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Robert M Califf - One of the best experts on this subject based on the ideXlab platform.
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extent of ST Segment depression and cardiac events in non ST Segment elevation acute coronary syndromes
European Heart Journal, 2005Co-Authors: Stefano Savonitto, Galen S Wagner, Karen S Pieper, Mauricio G Cohen, Alessandro Politi, Michael P Hudson, David F Kong, Yao Huang, Francesco Mauri, Robert M CaliffAbstract:Aims We sought to determine whether the extent of myocardial ischaemia on the admission electrocardiogram (ECG) has independent predictive value for short-term risk STratification of patients with non-ST-Segment elevation acute coronary syndromes (NSTE ACS). Although the presence of ischaemic ECG changes on admission has been shown to predict outcome, the relationship between the extent of ECG changes and the risk of cardiac events is STill ill defined. Methods and results We analysed the admission ECGs of 5192 ACS patients enrolled in the GUSTO-IIb trial, without an ECG indication for thrombolysis. ECG tracings showing one or more of the following were eligible: ST-Segment depression >0.5 mm, T-wave inversion >1 mm, and ST-Segment elevation >0.5 mm but <1 mm. ECG variables associated with unfavourable 30 day outcomes in a univariable analysis were further assessed in a multivariable logiSTic regression model including independent clinical predictors. In the multivariable clinical, enzymatic, and ECG model, the sum of ST-Segment depression (in millimetres) in all leads was a powerful independent predictor of 30 day death ( P <0.0001), with a continuous increase in risk with the extent of ST-Segment depression. The sum of ST-Segment depression ( P <0.0001) and the presence of minimal inferior ST-Segment elevation ( P <0.0001) or anterior ST-Segment elevation ( P =0.0182) were also independent predictors of the composite of death and myocardial infarction or reinfarction. The extent of ST-Segment depression showed a highly significant correlation with the prevalence of three-vessel ( P <0.0001) or left main coronary disease ( P <0.0001), and also with the peak levels of creatine kinase ( P <0.0001) during the index episode of ACS. Conclusion In patients with NSTE ACS, the sum of ST-Segment depression in all ECG leads is a powerful predictor of all-cause mortality at 30 days, independent of clinical variables and correlates with the extent and severity of coronary artery disease. The presence of even minimal (<1 mm) ST-Segment elevation in anterior or inferior leads is independently associated with adverse outcomes.
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prognoSTic value of ST Segment depression in acute coronary syndromes insights from paragon a applied to guSTo iib
Journal of the American College of Cardiology, 2001Co-Authors: Padma Kaul, Robert M Califf, Weiching Chang, Robert A Harrington, Galen S Wagner, Shaun G Goodman, Christopher B Granger, David J Moliterno, Frans Van De Werf, Eric J TopolAbstract:AbSTract OBJECTIVES Our objectives were to develop a risk-STratification model addressing the importance of the magnitude and diSTribution of ST Segment depression in predicting long-term outcomes and to validate the model in an analogous patient population. BACKGROUND Although patients without ST Segment elevation presenting with acute coronary syndromes represent an increasingly frequent population admitted to coronary care units, little attention has been paid to quantifying their ST Segment abnormalities. METHODS ST Segment depression was categorized into three groups: 1) no ST Segment depression; 2) 1-mm ST Segment depression in two contiguous leads; and 3) ST Segment depression ≥2 mm in two contiguous leads. A logiSTic regression model was developed using Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON-A) data to assess the prognoSTic value of the extent and diSTribution of ST Segment depression in predicting one-year mortality. The model was validated using the non-ST Segment elevation population in Global Use of STrategies To Open occluded arteries in acute coronary syndromes (GUSTO-IIb). RESULTS ST Segment depression was the STrongeST predictor of one-year mortality, accounting for 35% of the model’s predictive power. Patients with ST Segment depression ≥2 mm were ∼6 times (odds ratio [OR] 5.73, 95% confidence interval [CI] 2.8 to 11.6) more likely to die within one year than patients with no ST Segment depression. On validation, the model showed good discriminatory power (c-index = 0.75). Patients with ST Segment depression ≥2 mm in more than one region were almoST 10 times more likely to die within one year than patients with no ST Segment depression. CONCLUSIONS These data provide new evidence supporting the powerful prognoSTic value of the baseline electrocardiogram and, in particular, the magnitude and diSTribution of ST Segment depression in predicting unfavorable events.
