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PubMedDate not supplied

Does an open infarct-related artery after myocardial infarction improve electrical stability?

Arrhythmic events are responsible for the majority of sudden cardiac deaths after myocardial infarction. Many clinical studies have suggested that patency of the infarct-related artery, achieved by thrombolytic therapy or revascularization procedures, is a predictor of survival rates irrespective of myocardial salvage. The open-artery hypothesis suggests that an open infarct-related artery may result in other potential mechanisms, of benefits including electrical stability. This review focuses on the various levels and types of evidence supporting this contention.

Animals↗
PubMedDate not supplied

The role of myocardial viability in deriving benefit from reestablishing infarct-related artery flow after acute myocardial infarction.

Early, sustained patency of the infarct-related artery (IRA) induces myocardial salvage, which preserves left ventricular (LV) function and mediates better long-term outcome. However, the time course and the mechanisms of muscle recovery after myocardial infarction are not completely understood. A large body of evidence suggests that most of the improvement occurs during the hospital phase and is related to early and sustained thrombolysis in myocardial infarction 3 flow in the IRA. Nevertheless, the relationship between IRA status and regional and global LV mechanics in the chronic phase of the disease remains controversial. Some late recovery may occur, either spontaneously or after revascularization, even in the absence of documented myocardial ischemia. The interplay between vessel patency, coronary flow grade and severity of the residual stenosis, and the presence of stunned or hibernating myocardium in the area at jeopardy may explain this delayed improvement. Although there seems to be a limited time window in which myocardium can be salvaged, timely testing for viability, particularly in patients with poor LV function, is justified even in a later phase of the disease to challenge potential cardiac recovery.

Animals↗
PubMed2000

Survival analysis within one year of first acute myocardial infarction: comparison between non-Q and Q wave myocardial infarction.

BACKGROUND: Non-Q wave Myocardial Infarction (non-Q AMI) is related pathophysiologically to Q wave AMI, as each represents different stages of plaque rupture and thrombosis. Post-hospital re-infarction and recurrent angina are more frequent in non-Q AMI than in Q wave AMI, offsetting the higher early risk with Q wave AMI, with one-year survival rates similar in the two types of MI. OBJECTIVES: 1--Evaluation of early (< or = 28 days) and one-year total mortality from first non-Q AMI in comparison to QMI. 2--Analysis of recurrent acute ischaemic events (non-fatal reinfarction and unstable angina) in both types of MI in the same periods of time. POPULATION AND METHODS: A retrospective study of 1146 patients, mean age 65 +/- 13 years, 65% male, admitted at CCU with a first MI, from January 1988 to December 1997 (minimum follow-up period of one year, mean follow-up 42 +/- 37 months). We compared the baseline demographics and clinical characteristics (coronary risk factors, previous angina, MI evolution, recurrent cardiac events, 28 day mortality and one year mortality) of patients with non-Q AMI (NQ group = 239) and Q wave AMI (Q group = 907). RESULTS: The NQ group patients were significantly older (mean age: 67 +/- 12.6 vs 65 +/- 12.5 years; p < 0.05), included fewer smokers (29% vs 43%; p < 0.001) and were more symptomatic before the index infarction (stable angina: 40% vs 30%; p < 0.05; unstable angina: 16% vs 6%; p < 0.001), when compared to the Q group patients. There were no significant differences in MI evolution, in Killip-Kimbal class > or = 2, recurrent angina and in-hospital mortality (Q-12% vs NQ-9%; ns), although there was a higher combined risk of arrhythmias and AV conduction disturbances in patients with QMI (Q-34% vs NQ-26%; p < 0.05). The combined risk of unstable angina and reinfarction at one year was significantly higher in group NQ (NQ-13% vs Q-8.1%; p < 0.05). The NQ group showed no significant difference in 28 day total mortality (NQ-14% vs Q-17%; ns) or at one year follow-up (NQ-24% vs Q-26%; ns) when compared to the Q group. CONCLUSION: 1--Despite a lower severity of non-Q AMI in the acute phase, 28 day and one year total mortality were similar in the two groups. 2--Patients with non-Q AMI showed a higher incidence of recurrent ischemic events at one year follow-up.

Aged↗
PubMed2002

[Study of mortality due to myocardial infarction and alcoholism on the basis of the WHO MONICA and Acute Myocardial Infarction Registry programs].

