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Myocardial infarction in rats. Infarct size, myocyte hypertrophy, and capillary growth.

To determine the compensatory reserve capacity of the ventricular myocardium following infarction, the left coronary artery in rats was ligated, and the animals were killed 40 days later. Infarcts affecting an average 23% of the left ventricle were characterized by a 27% hypertrophic growth of the remaining myocardium that produced a complete replacement of the necrotic tissue. In contrast, infarcts with an average 50% loss of mass resulted in 83% expansion of the spared myocardium that was inadequate for a complete restoration of ventricular tissue. Myocyte hypertrophy was 26% and 78% in small and large infarcts, respectively. Cellular hypertrophy in both cases involved significant increases in myocyte transverse area and myocyte length. After large infarcts, there was an 18% reduction in capillary surface and a 16% increase in the diffusion distance. Corresponding values for small infarcts were -10% and 9%. These alterations combined with the deficient reconstitution of myocardial mass following large infarcts resulted in 25%, 29%, and 30% deficits in the absolute amounts of capillary lumen, surface, and length per ventricle respectively. Even with small infarcts, a deficit was seen in capillary luminal surface (-16%), and length (-19%). In conclusion, we have demonstrated that cardiac hypertrophy following myocardial infarction is consistent with cellular shape changes characteristic of a combination of concentric and eccentric hypertrophic growth. However, cardiac muscle cells appear to be unable to compensate for the loss of mass induced by a 50% infarct. The inadequate adaptation of the capillary vasculature in the infarcted hearts suggests that the injured ventricle is more vulnerable to additional ischemic episodes.

Animals↗

Early CT signs in acute middle cerebral artery infarction: predictive value for subsequent infarct locations and outcome.

During the first hours after acute ischemic stroke, the CT usually shows no abnormalities. Therapeutic trials of ischemia in the middle cerebral artery (MCA) territory involves decision-making when the CT may not show obvious ischemic changes. We reviewed 100 consecutive patients, admitted within 14 hours after a first stroke. Selective criteria were clinical presentation with MCA ischemia and at least two CTs (1 initial and 1 control). All CTs were retrospectively analyzed by at least two physicians blinded to the patient's status. On the first CT, early signs were hyperdense MCA sign (HMCAS), early parenchymatous signs (attenuation of the lentiform nucleus [ALN], loss of the insular ribbon [LIR], and hemispheric sulcus effacement [HSE]), midline shift, and early infarction. Subsequent infarct locations were classified according to total, partial superficial (superior or inferior), deep, or multiple MCA territories. Clinical features, etiology, and Rankin scale were collected. There were 52 women (mean age 70.8). The CTs were performed at mean 6.4 hours (1 to 14 hours) and before the sixth hour in 62% of the patients. Early CT was abnormal in 94% of the cases, and the abnormalities found were an HMCAS in 22 patients, ALN in 48, LIR in 59, HSE in 69, midline shift in 5, and early infarct in 7. CT was normal in six patients where it was performed earliest (mean 4.5 hours) and in the oldest patients (mean age 80.1). Early parenchymatous CT signs were significantly associated with subsequent MCA infarct location and extension: ALN and deep infarct, HSE and superficial infarct, LIR and large infarct. HMCAS was never found in isolation and was always associated with the three other signs in extended MCA infarct. The presence of two or three signs (ALN, LIR, or HSE) was associated with extended MCA infarct (p < 0.001) and poor outcome (p < 0.001). Our findings suggest that CT frequently discloses parenchymal abnormalities during the first hours of ischemic stroke. Early signs allow the prediction of subsequent infarct locations; CT may provide a simple tool in evaluating the early prognosis of MCA infarction and thus may be useful in selecting better treatments.

Adult↗

A comparative study of the coronary arterial structure in the left ventricular free wall in infarcted and non-infarcted human hearts.