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comparative prognoSTic significance of simultaneous versus independent resolution of ST Segment depression relative to ST Segment elevation during acute myocardial infarction
Journal of the American College of Cardiology, 1997Co-Authors: Akbar Shah, Robert M Califf, Galen S Wagner, Robin Boineau, Cynthia L Green, Nancy M Wildermann, Kathleen M Trollinger, James E Pope, Mitchell W KrucoffAbstract:AbSTract Objectives. We sought to determine the prognoSTic significance of simultaneous versus independent resolution of ST Segment depression that occurs concomitant with ST Segment elevation during acute myocardial infarction (AMI). Background. ST Segment depression in leads other than those showing ST Segment elevation during AMI is a common phenomenon. Whether this indicates adverse outcomes remains controversial. We hypothesized that the timing of ST Segment depression resolution relative to ST Segment elevation resolution might differentiate between a high risk group and a low risk group of patients. Methods. Continuous 12-lead ST Segment monitoring was performed after thrombolytic therapy for AMI in 413 patients, 261 of whom met technical criteria for analysis. Blinded analysis of ST Segment depression resolution patterns was used to group patients as follows: 1) no ST Segment depression at any time (control group); 2) ST Segment depression resolving simultaneously with ST Segment elevation (simultaneous group); and 3) ST Segment depression persiSTing after ST Segment elevation resolution (independent group). These patterns were correlated with the outcomes—recurrent angina, reinfarction, heart failure and death—using chi-square analysis and the Fisher exact teST for categoric variables and the Wilcoxon rank-sum teST for continuous variables. Results. The incidence of recurrent angina, reinfarction and heart failure was similar among the three groups. In-hospital mortality, however, was significantly higher in the independent group (13%) than either the simultaneous group (1%, p Conclusions. Continuous analysis of ST Segment resolution identifies, among patients with AMI with concomitantly occurring ST Segment elevation and depression, a subgroup with increased in-hospital mortality. The pathogenic mechanism of increased mortality is not currently known.
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prognoSTic significance of precordial ST Segment depression during inferior myocardial infarction in the thrombolytic era results in 16 521 patients
Journal of the American College of Cardiology, 1996Co-Authors: Eric D Peterson, Eric R Bates, Eric J Topol, Galen S Wagner, Christopher B Granger, William R Hathaway, Michael K Zabel, Karen S Pieper, Maarten L Simoons, Robert M CaliffAbstract:Objectives. We examined the prognoSTic significance of precordial ST Segment depression among patients with an acute inferior myocardial infarction. Background. Although precordial ST Segment depression has been associated with a poor prognosis, this correlation has not been adequately quantified, partly because of small sample sizes and methodologic limitations in previous STudies. Methods. We examined the clinical and angiographic outcomes of 16,521 patients with an acute inferior myocardial infarction who underwent thrombolysis in the Global Utilization of STreptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) STudy. Patients were classified into those without precordial ST Segment depression (n = 6,422 [38.9%]), those with ST Segment depression in leads V 1 to V 3 only (n = 5,850 [35.4%]), those with ST Segment depression in leads V 4 to V 6 only (n = 876 [5.3%]) and those with ST Segment depression in both leads V 1 to V 3 and leads V 4 to V 6 (n = 3,373 [20.4%]) on initial electrocardiography. Outcome measures included poSTinfarction complications (second- or third-degree heart block, congeSTive heart failure or shock) and 30-day and 1-year mortality. Results. Patients with precordial ST Segment depression had larger infarctions, more poSTinfarction complications and a higher mortality rate than those without precordial ST Segment depression (4.7% vs. 3.2% at 30 days; 5.0% vs. 3.4% at 1 year; both p 1 to V 6 or in leads V 4 to V 6 . The magnitude of precordial ST Segment depression (sum of leads V 1 to V 6 ) added significant independent prognoSTic information after adjuSTment for clinical risk factors; the risk of 30-day mortality increased by 36% for every 0.5 mV of precordial ST Segment depression. Conclusions. Assessment of the magnitude of precordial ST Segment depression is useful for acute risk STratification in patients with an inferior myocardial infarction.
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prognoSTic significance of precordial ST Segment depression during inferior myocardial infarction in the thrombolytic era results in 16 521 patients
Journal of the American College of Cardiology, 1996Co-Authors: Eric D Peterson, Eric R Bates, Eric J Topol, Galen S Wagner, Christopher B Granger, William R Hathaway, Michael K Zabel, Karen S Pieper, Maarten L Simoons, Robert M CaliffAbstract:Objectives.: We examined the prognoSTic significance of precordial ST Segment depression among patients with an acute inferior myocardial infarction.Background.: Although precordial ST Segment depr...
Yochai Birnbaum - One of the best experts on this subject based on the ideXlab platform.
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acute coronary syndromes presenting with transient diffuse ST Segment depression and ST Segment elevation in lead avr not caused by acute left main coronary artery occlusion description of two cases
Annals of Noninvasive Electrocardiology, 2013Co-Authors: Edward D Kim, Yochai BirnbaumAbstract:Background Diffuse ST-Segment depression in the inferior + anterolateral leads with ST-Segment elevation in lead aVR has been described as characteriSTic of diffuse circumferential subendocardial ischemia caused by acute subtotal occlusion of the left main coronary artery. Methods Here we describe two patients admitted for acute neurological disorders who developed transient diffuse ST-Segment depression in the inferior + anterolateral leads with ST-Segment elevation in lead aVR, associated with elevation of cardiac troponin-I. Results In both cases subsequent coronary angiography did not show significant left main STenosis or “left main equivalent” narrowings. Conclusions As both patients had acute neurological disorders, a possible association between the two conditions is discussed.
