Intravenous streptokinase infusion in acute myocardial infarction with electrocardiographic monitoring for myocardial reperfusion.

We present a case of thrombolytic therapy for acute myocardial infarction with high-dose intravenous streptokinase infusion in the emergency department. Resolution of ST segment elevation and relief of chest pain occurred within one hour of the infusion, and coronary angiographic study six days later showed a significant proximal obstruction (80%) of the right coronary artery. The patient underwent coronary artery bypass surgery eight weeks after his initial hospital presentation.

Coupling interval and types of ventricular ectopic activity associated with ventricular runs.

Repetitive 10-hour ECG recordings of 289 patients obtained within a year after myocardial infarction were analyzed for the presence of ventricular runs, and their association with various types of ventricular ectopic activity (VEA), average rate of premature ventricular complexes (PVCs), and coupling interval of PVCs initiating the runs. Tapes which contained complex VEA (bigeminy, multiform PVCs, couplets, or runs), early PVCs (coupling interval less than 400 msec), or late PVCs (coupling interval greater than 600 msec) had a substantially higher average PVC rate than those without them. The occurrence of ventricular runs was significantly more likely in tapes having other complex VEA or late PVCs than in those without them, and when tapes were stratified by PVC rates the presence of these dysrhythmias appeared to have an independent predictive value for the occurrence of runs. In contrast, the influence of early PVCs on the occurrence of runs was rather minimal, and this seemed to be related to their common association with the PVC rate. Furthermore, a larger percentage of isolated PVCs had coupling intervals between 400 msec and 600 msec, and most couplets (77%) and runs (67.8%) were initiated by PVCs with coupling intervals in this range. However, the proportion of either short (less than 400 msec) or long (greater than 600 msec) coupling interval PVCs initiating couplets or runs was significantly higher than those with intermediate coupling intervals (between 400 and 600 msec).

Long-term prognosis after first Q-wave (transmural) or non-Q-wave (nontransmural) myocardial infarction: analysis of 593 patients.

Follow-up results in 593 patients less than or equal to 7 years (mean 4.7) after hospital discharge for their first myocardial infarction (MI) are presented. Patients were grouped according to the presence or absence of Q waves on electrocardiograms after the MI and by peak serum glutamic oxalacetic transaminase (SGOT) level during hospitalization. Cardiac mortality varied. Patients with Q-wave infarcts and an SGOT level less than or equal to 240 IU/liter had a cardiac mortality of 3.1% per year, whereas patients with Q-wave MI and an SGOT level greater than 240 IU/liter had an 11% 6-month mortality and a 3.8% per year cardiac mortality thereafter. However, patients with non-Q-wave (nontransmural) MI had a excellent survival rate for 2 years (96.8%) which continued in patients aged less than or equal to 60 years thereafter. However, patients with non-Q-wave infarcts aged greater than 60 years had a 12% per year cardiac mortality in the third post-MI year and an additional 12% died each year thereafter. Early mortality was related to enzyme level, whereas late mortality was a function of type (Q-wave or non-Q-wave) and age.

Effect of infarct location on the in-hospital prognosis of patients with first transmural myocardial infarction.

We studied the in-hospital prognosis of 1105 patients who had their first transmural myocardial infarction; 611 patients (55.3%) had anterior myocardial infarction (AMI) and 494 (44.7%) had inferior myocardial infarction (IMI). Patients with IMI had a significantly lower in-hospital mortality rate (9.1% vs 15.6%, p = 0.0014) and significantly lower prevalences of congestive heart failure (39.4% vs 47.6%, p = 0.0066), cardiogenic shock ( 8.7% vs 12.6%, p = 0.0384) and conduction defects (left anterior hemiblock, right bundle branch block and intraventricular conduction defect). The patients with AMI had significantly higher peak enzyme levels, and a greater percentage of them (40.1% vs 25.9%) had SGOT greater than 240 IU/l, whereas more patients with IMI (34.6% vs 27.8%) had SGOT less than 120 IU/l (p = 0.0001). When the parallel subgroups were compared according to the peak SGOT levels (less than 120, 120-240, and greater than 240 IU/l, the differences in the mortality and morbidity between the two infarct locations diminished. However, patients with AMI still had a less favorable outcome. Logistic regression analysis demonstrated that both the peak enzyme level and the infarct location had an independent influence on the in-hospital prognosis of patients with first transmural infarction.