The structure and anastomoses of the coronary arteries were studied using coronary arteriography with barium sulfate (Micropaque) and gelatin as well as "cleared preparations" with tetralin. This was done in a total of 50 human autopsied hearts either with or without infarction and the patients had ranged from one to 84 years of age. Special emphasis was placed on the quantitative studies of the coronary anastomoses in the left ventricular free wall of 32 hearts including ten infarcted hearts. In addition histologic investigations were performed on 168 anastomotic channels selected arbitrarily from both the infarcted and non-infarcted hearts. The following results were obtained. 1. In the non-infarcted hearts, three different types of vessels, Type I, Type II and Type III respectively, were recognized in the left ventricular free wall. The number of anastomotic channels did not correlate with age, sex or weight of the heart. The number of anastomoses was closely related to the degree of coronary arterial narrowing and increased in the cases of severe narrowing. Anastomotic channels tended to be more frequent in the intracoronary and in the subendocardial layer and anastomoses of less than 150m in calibre were more numerous. 2. In the infarcted hearts the three types of vessels were changed as follows: localized increase of tree-like branching in the terminal portion of Type I vessels. Intercommunications between Type II vessels coursing parallel to the endocardial surface and between Type I and Type II vessels were found in the region of the endocardial layer up to the middle layer. Elongation of Type III vessels and an increase in their intercommunications were evident. Anastomoses in intercoronary and in the middle layer were found to have increased significantly. The percentage of anastomotic channels with large calibres, especially over 201 mu was increased, as compared with the non-infarcted hearts. 3. The wall thickness of anastomotic channels tended to be thinner in the infarcted hearts than in the non-infarcted ones. In the region adjacent to the infarction foci, attenuation of walls of the vessels was pronounced as compared with the wall thickness in anastomotic channels of similar size in the non-infarcted heats.

Adolescent↗

Dobutamine-induced ST-segment elevation associated with a biphasic response of wall motion in patients with a recent myocardial infarction is caused by myocardial ischaemia and is abolished by revascularization of the infarct-related artery.

OBJECTIVE: ST-segment elevation is frequently induced by dobutamine in patients with a recent myocardial infarction and may represent dyskinesia of the infarcted region or myocardial viability and ischaemia. Revascularization of the infarct-related artery may abolish myocardial ischaemia, and thus represents a useful tool to verify the significance of this finding. The aim of this study was to assess the relation between ST-segment elevation and wall motion response during dobutamine echo stress test and to evaluate the effect of coronary revascularization with percutaneous coronary angioplasty of the infarct-related artery on stress test results. METHODS AND RESULTS: Twenty-two patients (17 men; mean age 58+/-12 years) with a first acute myocardial infarction (5 anterior (23%) and 17 (77%) inferior) who showed ST-segment elevation during a dobutamine echo stress test performed early (7+/-5 days) after the acute event where included in the analysis. All patients underwent coronary arteriography followed by percutaneous revascularization with coronary angioplasty or atherectomy with or without stenting of the culprit lesion and a second dobutamine echo stress test at a mean of 40+/-20 days after revascularization. The minimal lumen diameter increased from 0.63+/-0.36 to 3+/-0.44 mm and % diameter stenosis decreased from 80+/-11 to 12+/-7 after revascularization. At baseline evaluation there were 62 normal moving segments (34%), 57 (32%) akinetic and 62 (34%) hypokinetic segments within the area at risk. Maximal ST-segment shift changed from a basal mean value of 0.41+/-0.6 to a peak value of 2.15+/-0.9 mm; angina developed in 6/22 patients (22%). A biphasic response to dobutamine indicative of myocardial ischaemia within the infarcted area was observed in 20/22 patients (91%) and in 54/74 (73%) segments showing wall motion abnormalities. After revascularization of the infarct-related artery 78 (43%) segments were considered to be normal, 46 (25%) akinetic and 57 (32%) hypokinetic. Dobutamine-induced ST-segment elevation in 6/22 cases (27%), but the amount of ST-segment shift at peak stress was significantly reduced (from 2.15+/-0.9 to 0.30+/-0.5 mm) and angina was present in 1 patient only (5%) despite a significant increase of double product compared to the pre-revascularization test (from 17,348+/-3536 to 21,005+/-4105, p < 0.003). At echocardiographic analysis, ischaemia involved only 4 segments (2%), 3 of them showing the persistence of a biphasic response to dobutamine. CONCLUSIONS: In patients with a recent myocardial infarction and no baseline dyskinesia dobutamine-induced ST-segment elevation in the infarct-related leads is usually associated with a biphasic response of wall motion within the infarcted region and may be considered an ancillary sign of myocardial ischaemia because it is abolished in the great majority of cases by successful revascularization of the infarct-related artery.