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prognoSTic significance of precordial ST Segment depression on admission electrocardiogram in patients with inferior wall myocardial infarction
Journal of the American College of Cardiology, 1996Co-Authors: Yochai Birnbaum, Samuel Sclarovsky, Izhak Herz, Bruria Zlotikamien, Angela Chetrit, Liraz Olmer, Gabriel I BarbashAbstract:Objectives. This STudy assessed retrospectively the correlation between the pattern of precordial ST Segment depression on the admission electrocardiogram (ECG) and hospital mortality in patients with an inferior myocardial infarction treated with intravenous thrombolytic therapy. Background. Previous STudies have shown that in acute inferior myocardial infarction, ST Segment depression in the precordial leads is associated with increased hospital mortality. However, the significance of the different patterns of precordial ST Segment depression has been evaluated in only two previous STudies. Methods. The STudy included 1,321 patients (1,020 men) who enrolled in the Global Utilization of STreptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial in Israel and received intravenous thrombolytic therapy. Patients with an ST Segment elevation ≥0.1 mV in at leaST two of the inferior leads were included. Patients were classified into four groups on the basis of their admission ECG: group I = patients with no precordial ST Segment depression (n = 346); group II = those for whom the sum of ST Segment depression in leads V1 to V3 was greater than that in leads V4 to V6 (n = 700); group III = those for whom the sum of ST depression in leads V1 to V3 was equal to that in leads V4 to V6 (n = 162); group IV = those with maximal ST depression in leads V4 to V6 (n = 113). Results. The overall hospital mortality rate was 3.6% (48 patients): for groups I, II, III and IV it was 2.9%, 2.8%, 4.3% and 9.7%, respectively. Multivariable logiSTic regression analysis confirmed that hospital mortality was independently associated with the pattern of precordial ST Segment depression. The odd ratios in group IV relative to group I was 2.78 (95% confidence interval 1.26 to 6.13, p = 0.007). Conclusions. The risk of mortality is higher in patients with an inferior myocardial infarction and maximal ST Segment depression in precordial leads V4 to V6 versus precordial leads V1 to V3 on the admission ECG.
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ST Segment depression in lateral limb leads in inferior wall acute myocardial infarction
European Heart Journal, 1995Co-Authors: David Hasdai, Yochai Birnbaum, Samuel Sclarovsky, Itzhak Herz, Alexander Mazur, Alejandro SolodkyAbstract:We examined whether the pattern of ST Segment depression in lateral leads (I, aVL, V5, V6) in the initial electrocardiogram of patients (n=88) with inferior wall acute myocardial infarction (ST Segment elevation of ≧1 mm in ≧2 inferior leads) correlates with the site of obSTruction, as determined angiographically during acute hospitalization. Of the 62 patients in which the culprit artery could be determined unequivocally, in 46 the culprit artery was the right coronary artery (20 proximal to the firST right ventricular branch and 26 diSTal), and in 16 the left circumflex coronary artery (seven proximal to the firST marginal branch or involving a high firST marginal branch, and nine with diSTal obSTruction). Significant ST Segment depression (ST≦1 mm) in leads I and aVL was more common in right coronary artery obSTruction (P<0.05 and P<0.0001, respectively). The absence of significant ST Segment depression in lead a VL was moST common in proximal circumflex obSTruction (P<0.0001), with a similar trend for lead I (P<0.11). ST Segment depression patterns in leads V5 and V6 were not indicative of the infarct-related artery or the site of obSTruction. Thus, significant ST Segment depression in leads I and aVL indicates right coronary artery-associated inferior wall acute myocardial infarction with a sensitivity of 70% and 100%, and a specificity of 63% and 38%, respectively, whereas the lack of ST Segment depression in these leads indicates proximal circumflex obSTruction with a sensitivity of 71% and 86%, and a specificity of 65% and 100%, respectively.