AIM: To study trends of mortality due to alcoholism (A) and cardiovascular diseases (CVD) in Novosibirsk in 1981 to 1998. MATERIALS AND METHODS: The WHO MONICA and Acute Myocardial Infarction Register programmes were used to survey the population of 3 Novosibirsk districts. There were notified 9016 cases of nonviolent death, by exclusing another pathology, with the exception of CVD and alcoholic intoxication. RESULTS: Mortality rates due to myocardial infarction (MI) were relatively stable throughout the observation period, except for 1988, 1994, and 1998 (a significant increase). Those due to A showed the following trend: stabilization in 1981-1982, a significant increase in 1983-1987, stabilization in 1988-1991, a significant increase in 1992-1994, and a decrease in 1995-1998. Mortality rate from MI were 2-3 times greater than that from A, with the exception of 1994-1995 when they were equal, i.e. the trends of mortality from MI and A did not coincide. Social stress is a factor that greatly influences MI death rates, mainly due to prehospital mortality. As social stress increases, younger age groups, both males and females, are afflicted, which is extremely hazardous for the population. By taking into account the mortality trends, it may be stated that A hardly affects death rates from MI. In the pattern of mortality from CVD, death rates from MI and A were 50-70% in males and 35-60% and females; those from MI were 35-55 and 30-45%, respectively. The increase in alcoholism mortality is associated with the population's addictive behavior in the period of social upheavals in the community. CONCLUSION: According to official statistics, the mortality trends do not reflect the actual state of things. This may be done only by stringently standardized programmes with their schemes of data collection and diagnosis verification. The WHO MONICA and Acute Myocardial Infarction programmes belong to such programmes.

Adult↗
PubMed1992

Late arrhythmic events and patency of the infarct-related coronary artery in survivors of acute myocardial infarction.

In the present study we evaluated the influence of intravenous thrombolysis and patency of the infarct-related coronary artery on both markers of ventricular electrical instability and incidence of late arrhythmic events after acute myocardial infarction (AMI). Ninety one patients surviving a first AMI who consecutively performed coronary angiography were enrolled in the present study; 44 patients (48%) received thrombolysis, 47 patients (52%) were treated conventionally. Of 91 patients, 90 (99%) had signal-averaged electrocardiogram (SAECG), and 40 (44%) programmed ventricular stimulation. No significant difference was observed between thrombolytic-treated and control group in late potential rate, SAECG determinants and ventricular arrhythmia inducibility. Of 91 patients, 40 (44%) had occlusion of the infarct-related artery: of these, 15 (37%) had late potentials compared with 5 of 51 patients (9%) with a patent artery (p < 0.01). Mean left ventricular ejection fraction was not significantly different between the two groups (0.50 +/- 0.15 vs 0.55 +/- 0.12; p = NS). No significant difference was present between the two groups of patients with regard to inducibility of sustained ventricular tachyarrhythmias, however an odds ratio of 3.5 was observed in the group with a closed vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

[Exertion tolerance in the early period after myocardial infarction, the results of echocardiographic examination and the clinical course of infarction].

The relation between exercise test, echocardiography and clinical course of acute myocardial infarction was investigated. 17-34 days after an acute myocardial infarction, before hospital discharge, 58 patients underwent exercise test and 17-28 days- echocardiography. Low exercise capacity was significant related to angina before infarction, maximal CKNAC and complications during clinical course. There was inverted correlation of asynergy index calculated from echocardiography with maximal workload achieved during exercise test.

Adult↗
PubMedDate not supplied

Electrocardiographic identification of the infarct-related artery in acute inferior myocardial infarction.