Adrenergic beta-Agonists↗

Estimation of infarct size by single measurements of creatine kinase levels in patients with a first myocardial infarction.

OBJECTIVE: Enzymatic estimation of infarct size is desirable in the reperfusion era, because a possible discrepancy with the observed asynergic area of the left ventricle may suggest the presence of stunned myocardium. Unfortunately, timely myocardial reperfusion produces a rapid washout of creatine kinase (CK) in blood flow, which overestimates infarct size. In this perspective, we investigated whether the mid-terminal portion of the CK time-activity curve could predict infarct size more reliably. METHODS: Enzymatic infarct size was calculated by peak CK levels, the CK area under the curve and by single CK values, in 103 patients with a first ST-elevation myocardial infarction, and compared to the left ventricular akinetic area. The wall motion asynergy score at follow-up was considered as the actual infarct size. RESULTS: In patients with peak CK within 10 h of symptom onset, CK levels at 30 h showed a high independent correlation (r = 0.83; P < 0.001) with infarct size. In patients with late peak CK (> 10 h), CK levels at 12 h turned out to be the best predictor of infarct size (r = 0.55; P < 0.01). At multivariate regression analysis, peak CK was the best predictor of infarct size in the whole population (r = 0.61; P < 0.001). CONCLUSIONS: In patients with ST-elevation myocardial infarction and early peak CK, infarct size at follow-up could be better estimated with single values of the mid-terminal portion of the CK time-activity curve.

Aged↗

Opposite effects of amlodipine and enalapril on infarct collagen and remodelling during healing after reperfused myocardial infarction.

OBJECTIVES: To compare the effects of the calcium channel blocker amlodipine versus the angiotensin-converting enzyme inhibitor enalapril with or without reperfusion on infarct collagen and remodelling during healing after anterior myocardial infarction (MI). ANIMALS AND METHODS: In vivo left ventricular (LV) remodelling and function (by quantitative echocardiography) and hemodynamics were measured over six weeks in dogs that were randomized 24 h after reperfusion (2 h after anterior MI) or no reperfusion to oral amlodipine (5 mg bid, n=6), enalapril (5 mg bid, n=6), placebo (bid, n=6) or sham surgery (n=6) for six weeks. Ex vivo infarct size, infarct collagen (hydroxyproline), collagen volume fraction and LV topography were measured at six weeks. RESULTS: Compared with placebo controls without reperfusion over six weeks in vivo, enalapril or amlodipine with or without reperfusion produced LV unloading and preserved volumes, shape and function, but enalapril limited LV hypertrophy more than amlodipine. However, compared with no reperfusion, amlodipine preserved infarct wall thickness and shape while enalapril decreased infarct wall thickness and increased the shape index. Ex vivo at six weeks, scar size as a percentage of risk was similar in the MI groups. Importantly, enalapril decreased infarct collagen already lowered by reperfusion, while amlodipine preserved infarct collagen after reperfusion and increased collagen volume fraction in spared myocardium. CONCLUSIONS: Preservation of infarct collagen limits infarct remodelling during healing after reperfused MI and preserves LV shape. Amlodipine and enalapril exert opposite effects on infarct collagen and remodelling after reperfused MI.

Amlodipine↗

Comparison of different noninvasive methods of infarct sizing during experimental myocardial infarction.

