Electrocardiographic patterns in acute inferior myocardial infarction with and without right ventricle involvement: classification, diagnostic and prognostic value, masking effect.

BACKGROUND: In acute inferior myocardial infarction (AIMI), the ST depression from V1 to V4 has been the subject of many papers, while the ST changes in other leads, their association, and the right ventricular (RV) involvement have been studied less. HYPOTHESIS: This study was performed to contribute to the meaning of the ST changes and RV involvement in AIMI. METHODS: Seventy-one patients, admitted within 6 h from symptom onset, all thrombolysed, were enrolled. We classified them according to ST patterns and RV involvement. We divided the right coronary artery into three segments, considering the origin of RV branch and the crux as dividing points. We established a coronary score attributing 2 points to each terminal branch. Comparisons were performed between the electrocardiographic (ECG) findings at onset, the creatine phosphokinase (CPK) peaks, the radionuclide ejection fractions, and the coronary angiographies. RESULTS: We found that the ST changes give indications regarding the site, extension, and extent of AIMI; RV involvement can mask posterior extension, points to the right coronary as the culprit vessel (100%), and, with high probability, indicates the proximal segment as the site of the lesion; the ECG signs of isolated AIMI indicate a peripheral obstruction; and a collateral circulation may appear relatively early. CONCLUSIONS: Our findings prove the diagnostic and prognostic value of the ST changes and RV involvement at the onset of AIMI and suggest that the higher in-hospital mortality and complication rates found with RV involvement and reported in the literature are related more to posterior extension, masked by RV involvement than to this involvement per se. Furthermore, these findings prove the clinical value of our classification of the AIMIs and distinction in segments of the right coronary artery.

Pericardial involvement in acute myocardial infarction in the post-thrombolytic era: clinical meaning and value.

Pericardial involvement (PI) in acute myocardial infarction (AMI) is a complication usually considered benign and has therefore received less attention than those more severe. It may be easily missed because it presents few symptoms and signs, which in turn may be confused with those of AMI. Its pathophysiology, diagnosis, and pitfalls are discussed. The GISSI-1 trial revealed a marked reduction of PI in the group treated with thrombolysis. This unexpected finding was later confirmed by the GISSI-2 trial and by other studies, drawing attention to its meaning. Data from the GISSI as well as from other studies have been reviewed and seem to indicate that PI is associated with larger AMIs and with a significant increase in 6- and 12-month mortality. This may be attributed to the consequences of late remodeling of a large infarction. These findings lead to the conclusion that PI should be granted more attention, and that it might identify patients with a poorer long-term outcome.

Comparison of frequency, diagnostic and prognostic significance of pericardial involvement in acute myocardial infarction treated with and without thrombolytics. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI).

Data from the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI) trial were reviewed to describe the epidemiology of pericardial involvement in patients treated with or without thrombolysis, and to establish its role as a marker of the extent of myocardial infarction and its prognostic value. In both GISSI-1 (n = 11,806) and 2 (n = 12,381), a specific item regarding presence/absence of clinically detected pericardial involvement was included in the study forms. In GISSI-1, patients with ST elevation and depression at the onset of myocardial infarction were admitted, whereas GISSI-2 included only those with ST elevation. Results of univariate analysis are presented as Mantel-Haenszel-Peto odds ratios with 95% confidence intervals. Cox proportional hazards models were used to assess the independent prognostic significance of pericardial involvement for in-hospital and long-term mortality. The main results indicate that: (1) the incidence of pericardial involvement in patients treated with thrombolytic agents is approximately half of that in the control group (6.7 vs 12.0%); (2) the earlier is the treatment, the lower is the incidence of pericardial involvement; (3) pericardial involvement is strongly associated with infarction size, evaluated by electrocardiograms, creatine kinase peak and echo assessments; and (4) pericardial involvement is associated with a higher long-term mortality, but is not an independent prognostic factor (RR 1.02; 95% confidence interval 0.82-1.26). Pericardial involvement is a reliable bedside, cost-free marker of myocardial infarction size and poorer outcome. Because it may elude detection owing to its transitory and often short duration, it should be given greater attention.

[A case of pheochromocytoma with atypical clinical presentation]. / Un caso di feocromocitoma con presentazione clinica atipica.

A case of pheochromocytoma that had undergone coronary arteriography because it stimulated coronary heart disease is presented. The correct diagnosis was suspected while checking the signs and symptoms during an episode of pulmonary edema and was definitely proved by computed tomography and scintigraphy with I 131 metaiodobenzylguanidine. The authors stress the importance of these new non invasive procedures in the diagnosis of site and nature of this disease.

[The Italian Group for the Study of Streptokinase in Myocardial Infarct: Study of electrocardiographic changes]. / G.I.S.S.I.: Studio delle alterazioni elettrocardiografiche.

The twofold purpose of the ECG sub-group study of G.I.S.S.I. (Gruppo Italiano per lo Studio della Streptokinasi nell'Infarto miocardico) is to evaluate whether exist different ECG evolution in pts with AMI treated with streptokinase (SK YES) and/or with coronary reperfusion (early CK peak) with respect to pts non treated with streptokinase (SK NO) and/or without coronary reperfusion (late CK peak) and to establish whether the ECG is useful to recognize the patients in which reperfusion occurs. Among 365 pts randomized for G.I.S.S.I., 209 pts with first myocardial infarction, admitted within 6 hours from the onset of pain, alive for at least 24 hours, were included. 98 were SK YES and 111 SK NO: 48 cases (group A) had the CK peak before 15th hour; 59 cases (group B) had the CK peak between 15th and 21th hour: 102 cases (group C) had the CK peak after 21th hour. In all the patients ECG was analyzed on admission and thereafter at 3rd, 6th, 9th, 12th, 24th hours and on 2nd, 3rd, 7th and 14th days. RESULTS--Anterior myocardial infarction--SK YES pts had in respected to SK NO pts a significantly lower sum of ST elevation on anterior leads (sigma ST increases V1-V6) at all times after admission starting from 6th hour. A similar behaviour was observed in groups A and B in respect to group C. SK YES pts when compared to SK NO pts had an earlier loss of the sum of R wave in anterior leads (sigma RV1-V6), although the difference was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of isometric force (handgrip) on R wave amplitude]. / Effetto dello sforzo isometrico (handgrip) sull'ampiezza dell'onda R.

We have measured R-wave amplitude during isometric stress-handgrip test in 30 normal subjects, without finding any significative variation. We believe, in according to our angiographic and echocardiographic experience, that such a behaviour is due to the absence of heart volume modification during handgrip test.