INTRODUCTION: Mortality and morbidity from acute inferior myocardial infarction (MI) are determined, among other factors, by the infarct-related artery (IRA). Several electrocardiographic (ECG) criteria have been proposed to differentiate between the right coronary artery (RCA) and the left circumflex coronary artery (LCx) as the IRA in inferior MI. Recently, a new criterion has been proposed (ST segment depression in lead aVR). It was our objective to evaluate the old and the new ECG criteria in identifying the IRA in patients with inferior MI. METHODS: Patients with inferior MI treated by primary angioplasty were included, following evaluation of the admission ECG. Patients with a previous history of Q-wave myocardial infarction and complete bundle branch block were excluded. The artery with the most severe lesion was considered the IRA. The following ECG criteria were assessed: ST depression in lead DI; ST depression in leads V1 and V2, ST elevation in lead DIII > DII, ST depression in V3/ST elevation in DIII ratio > 1.2 (classical criteria) and ST depression in lead aVR. ST-segment elevation or depression was measured 0.06 sec after the J point. RESULTS: 53 patients were included (mean age 59.1 +/- 13.9 years, 38 males). The RCA was the IRA in 38 patients and the LCx in 15. Baseline characteristics (age, gender, TIMI flow, Killip class, and pain-to-balloon time) were similar in both groups. All the classical criteria were able to identify the IRA. The new criterion--ST depression in lead aVR--identified the IRA in a small number of patients (sensitivity 33%, specificity 71%, p = NS). CONCLUSIONS: The 4 classical criteria were useful in identifying the IRA in patients with inferior MI. ST depression in lead aVR (a recently proposed new criterion), on the other hand, showed limited utility in differentiating between RCA and LCx.

Coronary Vessels↗
PubMed1992

[Assessment of right ventricular function using gated blood pool single photon emission computed tomography in inferior myocardial infarction with or without hemodynamically significant right ventricular infarction].

Right ventricular function was assessed using gated blood pool single photon emission computed tomography (GSPECT) in 10 normal subjects and 14 patients with inferior myocardial infarction. Three-dimensional background subtraction was achieved by applying an optimal cut off level. The patient group consisted of 6 patients with definite hemodynamic abnormalities indicative of right ventricular infarction (RVI) and 8 other patients with significant obstructive lesion at the proximal portion of right coronary artery without obvious hemodynamic signs of RVI. Right ventricular regional wall motion abnormalities were demonstrated on GSPECT functional images and the indices of right ventricular function (i.e. the right ventricular ejection fraction (RVEF), the right ventricular peak ejection rate (RVPER) and the right ventricular peak filling rate (RVPFR)) were significantly reduced in the patient group, not only in the patients with definite RVI but also in those without hemodynamic signs of RVI. The present study indicates that inferior infarction is frequently associated with RVI, even in the absence of definite hemodynamic signs, when the proximal portion of right coronary artery is obstructed. It is concluded that GSPECT is reliable for the assessment of right ventricular function and regional wall motion, and is also useful for the diagnosis of RVI.

Hemodynamics↗
PubMed2004

[Composition of risk factors among acute myocardial infarction patients in Israel: sub-analysis of the Israeli National Prospective Survey on Acute Myocardial Infarction in 2000].

BACKGROUND: Risk factor modification has been shown to reduce cardiovascular morbidity and mortality. Nevertheless, there is a debate regarding the relative importance of risk factors when analyzed by age, gender and ethnical background. The aim of the study was to define sub-populations with different classes of risk factors that may enable targeted and improved preventive approaches. METHODS: The study is a sub-analysis of the Israeli National Prospective Survey on Acute Myocardial Infarction in the year 2000. We evaluated the interactions between the classical risk factors and their correlation with the patients' age and gender. RESULTS: A total of 1,683 patients with acute myocardial infarction were hospitalized in 26 hospitals in Israel during February and March 2000. Seventy-three percent were men and 27% were women and their mean age was 66 +/- 13 years. Younger patients had significantly more risk factors than the older ones (P < or = 0.0001). Women were significantly older and had less risk factors than males (73 +/- 12 vs. 63 +/- 14, P < 0.01; 2.02 +/- 1.10 vs. 1.84 +/- 1.03, P < or = 0.002, respectively). One hundred and twenty-eight patients (7.8%) had no risk factors. Hyperlipidemia, current smoking and family history were common in younger patients, while hypertension and diabetes mellitus were more common in the older ones. Family history and smoking were significantly more common in males, whereas diabetes mellitus and hypertension were more common in females. CONCLUSIONS: There were defined sub-populations with different risk factors for acute myocardial infarction. Our findings suggest that in young patients cessation of smoking and control of hyperlipidemia are of crucial importance. Hypertension and diabetes mellitus are more common in women and older patients and their impact on the atherosclerotic process is gradual and manifests later in life. Further studies should clarify the relative importance of each risk factor and its control.