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implications of inferior ST Segment depression in anterior acute myocardial infarction electrocardiographic and angiographic correlation
American Heart Journal, 1994Co-Authors: Yochai Birnbaum, Alejandro Solodky, Itzhak Herz, Jairo Kusniec, Eldad Rechavia, Jaqueline Sulkes, Samuel SclarovskyAbstract:AbSTract This STudy assesses the significance of inferior ST-Segment depression during anterior acute myocardial infarction (AMI) by inveSTigating the relationship between inferior ST-Segment depression and (1) the site of the left anterior descending (LAD) coronary artery lesion and (2) ST-Segment deviation in the various anterior and lateral leads. We STudied 126 patients with anterior AMI who underwent coronary angiography within 21 days of hospitalization. The admission 12-lead electrocardiograms were evaluated for ST-Segment amplitude in each lead at 0.08 second after the J-point. Coronary angiography was evaluated for the site and severity of luminal narrowing of the coronary arteries. The site of the culprit lesion in the LAD artery, relative to the origin of the firST septal and diagonal branches, was determined. In four patients no lesion was identified in the LAD artery. Of the remaining 122 patients, 40 and 53 patients had a LAD artery lesion proximal to the firST septal and firST diagonal branches, respectively. Additional luminal narrowing (≥70% of diameter) was found in the circumflex and the right coronary arteries in 27 and 37 patients, respectively. ST-Segment depression of >1 mm in leads II, III, and aVF was noted in 24, 29, and 24 patients, respectively. The prevalence of a LAD artery preseptal and prediagonal lesion was higher in patients with inferior ST-Segment depression. The positive predictive values of ST-Segment depression >1 mm in leads II, III, and aVF for a lesion proximal to the firST septal branch were 58.3%, 65.5%, and 75%, respectively, and those for a prediagonal lesion were 70.8%, 79.3%, and 87.5%. The corresponding specificities were 88%, 88%, and 93% for a preseptal lesion, and 90%, 91%, and 96% for a prediagonal lesion. No differences were observed between the groups with interior ST-Segment depression in the diSTribution of single-vessel or three-vessel disease or significant right or circumflex coronary artery narrowing. Univariate linear regression models revealed that the magnitude of the ST amplitude in leads III and aVF is mainly affected by the ST amplitude in leads I and aVL (coefficient of the regression −0.75 and −0.80, R 2 = 43% and 68%, for lead III, respectively; coefficient of the regression −0.57, and −0.66, R 2 = 32% and 58%, for lead aVF, respectively). The magnitude of the ST deviation in the precordial leads has only a minor impact on the inferior ST-Segment deviation. Multivariate regression models confirmed that the ST deviation in leads III and aVF is mainly influenced by the ST levels in aVL. It is concluded that ST-Segment depression in the inferior leads during anterior AMI represents reciprocal changes to the high anterolateral region, shown by ST-Segment elevation in leads I and aVL. ST depression in the inferior leads predicts a culprit lesion proximal to the origin of the firST diagonal branch. No relationship was found between the magnitude of ST-Segment depression in leads II, III, and aVF and the occurrence of right coronary or left circumflex artery narrowing or three-vessel disease.
Galen S Wagner - One of the best experts on this subject based on the ideXlab platform.
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resolution of ST Segment depression a new prognoSTic marker in ST Segment elevation myocardial infarction
European Heart Journal, 2010Co-Authors: Michael C Tjandrawidjaja, Galen S Wagner, Christopher B Granger, Frans Van De Werf, Cynthia M Westerhout, Harvey D White, Thomas G Todaro, Kenneth W Mahaffey, Paul W ArmstrongAbstract:Aims To evaluate the prognoSTic impact of ST depression resolution among patients with ST-Segment elevation myocardial infarction (STEMI) undergoing primary PCI in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. Methods and results In this STudy, 4729 of 5745 patients had analysable ECGs demonSTrating concomitant ST-Segment depression. Resolution of ∑ST elevation (STE-R) and ∑ST depression (STD-R) on 30 min poST-PCI ECGs was dichotomized into those with ≥50 vs. I, triple vessel disease, and less frequent TIMI 3 flow in the culprit coronary vessel poST-PCI. After multivariable adjuSTment and accounting for STE-R, STD-R<50% remained an independent predictor for 90 day death and the composite of death, cardiogenic shock, or CHF. When compared with patients with both STE-R and STD-R≥50%, patients with both STE-R and STD-R<50% had the worST outcomes [hazard ratios (HR) 90 day death: 2.54; 95% confidence intervals (CI): 1.71–3.77; HR 90 day composite: 2.18; 95% CI: 1.63–2.91]. Conclusion When ST depression is present in STEMI patients undergoing primary PCI, STD-R<50% provides independent prognoSTic value that is incremental to STE-R.
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extent of ST Segment depression and cardiac events in non ST Segment elevation acute coronary syndromes
European Heart Journal, 2005Co-Authors: Stefano Savonitto, Galen S Wagner, Karen S Pieper, Mauricio G Cohen, Alessandro Politi, Michael P Hudson, David F Kong, Yao Huang, Francesco Mauri, Robert M CaliffAbstract:Aims We sought to determine whether the extent of myocardial ischaemia on the admission electrocardiogram (ECG) has independent predictive value for short-term risk STratification of patients with non-ST-Segment elevation acute coronary syndromes (NSTE ACS). Although the presence of ischaemic ECG changes on admission has been shown to predict outcome, the relationship between the extent of ECG changes and the risk of cardiac events is STill ill defined. Methods and results We analysed the admission ECGs of 5192 ACS patients enrolled in the GUSTO-IIb trial, without an ECG indication for thrombolysis. ECG tracings showing one or more of the following were eligible: ST-Segment depression >0.5 mm, T-wave inversion >1 mm, and ST-Segment elevation >0.5 mm but <1 mm. ECG variables associated with unfavourable 30 day outcomes in a univariable analysis were further assessed in a multivariable logiSTic regression model including independent clinical predictors. In the multivariable clinical, enzymatic, and ECG model, the sum of ST-Segment depression (in millimetres) in all leads was a powerful independent predictor of 30 day death ( P <0.0001), with a continuous increase in risk with the extent of ST-Segment depression. The sum of ST-Segment depression ( P <0.0001) and the presence of minimal inferior ST-Segment elevation ( P <0.0001) or anterior ST-Segment elevation ( P =0.0182) were also independent predictors of the composite of death and myocardial infarction or reinfarction. The extent of ST-Segment depression showed a highly significant correlation with the prevalence of three-vessel ( P <0.0001) or left main coronary disease ( P <0.0001), and also with the peak levels of creatine kinase ( P <0.0001) during the index episode of ACS. Conclusion In patients with NSTE ACS, the sum of ST-Segment depression in all ECG leads is a powerful predictor of all-cause mortality at 30 days, independent of clinical variables and correlates with the extent and severity of coronary artery disease. The presence of even minimal (<1 mm) ST-Segment elevation in anterior or inferior leads is independently associated with adverse outcomes.