Urgent myocardial revascularization for dissection of the left main coronary artery: a complication of coronary angiography.

Acute subintimal dissection of the left main coronary artery (LMCA) is a rare but devastating complication of selective coronary angiography. The compromise of the coronary blood flow to an extensive area of myocardium becomes clinically evident in most patients shortly after the injury. Three patients who had catheter-induced LMCA dissection were successfully managed with aorta-coronary artery bypass. We recommend that urgent myocardial revascularization using standard techniques should be carried out in all patients following this injury.

Left ventricular function in end-stage renal disease: echocardiographic classification.

We used echocardiography (ECHO) to detect pericardial effusions and assess left ventricular (LV) function in 39 patients with end-stage renal disease (ESRD). Pericardial effusions were present in 24 patients (62%). Thirty-one patients (79%) had concentric hypertrophy and 20 patients (51%) had decreased LV compliance. The majority of patients with concentric hypertrophy and decreased LV compliance had normal LV internal dimensions and contractility. Six patients (15%) had ECHO results compatible with congestive cardiomyopathy. An echocardiographic distinction between congestive heart failure, decreased LV compliance, and salt and water overload in ESRD has allowed an appropriate therapeutic decision as to whether to administer cardiac glycosides or increase ultrafiltration as a treatment for pulmonary congestion. ECHO is a safe, convenient, and noninvasive method of assessing serial LV function, and it can be used to document progressive deterioration of LV function in ESRD.

Cardiac arrhythmias in end-stage renal disease.

In 16 patients with end-stage renal disease (ESRD), 24-hour electrocardiographic recordings showed an incidence of supraventricular and ventricular arrhythmias similar to that in patients who had had myocardial infarction and in low-risk subjects. Eight patients (50%) with ESRD had supraventricular complexes. This incidence was significantly higher than that after myocardial infarction (P < .001). Fifteen ESRD patients (94%) had premature ventricular complexes (PVCs), including nine (56%) with complex PVCs (multiform PVCs, couplets, or runs). The incidence of PVCs as well as complex PVCs in patients with ESRD was comparable to that of the patients who had had myocardial infarction but was significantly higher than that found in low-risk subjects (P less than .005 for PVCs and P less than .05 for complex PVCs). The high incidence of complex PVCs in patients with ESRD may predispose them to increased cardiovascular death, and further investigation of this finding is indicated.

In-hospital prognosis of patients with first nontransmural and transmural infarctions.

We studied the in-hospital mortality and morbidity of 745 patients who had suffered a first myocardial infarction. One hundred twenty-four patients (16.6%) had nontransmural infarction and 621 (83.4%) had transmural infarction. Both groups of patients were similar in the distribution of age, sex, and coronary risk factors. Patients with nontransmural infarction had a significantly lower mortality (3% vs 11%, p less than 0.01) and a lower prevalence of premature ventricular complexes (81% vs 88%, p less than 0.05). The patients with transmural infarction were distributed evenly among the three subgroups with peak SGOT levels less than 120 units, 120-240 units and more than 240 units (31%, 34% and 35%, respectively), while most patients with nontransmural infarction (60%) had peak SGOT levels less than 120 units (p less than 0.0001). When the in-hospital mortality and morbidity were compared between the parallel subgroups, the prognosis of patients with the two types of infarctions was similar. This study shows that the peak SGOT level is more important than the type of infarction in determining the acute mortality and morbidity of first myocardial infarction.

Epicardial pacemaker complicated by cardiac tamponade and constrictive pericarditis.

Following insertion of an epicardial pacemaker, our patient developed cardiac tamponade complicated by subacute constrictive pericarditis. Echocardiographic findings and intracardiac pressures were typical of constrictive pericarditis, which was confirmed at surgery. Although rare, these unusual complications should be considered in patients who develop evidence of reduced cardiac output following either transvenous or epicardial electrode placement.

Posterior pseudoaneurysm of the left ventricle: a prospective echocardiographic diagnosis.

A 69-year-old man had a posterior pseudoaneurysm of the left ventricle shown by echocardiography and cardiac catheterization. The patient had resection of the pseudoaneurysm and did well. The case illustrates the usefulness of echocardiography for detecting and evaluating left ventricular pseudoaneurysm and the effectiveness of surgery for that entity.