Adult↗
PubMed2004

Prodromal angina reduces infarcted mass less in interventionally reperfused than in thrombolysed myocardial infarction.

UNLABELLED: There is a lot of evidence that angina during the 24-48 h before a reperfused myocardial infarction improves the evolution of the patients. However, there are studies that failed to demonstrate this protective effect of preinfarction angina in an interventional reperfusion setting. OBJECTIVE: To compare the effect of preinfarction angina (PIA) on inhospital evolution of thrombolysis vs. interventionally reperfused acute myocardial infarction (AMI). MATERIAL AND METHOD: There were prospectively studied 133 consecutive AMI patients, eligible for reperfusion (thrombolysis or interventional). History of PIA under 48 hours was obtained. Evolution of AMI was evaluated considering the following end-points: the ratio between the number of ECG leads with final pathologic Q wave and the number of leads with initial ST elevation, CK-MB values, separate and composite incidence of death, heart failure, shock and incidence of serious arrhythmia (sustained VT or ventricular fibrillation). RESULTS: ECG ratio was lower in patients with PIA (0.511 +/- 0.281 vs. 0.646 +/- 0.274, p=0.02) in thrombolysed patients, but it was higher in interventionally reperfused patients (0.740 +/- 0.418 vs. 0.554 +/- 0.295 p=0.11). CK-MB values were lowered by PIA in thrombolysed AMI (122 +/- 74 vs. 190 +/- 89, p=0.0003), but they were not in the interventional group. Clinical end-points were slightly less frequent in patients with PIA, in both reperfusion groups, but not statistically significant. Major arrhythmia occurred less frequently in interventionally reperfused patients with PIA (9.5% vs. 31.6%, p=0.12). CONCLUSION: Preinfarction angina under 48 hours significantly reduces infarcted mass (measured by ECG and enzymes) in thrombolysed patients, but not in the interventional group. However, PIA reduced arrhythmic end-point in interventional setting.

Aged↗
PubMed2006

Initial infarct size predicts subsequent cardiac remodeling in the rat infarct model: an in vivo serial pinhole gated SPECT study.

UNLABELLED: The rat infarct model is widely used to study left ventricular (LV) remodeling, a main cause of heart failure characterized by progressive LV dilatation. Using pinhole collimators and advances in data processing, gated SPECT was recently adapted to image the rat heart. The aim of this study was to assess this new imaging technique for predicting and quantifying variable LV remodeling from the rat infarct model. METHODS: Pinhole 99mTc-sestamibi gated SPECT was validated for determining LV volume and identifying the necrotic and nonviable LV segments (<50% of 99mTc-sestamibi uptake) in rats, and it was applied to monitor rat LV function from 48 h to 12 wk after occlusion of the left anterior descending coronary artery (LAD) (n = 20) or sham operation (n = 9). RESULTS: In LAD-occluded rats, 48-h SPECT necrosis was large (> or =30% LV) in 6, limited (<30% LV) in 6, and undetectable in 8. End-diastolic volume of LAD-occluded rats was equivalent to that of sham-operated rats at 48 h (320 +/- 84 microL vs. 293 +/- 48 microL; not significant) but became higher at 12 wk (501 +/- 191 microL vs. 343 +/- 46 microL; P = 0.01). The follow-up increase in end-diastolic volume, which reflects the remodeling process, was closely related to the initial extent of necrosis revealed by the SPECT images (P < 0.001; R2= 0.85). This increase was limited in sham-operated rats (50 +/- 15 microL) and in the LAD-occluded rats with undetectable necrosis (55 +/- 35 microL) but it was around 3- and 7-fold higher in the LAD-occluded rats with limited (165 +/- 57 microL) and large (366 +/- 113 microL) necrosis, respectively. CONCLUSION: The variable LV remodeling documented after coronary occlusion in rats closely relates to the variable extent of necrosis provided by this model. Pinhole gated SPECT allows this remodeling to be predicted and quantified and, hence, constitutes an original tool for the experiments scheduled on the rat infarct model.

Animals↗
PubMed2006

Frequency of infarct-related artery with myocardial bridging in patients with ST-elevation myocardial infarction and its impact upon percutaneous coronary intervention.