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consideration of the total ST Segment deviation on the initial electrocardiogram for predicting final acute poSTerior myocardial infarct size in patients with maximum ST Segment deviation as depression in leads v1 through v3 a frisc ii subSTudy
Journal of Electrocardiology, 2005Co-Authors: Rasmus S Ripa, Bo Lagerqvist, Peter Clemmensen, Lene Holmvang, Charles Maynard, Maria Sejersten, Peer Grande, Bertil Lindahl, Lars Wallentin, Galen S WagnerAbstract:AbSTract Background Because patients with acute left circumflex occlusion are typically characterized primarily on the STandard 12-lead electrocardiogram (ECG) by ST depression, they do not qualify to receive reperfusion therapy. Documentation of a relationship between the quantities of acute ST change and final QRS eSTimated acute myocardial infarction (AMI) size could form the basis for clinical trials to determine the value of reperfusion therapy. Method The Fragmin and FaST Revascularization during InSTability in Coronary artery disease trial included 3214 patients with unSTable coronary artery disease. Two percent of the patients (n = 69) had maximum ST-Segment depression in leads V1 through V3 and were selected for this STudy. Initial ECG changes were compared to final myocardial infarction size, using the SelveSTer QRS score as the end point. Results The quantity of initial ST-Segment deviation correlated with the final AMI size (r = 0.43, P Conclusion The quantitative initial ST-Segment deviation correlates linearly to the final AMI size in patients with maximum ST-Segment depression in leads V1 through V3. The formula derived could be valuable for selecting patients who fail to meet STrict ST-elevation AMI criteria for emergency intravenous or intracoronary reperfusion therapy.
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prognoSTic value of ST Segment depression in acute coronary syndromes insights from paragon a applied to guSTo iib
Journal of the American College of Cardiology, 2001Co-Authors: Padma Kaul, Robert M Califf, Weiching Chang, Robert A Harrington, Galen S Wagner, Shaun G Goodman, Christopher B Granger, David J Moliterno, Frans Van De Werf, Eric J TopolAbstract:AbSTract OBJECTIVES Our objectives were to develop a risk-STratification model addressing the importance of the magnitude and diSTribution of ST Segment depression in predicting long-term outcomes and to validate the model in an analogous patient population. BACKGROUND Although patients without ST Segment elevation presenting with acute coronary syndromes represent an increasingly frequent population admitted to coronary care units, little attention has been paid to quantifying their ST Segment abnormalities. METHODS ST Segment depression was categorized into three groups: 1) no ST Segment depression; 2) 1-mm ST Segment depression in two contiguous leads; and 3) ST Segment depression ≥2 mm in two contiguous leads. A logiSTic regression model was developed using Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON-A) data to assess the prognoSTic value of the extent and diSTribution of ST Segment depression in predicting one-year mortality. The model was validated using the non-ST Segment elevation population in Global Use of STrategies To Open occluded arteries in acute coronary syndromes (GUSTO-IIb). RESULTS ST Segment depression was the STrongeST predictor of one-year mortality, accounting for 35% of the model’s predictive power. Patients with ST Segment depression ≥2 mm were ∼6 times (odds ratio [OR] 5.73, 95% confidence interval [CI] 2.8 to 11.6) more likely to die within one year than patients with no ST Segment depression. On validation, the model showed good discriminatory power (c-index = 0.75). Patients with ST Segment depression ≥2 mm in more than one region were almoST 10 times more likely to die within one year than patients with no ST Segment depression. CONCLUSIONS These data provide new evidence supporting the powerful prognoSTic value of the baseline electrocardiogram and, in particular, the magnitude and diSTribution of ST Segment depression in predicting unfavorable events.
