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Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction.

ABSTRACT: BACKGROUND:Admission electrocardiographic (ECG) findings of non-ST-segment elevation myocardial infarction (NSTEMI) include transient ST-segment elevation (TSTE), ST-segment depression (STD), T-wave inversion (TWI), and no ischemic changes (NIC). HYPOTHESIS:This study aimed to assess the prognostic value of qualitative ECG findings at presentation and to clarify the influence of invasive treatment on the prognostic value of admission ECG findings. METHODS:We analyzed the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) study post hoc. NSTEMI patients were included and classified into four groups per ECG findings. Study endpoints were in-hospital and 30-day mortality rates and major adverse events (MAE). We performed multivariate logistic regression, adjusting for covariates in the Global Registry of Acute Coronary Events risk model, with subset analyses of patients treated with or without invasive management. RESULTS:STD patients had significantly higher in-hospital and 30-day mortality rates/MAE than TWI patients, which had lower in-hospital mortality rate/MAE than the NIC group. TSTE patients had intermediate outcomes. In multivariate logistic regression using the TWI group as the reference, STD and NIC remained independently associated with worse outcomes. Subset analysis showed prognostic value of admission ECG in non-invasively managed but not in invasively managed patients. CONCLUSIONS:STD was associated with adverse outcomes, TWI with benign prognoses. NIC should not be taken to indicate low risk. Qualitative analysis of admission ECG is suitable for rapid risk stratification of NSTMI patients at presentation. However, it may not be predictive of short-term outcomes of NSTEMI patients after invasive management.

SUBMITTER: Chen PF

PROVIDER: S-EPMC7299002 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction.

Chen Peng-Fei PF Tang Liang L Pei Jun-Yu JY Yi Jun-Lin JL Xing Zhen-Hua ZH Fang Zhen-Fei ZF Zhou Sheng-Hua SH Hu Xin-Qun XQ

Clinical cardiology 20200303 6

<h4>Background</h4>Admission electrocardiographic (ECG) findings of non-ST-segment elevation myocardial infarction (NSTEMI) include transient ST-segment elevation (TSTE), ST-segment depression (STD), T-wave inversion (TWI), and no ischemic changes (NIC).<h4>Hypothesis</h4>This study aimed to assess the prognostic value of qualitative ECG findings at presentation and to clarify the influence of invasive treatment on the prognostic value of admission ECG findings.<h4>Methods</h4>We analyzed the Ac ...[more]

PMID: 32125713

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Project description:ObjectivesGlobal left ventricular (LV) function is routinely used to assess cardiac function; however, myocardial strain is able to identify more subtle dysfunction. We aimed to determine the recovery and prognostic value of featuring tracking (FT) cardiovascular magnetic resonance (CMR) strain in ST-segment elevation myocardial infarction (STEMI) patients with a concurrent chronic total occlusion (CTO).MethodsIn the randomized EXPLORE trial, there was no significant difference in global LV function after percutaneous coronary intervention (PCI) of the CTO, compared with no-CTO PCI, post-STEMI. In the current study, we included 200 of the 302 EXPLORE patients with a baseline CMR, of which 180 also had 4-month follow-up (serial) CMR. Global longitudinal strain (GLS) was calculated from 3 long-axis views. Global circumferential strain (GCS) and segmental strain were calculated from 3 short-axis views (basal, mid, and apical).ResultsGlobal strain significantly improved at 4 months (GLS ? -?1.8?±?4.3%, p?<?0.001; GCS ? -?1.7?±?4.7%, p?<?0.001); however, there was no treatment effect of CTO-PCI on strain recovery. GLS was a significant predictor for 4 months of LV ejection fraction (p?=?0.006), incremental to other CMR parameters including infarct size. For mortality, infarct size remained the strongest predictor. On regional level, segmental strain independently predicted recovery in the dysfunctional segments (p?<?0.001).ConclusionsGlobal and segmental myocardial strains significantly improved over time, with no effect of CTO-PCI. Global strain was associated with outcome and segmental strain was an independent predictor for regional LV recovery in the dysfunctional CTO territory. Further research is needed to determine the additional prognostic value of strain beyond routine CMR parameters.Key points• In STEMI patients with a concurrent CTO, strain significantly improves over time, regardless of CTO-PCI. • Global strain is an independent predictor for functional recovery, incremental to infarct size, LVEF, and clinical parameters. • Segmental strain was able to predict the recovery of wall thickening, incremental to transmural extent of infarction.

Project description:ImportanceChallenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors.ObjectiveTo examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.Design, setting, and participantsThis multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.ExposuresCreation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology.Main outcomes and measuresPrimary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.ResultsA total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04).Conclusions and relevanceA hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

Dataset Information

Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction.

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Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction.

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