This study evaluated the accuracy of several noninvasive infarct-sizing techniques in 12 awake, unsedated dogs with multivessel coronary obstructions and acute anterior myocardial infarcts. Estimations of infarct size by scintigraphy with technetium-99m Sn pyrophosphate (Tc-PP), serum creatine phosphokinase (CPK) release, peak serum myoglobin levels by radioimmunoassay, and precordial ECG mapping were compared and correlated with histologic measurements of infarct size. The comparisons indicate that precordial ST segments mapping, serum CPK release measurements and peak serum CPK, peak serum myoglobin, and Tc-PPi myocardial scintigraphy all provide approximate estimates of infarct size in this model. Each technique also has certain important limitations, however, including: (A) precordial mapping is relatively insensitive in the identification of small anterior infarcts, (B) serial serum CPK release measurements when obtained for only 24 hr after infarction tend to underestimate large anterior infarct size, and (C) Tc-PPi myocardial scintigrams may fail to recognize anterior infarcts less than 3 gm in size and may overestimate the size of small predominantly subendocardial infarcts. The findings also show that the closest estimate of histologic infarct size in this model was provided by combining two of the noninvasive techniques (precordial mapping to identify sites with 2 or more millimeters of ST segments elevation and Tc-PPi myocardial scintigrams) rather than by relying exclusively on any one technique alone.

Animals↗

Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction.

BACKGROUND: Intravenous thrombolytic therapy is the standard care for patients with acute myocardial infarction, based upon its widespread availability and ability to reduce patient mortality well demonstrated in randomised trials. Despite its proven efficacy, thrombolytic therapy has limitations. Many patients are ineligible for treatment with thrombolytics. Of those given thrombolytic therapy, 10 to 15 percent have persistent occlusion or reocclusion of the infarct-related artery. Consequently, primary angioplasty (primary PTCA) has been advocated as a better treatment of myocardial infarction. OBJECTIVES: To determine whether primary coronary angioplasty is superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction. SEARCH STRATEGY: Electronic search of The Cochrane Library (1998; Issue 2). MEDLINE (to January 1998); references from reviews, trials and previously published meta-analyses; and experts. Date of most recent searches January 1998. SELECTION CRITERIA: All unconfounded, randomised controlled trials comparing primary angioplasty against intravenous thrombolysis in patients with acute myocardial infarction DATA COLLECTION AND ANALYSIS: At least two independent reviewers abstracted data on morbidity and mortality and trial characteristics. The following outcomes were assessed: total mortality at the end of the study, reinfarction, stroke of any type, composite endpoint of death and reinfarction, recurrent ischemia, severe bleeding and coronary artery bypass grafting. MAIN RESULTS: Ten trials including 2573 subjects were identified. Compared to thrombolytic therapy, primary angioplasty was associated with a significant reduction in short-term mortality at the end of the studies (relative reduction in risk RRR = 32% 95%CI = 5%;50%). Similar reductions were observed for the rate of reinfarction (RRR = 52%, 95%CI = 30%;67%), recurrent ischemia (RRR = 54%; 95%CI = 39%, 66%) and for the combined criteria death or reinfarction (RRR = 46%; 95%CI=30%;58%). The frequency of strokes of any cause was significantly decreased by 66% (95%CI=28%;84%). No significant difference was observed for the incidence of major bleeding (relative risk RR =1.18, 95%CI = 0.73;1.90) but the confidence interval was large. The superiority of the primary angioplasty over thrombolysis in terms of the composite endpoint (mortality and reinfarction) was less with accelerated t-PA (RR=0.70, 95%CI=0.51;0. 97) than with streptokinase (RR=0.30, 95%CI=0.17;0.53). The biggest and most recent trial, Gusto 2B ( approximately approximately GUSTO-2B 97 approximately approximately ), which involved general as well as higly specialised centres, obtained less favorable results. REVIEWER'S CONCLUSIONS: This meta-analysis suggests that angioplasty provides a short-term clinical advantage over thrombolysis which may not be sustained. Primary angioplasty when available promptly at experienced centres, may be considered the preferred strategy for myocardial reperfusion. In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy.

