0.008). CONCLUSION: LA enlargement is suitable to predict thromboembolic markers in patients with non-valvular AF. The indexed and non-indexed LA AP diameter and indexed LA ellipsoid volume were the most accurate parameters for predicting thromboembolic markers.

Value of global longitudinal strain by two dimensional speckle tracking echocardiography in predicting coronary artery disease severity.

BACKGROUND: Significant coronary artery stenosis might cause persistently impaired longitudinal left ventricle (LV) function at rest. LV global longitudinal strain (LVGLS) can be accurately assessed by 2D speckle-tracking strain echocardiography(2D-STE). OBJECTIVE: We aimed to evaluate the diagnostic accuracy of LV global longitudinal strain obtained by 2D-STE in prediction of severity of CAD. METHODS: Eighty patients with suspected stable angina pectoris were included. They underwent transthoracic echocardiography (TTE) to measure LV ejection fraction, 2-D-STE to measure GLS and coronary angiography (CA). The patients were divided into two groups: group 1 (58 patients) with significant (>70%) CAD, and group 2 (22 patients) with non-significant (<70%) CAD. Images were obtained in the apical long-axis, four-chamber, and two chamber views. Regional longitudinal systolic strain was measured in 17 myocardial segments and averaged to provide global longitudinal strain (LVGLS). RESULTS: There was significant decrease in GLS in group 1 compared to group 2 (-11.86 ± 2.89% versus -18.65 ± 0.79%, P < 0.000). The optimal cutoff value of GLS for prediction of significant CAD was -15.6% [AUC 0.88, 95% CI 0.78-0.96 p < 0.000]. The sensitivity, specificity and accuracy of GLS for detecting significant CAD were 93.1%, 81.8%,and 90% respectively.There was a significant positive correlation between GLS and EF (r = 0.33; p = 0.036).There was incremental significant decrease in GLS with increasing number of coronary vessels involved. CONCLUSION: Measurement of global longitudinal strain using 2D speckle tracking echocardiography is sensitive and accurate tool in the prediction of severe CAD.

Value of N-terminal pro brain natriuretic peptide in predicting prognosis and severity of coronary artery disease in acute coronary syndrome.

BACKGROUND: Measurement of N-terminal pro brain natriuretic peptide (NT-proBNP) in the evaluation of patients with acute coronary syndrome has appeared to be a useful prognostic marker of cardiovascular risk. AIM OF THE WORK: To assess the in-hospital prognostic value of NT-proBNP in patients with acute coronary syndrome (ACS) and its relation to the severity of coronary artery disease. PATIENTS AND METHODS: This study included 132 consecutive patients with ACS, 64 patients with unstable angina (UA), 46 patients with non-ST segment elevation myocardial infarction (NSTEMI), and 22 patients with ST segment elevation myocardial infarction (STEMI). ECG, echocardiography and pre and post coronary angiography measurement of troponin I, creatine kinase (Ck), C-reactive protein (CRP) and NT-proBNP were done. Patients were divided into two groups: Group A with NT-proBNP less than 474 pg/ml and Group B with NT-proBNP equal or more than 474 pg/ml. RESULTS: There was a significant negative correlation between NT-proBNP and ejection fraction. Incidence of heart failure and duration of hospital stay were significantly higher in Group B (with NT-proBNP equal or more than 474 pg/ml) than Group A (with NT-proBNP less than 474 pg/ml). Moreover, there was a trend to an increased incidence of cardiogenic shock and mortality in Group B compared to Group A. The number of coronary vessels affected, severity of stenosis and proximal left anterior descending artery (LAD) disease were higher in Group B than in Group A. TIMI flow grade was significantly higher in Group A than in Group B. CONCLUSION: NT-proBNP is a valuable marker for predicting prognosis and severity of coronary artery disease in patients with acute coronary syndrome.