BACKGROUND: Myocardial bridging (MB) as a congenital condition with a reported frequency of 5% - 12% in diagnostic coronary angiography may be an important factor causing myocardial ischemia. However, its frequency in the infarct-related artery (IRA) of patients with ST-elevation myocardial infarction (STEMI) and the impact upon percutaneous coronary intervention (PCI) remain undetermined. In this study, we investigated MB frequency and its impact upon primary PCI in patients with STEMI. METHODS: The data of coronary angiography for 554 consecutive patients with STEMI who had undergone successful primary PCI were retrospectively analyzed to identify a frequency of MB in the IRA and its association with gender and age. According to the angiographic findings, the patients were divided into MB patients and non-MB patients. The endpoints of this study included immediate angiographic findings after primary PCI and 6-month major adverse cardiac events (MACE) (death, recurrent myocardial infarction, target lesion or vessel revascularization) between the MB patients and the non-MB patients. RESULTS: A frequency of MB in the IRA of 46 patients (8.3%) was identified in this series; it was more common in patients > or = 65 years old (36/206) than in those < 65 years old (10/348) (17.5% vs 2.9%, P < 0.001). The trend of MB in the IRA was observed more frequently in women without significant difference than in men (10.2% vs 7.8%). TIMI grade III flow was achieved in 91.9% (509/554) of all patients following primary PCI, in 60.9% (28/46) of the MB patients and in 94.7% (481/508) of the non-MB patients respectively (P < 0.001). The in-hospital mortality was 4.7% (26/554) in this series including 13.0% (6/46) of the MB patients and 3.9% (20/508) of the non-MB patients (P < 0.001). A significant difference in 6 months MACE was seen between the MB patients (19%) and the non-MB patients (6.2%) (P < 0.001). CONCLUSIONS: MB in the IRA is relatively common in elderly patients with STEMI with a more evident trend in women, suggesting that arteriosclerosis and plaque rupture occurs more easily in the proximal artery to MB than in younger patients. Poor TIMI grade flow in patients with MB in the IRA after primary PCI may contribute to a high in-hospital mortality rate (13%) and 6-month MACE (19%) in the MB patients.

Adult↗
PubMed1991

[An analysis of ST segment shift in procordial leads in patients with acute inferior myocardiac infarction with and without right ventricular infarction].

ST segment change in procordial leads was analysed in 58 patients with acute inferior myocardial infarction (IMI). ST segment depression in V2 lead was negatively correlated with ST segment elevation in a VF lead in patients with IMI. ST segment depression in V2 lead was not observed when IMI was accompanied by right ventricular infarction. It indicates that ST segment depression in procordial leads was the reciprocal change of ST segment elevation in inferior leads. The direction and amplitude of ST segment shift in procordial leads may be affected by the presence of right ventricular infarction (RVI). The ratio of ST V2/ST aVF less than 0.5 may suggest a diagnosis of IMI with accompanying RVI.

Electrocardiography↗
PubMed1990

[Mitral valve replacement in post-infarction rupture of the papillary muscle. Apropos of 13 cases surgically treated during the acute phase of infarction].

Between 1983 and 1988, thirteen patients (12 men and 1 women, average age 63 years) were operated in the acute phase of myocardial infarction for papillary muscle rupture (PMR). The rupture involved the posterior papillary muscle in 12 cases. The average left ventricular ejection fraction was 47 +/- 9 per cent (range 34 to 63%). Pulmonary capillary pressures ranged from 76 to 41 mmHg (average 35 mmHg). Eleven patients presented with acute pulmonary oedema and 7 had cardiogenic shock. Coronary arteriography showed triple vessel disease in 3 cases, double vessel disease in 7 cases and single vessel disease in 3 cases. Surgery was carried out on average 2.7 days after the rupture and 10 days after the initial infarct. In addition to mitral valve replacement (N = 13), 11 patients underwent a myocardial revascularisation procedure. The operative mortality was 15 per cent (N = 2). Papillary muscle rupture in the acute phase of myocardial infarction causes cardiac failure which is related more to the mechanical abnormality than to an alteration of left ventricular function. Considering the operative mortality and the natural history of PMR treated medically, the authors recommend early surgery as the only management which can improve the precarious haemodynamic status of patients with this complication.

Aged↗
PubMed1990

Pivotal role of early and sustained infarct vessel patency in patients with acute myocardial infarction.