Angioplasty, Balloon, Coronary↗

Effects on infarct size and left ventricular function of early intravenous injection of anistreplase in acute myocardial infarction. The APSIM Study Investigators.

A total of 231 patients suffering from a first acute myocardial infarction were randomly allocated within 4 hours following the onset of symptoms either to anistreplase or anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 minutes, or to conventional heparin therapy, 5000 IU in bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. A total of 112 patients received anistreplase and 119 received heparin within a mean period of 188 +/- 62 min following the onset of symptoms. Infarct size was estimated from single photon emission computerized tomography and expressed in percentage of the total myocardial volume. The patency rate of the infarct-related artery was 77% in the anistreplase group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the anistreplase group than in the heparin group (6 absolute percentage point difference). A significant 31% reduction in infarct size was found in the anistreplase group (33% for the anterior wall infarction subgroup [p less than 0.05] and 16% for the inferior wall infarction subgroup, NS). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -.73, p less than 0.01). In conclusion, early infusion of anistreplase in acute myocardial infarction produced a high early patency rate, a significant limitation of infarct size, and a significant preservation of left ventricular systolic function, mainly in the anterior wall infarctions.

Acute Disease↗

Increased expression of connective tissue growth factor in the infarct zone of experimentally induced myocardial infarction in rats.

Connective tissue growth factor (CTGF), a 36- to 38-kDa peptide, is selectively induced by transforming growth factor-beta and has been suggested to contribute to tissue repair. To test the hypothesis that CTGF is expressed in myocardial infarct tissue following acute myocardial infarction (AMI), we examined CTGF expression after AMI was experimentally induced in rats. Myocardial infarction was induced by left coronary artery ligation in male Sprague-Dawley rats. Northern blotting demonstrated that the CTGF mRNA expression on days 2, 7 and 14 was increased by 6-, 23- and 8-fold, respectively, compared to that in the pre-ligation hearts. In situ hybridization revealed CTGF mRNA signals on day 2 in myocytes in the infarct marginal zone and spindle-shaped mesenchymal cells (presumably myofibroblasts and fibroblasts) located between surviving myocytes in the infarct peripheral zone. On day 7, the signals were observed in the inner lesion of the infarct around infarct granulation tissue. Western blotting demonstrated that the CTGF protein expression on days 2, 7 and 14 was increased compared to the pre-ligation hearts. Immunopositive staining for CTGF was observed in the inner lesion of the infarct tissue on day 7. In conclusion, the findings demonstrated the increased expression of CTGF in the infarct tissue. Myocytes in the infarct marginal zone and spindle-shaped mesenchymal cells (presumably myofibroblasts and fibroblasts) were the cells responsible for CTGF production.

Animals↗

Comparative study of rest technetium-99m sestamibi SPET and low-dose dobutamine stress echocardiography for the early assessment of myocardial viability after acute myocardial infarction: importance of the severity of the infarct-related stenosis.

Rest technetium-99m sestamibi single-photon emission tomography (SPET) has been shown to underestimate viability in some patients with chronic ischaemic myocardial dysfunction. The present study was designed to appraise the value of 99mTc-sestamibi as a viability tracer in patients with a recent myocardial infarction and to determine factors that might influence its accuracy in assessing infarct size. Therefore, rest 99mTc-sestamibi SPET, low-dose dobutamines stress echocardiography and quantitative coronary angiography were performed in 51 patients with a recent myocardial infarction. Perfusion activity and regional wall motion were scored semi-quantitatively using the same segmental division of the left ventricle. Assessment of 99mTc-sestamibi uptake as a marker of viability was performed by comparing a binary uptake score (viable=>50% vs necrotic =</=50% of the maximal tracer activity) with a binary wall motion classification during low-dose dobutamine infusion (viable=normal/hypokinetic vs necrotic=akinetic/dyskinetic). Infarct size, expressed as the number of segments with evidence of necrotic tissue, was significantly greater in the scintigraphic study than in the echocardiographic study (2.8+/-1.5 vs 2.2+/-1.3, P=0.006). This overestimation of infarct size by 99mTc-sestamibi was present only in patients with a severe infarct-related stenosis (% diameter stenosis >/=65%-100%) and particularly those with "late" reperfusion therapy (time delay >/=180 min). In patients without a severe infarct-related stenosis, 99mTc-sestamibi was able to accurately distinguish viable from necrotic segments. Thus, rest 99mTc-sestamibi scintigraphy early after acute myocardial infarction may underestimate residual viability within the infarct region, particularly in patients with low flow state coronary anatomy, as a result of a severe infarct-related stenosis and/or late reperfusion therapy.