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comparative prognoSTic significance of simultaneous versus independent resolution of ST Segment depression relative to ST Segment elevation during acute myocardial infarction
Journal of the American College of Cardiology, 1997Co-Authors: Akbar Shah, Robert M Califf, Galen S Wagner, Robin Boineau, Cynthia L Green, Nancy M Wildermann, Kathleen M Trollinger, James E Pope, Mitchell W KrucoffAbstract:AbSTract Objectives. We sought to determine the prognoSTic significance of simultaneous versus independent resolution of ST Segment depression that occurs concomitant with ST Segment elevation during acute myocardial infarction (AMI). Background. ST Segment depression in leads other than those showing ST Segment elevation during AMI is a common phenomenon. Whether this indicates adverse outcomes remains controversial. We hypothesized that the timing of ST Segment depression resolution relative to ST Segment elevation resolution might differentiate between a high risk group and a low risk group of patients. Methods. Continuous 12-lead ST Segment monitoring was performed after thrombolytic therapy for AMI in 413 patients, 261 of whom met technical criteria for analysis. Blinded analysis of ST Segment depression resolution patterns was used to group patients as follows: 1) no ST Segment depression at any time (control group); 2) ST Segment depression resolving simultaneously with ST Segment elevation (simultaneous group); and 3) ST Segment depression persiSTing after ST Segment elevation resolution (independent group). These patterns were correlated with the outcomes—recurrent angina, reinfarction, heart failure and death—using chi-square analysis and the Fisher exact teST for categoric variables and the Wilcoxon rank-sum teST for continuous variables. Results. The incidence of recurrent angina, reinfarction and heart failure was similar among the three groups. In-hospital mortality, however, was significantly higher in the independent group (13%) than either the simultaneous group (1%, p Conclusions. Continuous analysis of ST Segment resolution identifies, among patients with AMI with concomitantly occurring ST Segment elevation and depression, a subgroup with increased in-hospital mortality. The pathogenic mechanism of increased mortality is not currently known.
Samuel Sclarovsky - One of the best experts on this subject based on the ideXlab platform.
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ST Segment deviation pattern of takotsubo cardiomyopathy similar to acute pericarditis diffuse ST Segment elevation
Journal of Electrocardiology, 2013Co-Authors: Zhan Zhongqun, Samuel Sclarovsky, Wang Chongquan, Kjell Nikus, He Chaorong, Mao ShanAbstract:AbSTract Background Possible similarities or differences in the ST- and PR-Segment deviations in the electrocardiogram of takotsubo cardiomyopathy (TTC) and acute pericarditis (AP) are not well defined. Methods We compared different parameters of the admission electrocardiogram in eight patients with TTC and eight patients with AP with ST-Segment elevation in the acute phase. Results We found significant differences in the maximal magnitude of the T wave in the precordial leads, but not in the ST- and PR-Segment deviation patterns between the two patient groups. All the patients in the two groups showed consiSTent ST-Segment depression in lead aVR and absence of ST-Segment elevation in lead V1. Conclusions The ST- and PR-Segment deviation patterns in TTC are similar to that of AP, namely diffuse ST-Segment elevations with reciprocal changes in aVR and V1 and PR-Segment elevation in aVR accompanied by PR-Segment depression in the inferior leads, possibly indicating that TTC has ECG characteriSTics of circumferential subepicardial ischemia in the acute phase.
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prognoSTic significance of precordial ST Segment depression on admission electrocardiogram in patients with inferior wall myocardial infarction
Journal of the American College of Cardiology, 1996Co-Authors: Yochai Birnbaum, Samuel Sclarovsky, Izhak Herz, Bruria Zlotikamien, Angela Chetrit, Liraz Olmer, Gabriel I BarbashAbstract:Objectives. This STudy assessed retrospectively the correlation between the pattern of precordial ST Segment depression on the admission electrocardiogram (ECG) and hospital mortality in patients with an inferior myocardial infarction treated with intravenous thrombolytic therapy. Background. Previous STudies have shown that in acute inferior myocardial infarction, ST Segment depression in the precordial leads is associated with increased hospital mortality. However, the significance of the different patterns of precordial ST Segment depression has been evaluated in only two previous STudies. Methods. The STudy included 1,321 patients (1,020 men) who enrolled in the Global Utilization of STreptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial in Israel and received intravenous thrombolytic therapy. Patients with an ST Segment elevation ≥0.1 mV in at leaST two of the inferior leads were included. Patients were classified into four groups on the basis of their admission ECG: group I = patients with no precordial ST Segment depression (n = 346); group II = those for whom the sum of ST Segment depression in leads V1 to V3 was greater than that in leads V4 to V6 (n = 700); group III = those for whom the sum of ST depression in leads V1 to V3 was equal to that in leads V4 to V6 (n = 162); group IV = those with maximal ST depression in leads V4 to V6 (n = 113). Results. The overall hospital mortality rate was 3.6% (48 patients): for groups I, II, III and IV it was 2.9%, 2.8%, 4.3% and 9.7%, respectively. Multivariable logiSTic regression analysis confirmed that hospital mortality was independently associated with the pattern of precordial ST Segment depression. The odd ratios in group IV relative to group I was 2.78 (95% confidence interval 1.26 to 6.13, p = 0.007). Conclusions. The risk of mortality is higher in patients with an inferior myocardial infarction and maximal ST Segment depression in precordial leads V4 to V6 versus precordial leads V1 to V3 on the admission ECG.