Thrombolytic therapy in acute myocardial infarction unequivocally has improved short- and long-term mortality. The fundamental goal of therapy for evolving myocardial infarction is early and sustained infarct vessel recanalization. The mechanisms linking an open artery with improved long-term survival and other clinical outcomes are presented with use of data from extensive clinical trials.

Angioplasty, Balloon, Coronary↗
PubMed1988

Evolving myocardial infarction in the rat in vivo: an inappropriate model for the investigation of drug-induced infarct size limitation during sustained regional ischaemia.

Despite the rat heart having very low collateral flow, there are many reports of pharmacological limitation of infarct size in rats with permanent coronary occlusion. Investigating possible artefacts, cardiac function was measured in isolated rat hearts (n = 12/group) 1, 2, 4, 6, 12, 18, 24, or 48 h after permanent coronary occlusion. In sham operated controls, cardiac output was 63.8 +/- 3.8 ml/min; in rats with occlusion this fell to 37.7 +/- 3.3 ml/min after 1 h of occlusion and did not increase during the 48 h of study. Lumen areas, areas of underperfusion, and minimum wall thickness were unchanged after 4 h of occlusion. Between 4 and 12 h, substantial wall thinning occurred (midinfarct wall thickness decreased from 3.69 +/- 0.24 mm to 2.01 +/- 0.16 mm). After 12 h of occlusion, wall thinning and expansion of the infarct increased lumen volume by three- to fourfold. Wall thinning resulted in a progressive decrease in the volume of the zone of underperfusion (which decreased by almost 30% over 48 h). Tetrazolium negative tissue was not evident in the first 4 h of occlusion but by 12 h, 85.0 +/- 2.6% of the underperfused tissue was necrotic. Gross examination of sections often indicated apparently tetrazolium positive tissue within the zone of underperfusion. Microscopic examination of histological sections revealed this tissue to be necrotic but, in contrast to the tetrazolium negative tissue within the zone of underperfusion, not yet subject to white cell infiltration. "Apparent" infarct size limitation in the rat heart might be due to: (1) incorrect designation of tissue as tetrazolium positive within the severely ischaemic zone of underperfusion; (2) inappropriately equating the zone of underperfusion (measured at the end of ischaemia) to the risk zone (measured at the onset of ischaemia); (3) the possibility that some drugs might affect white cell infiltration, tetrazolium staining characteristics, wall thinning, and tissue remodelling.

Animals↗
PubMed1989

[Right ventricular myocardial infarction. Prognostic significance of ST elevation in right chest leads V3R-V7R in patients with acute inferior/posterior myocardial infarction].

The prognostic significance of ST-elevation greater than or equal to 1 mm in right chest leads V3R-V7R during inferior/posterior acute myocardial infarction (AMI) was evaluated in 86 consecutive patients with their first inferior/posterior AMI, and compared with the prognosis for 72 patients with first anterior AMI. At follow-up, the maximum observation time was 3.0 years (mean 1.8 years). A total of 49 patients died. Using Cox multivariate analysis, ST-elevation in right chest leads during inferior/posterior AMI was found to be an independent predictor of the prognosis in patients surviving the initial ten days after infarction (n = 129). For these patients, the cumulative survival was better after inferior/posterior AMI with ST-elevation in V3R-V7R (n = 25) compared with; (1) all other infarcts (n- 104, p = 0.05), (2) inferior/posterior AMI without ST-elevation in these leads (n = 45, p = 0.09), and (3) anterior AMI (n = 59, p = 0.08).

Adult↗
PubMed1988

Potential time saving with pre-hospital intervention in acute myocardial infarction. Report of the European Myocardial Infarction Project (E.M.I.P) Sub-Committee.

The European Myocardial Infarction Project (E.M.I.P.) participants have evaluated out-of-hospital coronary care services in different cities within the E.E.C. and concluded that these facilities would support a study within these European centres on pre-hospital intervention in myocardial infarction. Based on a pilot study of 2443 patients with suspected myocardial infarction, simple criteria based on chest pain and first ECG finding have been defined to allow selection of out-of-hospital patients for a trial of pre-hospital drug evaluation. Pre-hospital treatment should reduce delay to intervention by about 1 h.

Adrenergic beta-Antagonists↗