Cardiotonic Agents↗

Mild hypothermia reduces infarct size in the beating rabbit heart: a practical intervention for acute myocardial infarction?

The present study describes a method for rapidly cooling the whole body via its blood pool and tests whether cooling instituted after ischemia has begun can still limit infarction. We also evaluated whether the cardiac protection seen with cooling could be added to that from ischemic preconditioning. Recently it was reported that lowering myocardial temperature by only several degrees greatly slows the extent of myocardial infarction in the beating heart experiencing regional ischemia. To further explore the potential of hypothermia for myocardial protection, rabbits underwent either a 30-, 45- or 60-min coronary artery occlusion and 3-h reperfusion. Blood from a carotid artery was allowed to circulate through a heat exchanger immersed in ice water and return to a jugular vein until the blood temperature in the left atrium reached the target temperature of 35 or 32 degrees C. Furthermore, to elucidate the mechanism of hypothermia's protection, we also examined its effect on isolated cardiomyocytes. Rewarming began upon reperfusion in all protocols. Cooling to 32 degrees C before a 30-min ischemia reduced infarct size from 37.3 +/- 2.5% (n = 6) of the risk zone in normothermic controls to 3.6 +/- 0.3% (n = 6). When cooling was begun 10 or 20 min after the onset of ischemia infarct size was still significantly smaller [8.1 +/- 1.2% and 22.8 +/- 1.8%, respectively (n = 6 in each group)]. Less but significant protection was also seen with cooling to 35 degrees C. Cooling caused only mild bradycardia and hypotension and no apparent arrhythmias. Forty-five min of regional ischemia caused 50.7 +/- 3.3% (n = 6) of risk zone to infarct in untreated hearts. Preconditioning with 5-min ischemia/10-min reperfusion reduced infarct size to 27.5 +/- 2.5% (n = 6). Cooling to 32 degrees C starting 20 min after the onset of ischemia protected the heart (28.7 +/- 2.6% infarction, n = 8), and this protection could be added to the effect from ischemic preconditioning (6.3 +/- 2.3% infarction, n = 6). In the myocyte model, hypothermia and ischemic preconditioning delayed the progressive increase in osmotic fragility that occurs during simulated ischemia in an additive way, but only hypothermia delayed the appearance of contracture suggesting that different mechanisms are involved. Hence blood pool cooling was easily induced and well tolerated and protected the beating heart against infarction even when hypothermia was started after the onset of coronary occlusion. We conclude that hypothermia might be a simple and useful therapy for patients presenting with acute myocardial infarction.

Animals↗

Insular infarcts and electrocardiographic changes at admission: results of the PRognostic of Insular CErebral infarctS Study (PRINCESS).

BACKGROUND AND PURPOSE: Previous studies showed that insular strokes are associated with electrocardiographic (ECG) changes. However, they did not take into account the 1(st) ECG recorded at admission, but continuous ECG recorded up to 72 hours after onset. Whether these changes are the consequence of the infarct, or are associated with a cardiac source of cerebral ischemia, remains unsettled. If ECG changes are the consequence of insular infarcts, they should not have developed by the time of admission. The aim of this study was to test the hypothesis that ECG changes in patients with insular infarcts are not present at admission. METHODS: We recruited consecutive patients admitted within 48 hours (median 3 hours) after the onset of symptoms of acute hemispheric cerebral ischemia. We compared ECG variables between patients with and without insular infarcts, and with left and right insular infarcts. RESULTS: The study population consisted of 208 patients (94 men; median age: 69 years). Seventy patients had a recent insular infarct (right in 33). ECG variables did not significantly differ between patients with and without insular infarcts, and with left and right insular infarcts. These results were not explained by a lack of statistical power (1-beta >/= 0.90). CONCLUSION: The lack of statistical link between insular infarcts and ECG changes at admission, suggests that ECG changes are not associated with the cause of insular infarcts, but are their consequence.