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ST Segment depression in lateral limb leads in inferior wall acute myocardial infarction
European Heart Journal, 1995Co-Authors: David Hasdai, Yochai Birnbaum, Samuel Sclarovsky, Itzhak Herz, Alexander Mazur, Alejandro SolodkyAbstract:We examined whether the pattern of ST Segment depression in lateral leads (I, aVL, V5, V6) in the initial electrocardiogram of patients (n=88) with inferior wall acute myocardial infarction (ST Segment elevation of ≧1 mm in ≧2 inferior leads) correlates with the site of obSTruction, as determined angiographically during acute hospitalization. Of the 62 patients in which the culprit artery could be determined unequivocally, in 46 the culprit artery was the right coronary artery (20 proximal to the firST right ventricular branch and 26 diSTal), and in 16 the left circumflex coronary artery (seven proximal to the firST marginal branch or involving a high firST marginal branch, and nine with diSTal obSTruction). Significant ST Segment depression (ST≦1 mm) in leads I and aVL was more common in right coronary artery obSTruction (P<0.05 and P<0.0001, respectively). The absence of significant ST Segment depression in lead a VL was moST common in proximal circumflex obSTruction (P<0.0001), with a similar trend for lead I (P<0.11). ST Segment depression patterns in leads V5 and V6 were not indicative of the infarct-related artery or the site of obSTruction. Thus, significant ST Segment depression in leads I and aVL indicates right coronary artery-associated inferior wall acute myocardial infarction with a sensitivity of 70% and 100%, and a specificity of 63% and 38%, respectively, whereas the lack of ST Segment depression in these leads indicates proximal circumflex obSTruction with a sensitivity of 71% and 86%, and a specificity of 65% and 100%, respectively.
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implications of inferior ST Segment depression in anterior acute myocardial infarction electrocardiographic and angiographic correlation
American Heart Journal, 1994Co-Authors: Yochai Birnbaum, Alejandro Solodky, Itzhak Herz, Jairo Kusniec, Eldad Rechavia, Jaqueline Sulkes, Samuel SclarovskyAbstract:AbSTract This STudy assesses the significance of inferior ST-Segment depression during anterior acute myocardial infarction (AMI) by inveSTigating the relationship between inferior ST-Segment depression and (1) the site of the left anterior descending (LAD) coronary artery lesion and (2) ST-Segment deviation in the various anterior and lateral leads. We STudied 126 patients with anterior AMI who underwent coronary angiography within 21 days of hospitalization. The admission 12-lead electrocardiograms were evaluated for ST-Segment amplitude in each lead at 0.08 second after the J-point. Coronary angiography was evaluated for the site and severity of luminal narrowing of the coronary arteries. The site of the culprit lesion in the LAD artery, relative to the origin of the firST septal and diagonal branches, was determined. In four patients no lesion was identified in the LAD artery. Of the remaining 122 patients, 40 and 53 patients had a LAD artery lesion proximal to the firST septal and firST diagonal branches, respectively. Additional luminal narrowing (≥70% of diameter) was found in the circumflex and the right coronary arteries in 27 and 37 patients, respectively. ST-Segment depression of >1 mm in leads II, III, and aVF was noted in 24, 29, and 24 patients, respectively. The prevalence of a LAD artery preseptal and prediagonal lesion was higher in patients with inferior ST-Segment depression. The positive predictive values of ST-Segment depression >1 mm in leads II, III, and aVF for a lesion proximal to the firST septal branch were 58.3%, 65.5%, and 75%, respectively, and those for a prediagonal lesion were 70.8%, 79.3%, and 87.5%. The corresponding specificities were 88%, 88%, and 93% for a preseptal lesion, and 90%, 91%, and 96% for a prediagonal lesion. No differences were observed between the groups with interior ST-Segment depression in the diSTribution of single-vessel or three-vessel disease or significant right or circumflex coronary artery narrowing. Univariate linear regression models revealed that the magnitude of the ST amplitude in leads III and aVF is mainly affected by the ST amplitude in leads I and aVL (coefficient of the regression −0.75 and −0.80, R 2 = 43% and 68%, for lead III, respectively; coefficient of the regression −0.57, and −0.66, R 2 = 32% and 58%, for lead aVF, respectively). The magnitude of the ST deviation in the precordial leads has only a minor impact on the inferior ST-Segment deviation. Multivariate regression models confirmed that the ST deviation in leads III and aVF is mainly influenced by the ST levels in aVL. It is concluded that ST-Segment depression in the inferior leads during anterior AMI represents reciprocal changes to the high anterolateral region, shown by ST-Segment elevation in leads I and aVL. ST depression in the inferior leads predicts a culprit lesion proximal to the origin of the firST diagonal branch. No relationship was found between the magnitude of ST-Segment depression in leads II, III, and aVF and the occurrence of right coronary or left circumflex artery narrowing or three-vessel disease.
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ST Segment resolution 60 minutes after combination treatment of abciximab with reteplase or reteplase alone for acute myocardial infarction 30 day mortality results from the resolution of ST Segment after reperfusion therapy subSTudy
American Journal of Cardiology, 2004Co-Authors: Fernando A Cura, Eric J Topol, Marco Roffi, Narcis Pasca, Katherine E Wolski, Michael A Lincoff, Michael S LauerAbstract:The combination of abciximab with thrombolytic therapy when treating acute ST-elevation myocardial infarction has been hypothesized to enhance microvascular perfusion. Resolution of ST-Segment elevation after thrombolytic therapy is believed to be a marker of myocardial reperfusion and to predict mortality rate. Among 16,588 patients enrolled in the Fifth Global Use of STrategies to Open Occluded Arteries in Acute Myocardial Infarction trial, 1,764 consecutive patients from selected centers had their STudy electrocardiograms evaluated by a core laboratory for ST-Segment deviation resolution 60 minutes after treatment. Patients were categorized into 4 groups: complete resolution (>70%), partial resolution ( 70% ST-Segment resolution within 60 minutes had markedly decreased mortality rates, irrespective of treatment.
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prognoSTic value of ST Segment depression in acute coronary syndromes insights from paragon a applied to guSTo iib
Journal of the American College of Cardiology, 2001Co-Authors: Padma Kaul, Robert M Califf, Weiching Chang, Robert A Harrington, Galen S Wagner, Shaun G Goodman, Christopher B Granger, David J Moliterno, Frans Van De Werf, Eric J TopolAbstract:AbSTract OBJECTIVES Our objectives were to develop a risk-STratification model addressing the importance of the magnitude and diSTribution of ST Segment depression in predicting long-term outcomes and to validate the model in an analogous patient population. BACKGROUND Although patients without ST Segment elevation presenting with acute coronary syndromes represent an increasingly frequent population admitted to coronary care units, little attention has been paid to quantifying their ST Segment abnormalities. METHODS ST Segment depression was categorized into three groups: 1) no ST Segment depression; 2) 1-mm ST Segment depression in two contiguous leads; and 3) ST Segment depression ≥2 mm in two contiguous leads. A logiSTic regression model was developed using Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON-A) data to assess the prognoSTic value of the extent and diSTribution of ST Segment depression in predicting one-year mortality. The model was validated using the non-ST Segment elevation population in Global Use of STrategies To Open occluded arteries in acute coronary syndromes (GUSTO-IIb). RESULTS ST Segment depression was the STrongeST predictor of one-year mortality, accounting for 35% of the model’s predictive power. Patients with ST Segment depression ≥2 mm were ∼6 times (odds ratio [OR] 5.73, 95% confidence interval [CI] 2.8 to 11.6) more likely to die within one year than patients with no ST Segment depression. On validation, the model showed good discriminatory power (c-index = 0.75). Patients with ST Segment depression ≥2 mm in more than one region were almoST 10 times more likely to die within one year than patients with no ST Segment depression. CONCLUSIONS These data provide new evidence supporting the powerful prognoSTic value of the baseline electrocardiogram and, in particular, the magnitude and diSTribution of ST Segment depression in predicting unfavorable events.
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prognoSTic significance of precordial ST Segment depression during inferior myocardial infarction in the thrombolytic era results in 16 521 patients
Journal of the American College of Cardiology, 1996Co-Authors: Eric D Peterson, Eric R Bates, Eric J Topol, Galen S Wagner, Christopher B Granger, William R Hathaway, Michael K Zabel, Karen S Pieper, Maarten L Simoons, Robert M CaliffAbstract:Objectives. We examined the prognoSTic significance of precordial ST Segment depression among patients with an acute inferior myocardial infarction. Background. Although precordial ST Segment depression has been associated with a poor prognosis, this correlation has not been adequately quantified, partly because of small sample sizes and methodologic limitations in previous STudies. Methods. We examined the clinical and angiographic outcomes of 16,521 patients with an acute inferior myocardial infarction who underwent thrombolysis in the Global Utilization of STreptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) STudy. Patients were classified into those without precordial ST Segment depression (n = 6,422 [38.9%]), those with ST Segment depression in leads V 1 to V 3 only (n = 5,850 [35.4%]), those with ST Segment depression in leads V 4 to V 6 only (n = 876 [5.3%]) and those with ST Segment depression in both leads V 1 to V 3 and leads V 4 to V 6 (n = 3,373 [20.4%]) on initial electrocardiography. Outcome measures included poSTinfarction complications (second- or third-degree heart block, congeSTive heart failure or shock) and 30-day and 1-year mortality. Results. Patients with precordial ST Segment depression had larger infarctions, more poSTinfarction complications and a higher mortality rate than those without precordial ST Segment depression (4.7% vs. 3.2% at 30 days; 5.0% vs. 3.4% at 1 year; both p 1 to V 6 or in leads V 4 to V 6 . The magnitude of precordial ST Segment depression (sum of leads V 1 to V 6 ) added significant independent prognoSTic information after adjuSTment for clinical risk factors; the risk of 30-day mortality increased by 36% for every 0.5 mV of precordial ST Segment depression. Conclusions. Assessment of the magnitude of precordial ST Segment depression is useful for acute risk STratification in patients with an inferior myocardial infarction.
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prognoSTic significance of precordial ST Segment depression during inferior myocardial infarction in the thrombolytic era results in 16 521 patients
Journal of the American College of Cardiology, 1996Co-Authors: Eric D Peterson, Eric R Bates, Eric J Topol, Galen S Wagner, Christopher B Granger, William R Hathaway, Michael K Zabel, Karen S Pieper, Maarten L Simoons, Robert M CaliffAbstract:Objectives.: We examined the prognoSTic significance of precordial ST Segment depression among patients with an acute inferior myocardial infarction.Background.: Although precordial ST Segment depr...