Adolescent↗

Factors associated with recurrent myocardial infarction within one year after acute myocardial infarction.

In a large population of patients (n = 3666) who were discharged from the hospital after acute myocardial infarction and followed up for 1 year, factors associated with recurrent nonfatal (n = 171) or fatal (n = 74) infarction were identified. Also, the effects of combining various end points (recurrent nonfatal or fatal infarction and other cardiac death) in multivariate analyses, a practice common in many small studies that evaluate the predictive-value of various treatments or special tests, was examined. In univariate analyses, patients with nonfatal recurrent infarction did not differ with respect to age or gender from infarct-free survivors, but they more often had a history of previous myocardial infarction, congestive heart failure, angina pectoris, and diabetes; more severe pulmonary congestion was present on chest x-ray during the admission, and a non-Q wave index infarction was more frequent. Patients with either a fatal or nonfatal recurrent infarction had more angina pectoris during follow-up (55% to 60%) compared with 27% in event-free survivors and 31% in patients who died of other cardiac causes in whom this factor could be assessed before death. In multivariate analyses, historical and clinical prognostic factors were ranked differently for fatal or nonfatal reinfarction and other cardiac causes of death; angina pectoris at follow-up was highly related to recurrent infarction (fatal or nonfatal), along with a history of diabetes, and a non-Q wave index infarction. These factors were not independently related to other causes of cardiac death.(ABSTRACT TRUNCATED AT 250 WORDS)

California↗

The relationship between 1-year mortality and infarct location in patients with non-Q wave myocardial infarction.

The association between 1-year mortality and infarct location was evaluated in 544 patients with acute non-Q wave myocardial infarction. Infarcts were anterior (alone or including other locations) in 51.1% (n = 278) of cases, localizable but not anterior 29.6% (n = 161) of the time, and nonlocalizable in 19.3% (n = 105) of patients. One-year actuarial mortality (73 deaths) was 16.9% in the anterior group, 13.3% in the nonanterior group, and 6.8% in nonlocalizable patients (p = 0.037). Anterior and localizable nonanterior mortality were similar (p = 0.367). However, there were differences when mixed location infarcts were excluded. Mortality in the inferior infarction only group (2.8%, n = 36) was less than in the lateral infarction only group (16.8%, n = 79, p = 0.041) and almost significantly less than in the anterior only group (15.1%, n = 62, p = 0.064). The positive prognosis in the inferior infarction only group may be associated with the low rate of ST depression among these patients compared with those with other infarct locations (p less than 0.0001). Mortality among localizable infarcts (15.5%) was greater than among those that were nonlocalizable (6.8%, p = 0.021). Despite the low overall risk of the nonlocalizable infarcts, 41.9% (n = 44) of these patients developed at least one important risk factor while in hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

Importance of myocardial infarct artery patency on the prevalence of ventricular arrhythmia and late potentials after thrombolysis in acute myocardial infarction.

Sustained infarct artery patency is an important determinant of survival in patients with acute myocardial infarction. We studied 61 patients with acute myocardial infarction who received intravenous recombinant tissue-type plasminogen activator, aspirin or heparin within 6 hours of symptom onset, to determine if infarct artery patency after intravenous thrombolytic therapy influences myocardial electrical stability as measured by the prevalence of spontaneous ventricular ectopy or late potential activity. Infarct artery patency was determined by angiographic evaluation 2.5 +/- 3 days after infarction. Forty-eight patients (79%) had a patent infarct-related artery and 13 (21%) patients had an occluded vessel. The mean number of ventricular premature complexes (VPCs)/hour (p less than 0.01) and the prevalence of late potentials (54 vs 19%; p less than 0.03) were significantly higher in patients with an occluded versus patent-infarct related vessel. Although VPC frequency and late potentials were not influenced by the time to thrombolytic treatment, patients with a patent infarct-related artery had a lower prevalence of late potentials regardless of whether treatment was initiated less than or equal to 2 hours (25% patent vs 50% occluded; p = not significant) or 2 to 6 hours (16% patent vs 55% occluded; p greater than 0.03) after symptom onset. Thus, successful thrombolysis decreases the frequency of ventricular ectopic activity and late potentials in the early postinfarction phase. The reduction in both markers of electrical instability may help explain why the prognosis after successful thrombolysis is improved after acute myocardial infarction.

Aged↗

Patency of the infarct-related artery and left ventricular function as the major determinants of survival after Q-wave acute myocardial infarction.

One hundred seventy-two patients with 1-vessel disease documented at predischarge angiography who had been followed for 43 +/- 30 months after an initial Q-wave acute myocardial infarction were retrospectively evaluated to investigate the prognostic value of infarct-related artery patency and left ventricular (LV) function. Multiple logistic regression analysis revealed that only infarct artery patency (Thrombolysis in Myocardial Infarction [TIMI] grades 2-3 vs 0-1) (Z = 2.24; p < 0.05) and end-systolic volume index (Z = -2.67; p < 0.01) were independently related to survival. Sixteen cardiac deaths were observed; all 16 patients had LV dysfunction (defined as end-systolic volume index > 40 ml/m2), and 15 had an occluded infarct-related artery. In the subgroup with LV dysfunction, the 10-year percent survival rate was 20% among patients with TIMI grade 0 to 1 versus 96% with grade 2-3 (p < 0.001). Patency of the infarct-related artery was also the only independent predictor of recurrent ischemia (Z = 2.59; p < 0.01). In conclusion, both infarct-related artery patency and LV function are independent predictors of survival after Q-wave acute myocardial infarction. Patients with normal LV function have an excellent long-term prognosis, which is only partially counterbalanced by the tendency toward clinical instability observed in those with an open infarct-related vessel. However, when an occluded infarct-related artery is observed in the setting of LV dysfunction, the long-term outcome appears to be relatively poor.

Cardiac Volume↗

The effect of infarct size on atrioventricular and intraventricular conduction disturbances in acute myocardial infarction.

The effect of infarct size estimated from serial CK-MB isoenzyme determinations on the incidence of atrioventricular and intraventricular conduction disturbances was examined in 250 patients suffering their first myocardial infarction. The size of the infarct was significantly greater (P less than 0.001) in 72 patients with conduction disturbances than in 178 without conduction defects (54 +/- 29 vs. 35 +/- 22 CK-MB gEq). The largest size was observed in 10 patients with bifascicular block (71 +/- 38 CK-MB gEq). Within the group of patients with intraventricular conduction disturbances, the size of the infarct was significantly greater (P less than 0.01) when localized inferiorly rather than anteriorly (91 +/- 10 vs. 58 +/- 27 CK-MB gEq). The size in those patients with complete atrioventricular block and anterior infarction was larger than in those with an inferior lesion (76 +/- 21 vs. 52 +/- 33 CK-MB gEq). The size in those patients with inferior infarction and complete block was significantly greater (P less than 0.05) than in patients with similarly positioned infarction without conduction disturbances (52 +/- 33 vs. 35 +/- 22 CK-MB gEq). There was no significant difference in the size of infarct when inferior infarction was complicated by first- and second-degree block in comparison to those without conduction defects (38 +/- 23 vs. 35 +/- 22 CK-MB gEq). A correlation was observed between the size of infarction and the incidence of conduction disturbances (P less than 0.001); the greater the size the higher the incidence of conduction disturbances.

Adult↗