Abstract
Background: The relationship between the severity of chronic‐phase stenosis of infarct‐related lesions (IRLs) and chronic left ventricular function in anterior acute myocardial infarctions (AMI) has not been adequately investigated.
Hypothesis: This study investigated whether ST elevation in lead aVL of admission electrocardiogram (ECG) would be a determinant factor of the relationship between the severity of stenosis of the IRL and chronic left ventricular function after anterior wall AMI.
Methods: One month after AMI, the IRL was evaluated by coronary angiography in 98 patients with anterior AMI, and left ventricular ejection fraction (LVEF) was determined using multigated radionuclide angiocardiography. Patients were classified according to the severity of the IRL: patients with 100% occlusion (Group O), patients with 90 to 99% stenosis (Group H), and patients with ≤ 75% stenosis (Group L). Patients with ST elevation ≥ 0.1 mV in the aVL lead on their admission ECG were included in the ST‐elevation group, and those with ST elevation < 0.1 mV were included in the non‐ST‐elevation group.
Results: The LVEF was greater in the non‐ST‐elevation group than in the ST‐elevation group (p<0.0001), and the LVEF in a whole group as follows: Group L LVEF>Group H LVEF>Group O LVEF (p = 0.0160). In the ST‐elevation group, LVEF was higher in Group L than in the other groups (p = 0.0251). There were three independent predictors of a reduced LVEF: ST‐elevation in aVL [odds ratio (OR): 3.38, p = 0.0044], IRL stenosis ≥ 90% (OR: 2.90, p = 0.0044), and the IRL occurring in the left anterior descending artery proximal to the first diagonal branch (OR: 6.31, p = 0.0024).
Conclusion: Left ventricular function was preserved, regardless of the severity of residual stenosis, in patients without ST elevation in aVL if the IRL was not totally occluded. In patients with ST elevation in aVL, LVEF was lower in patients with more severe stenosis, even if the IRL was patent.
Keywords: myocardial infarction, electrocardiography, left ventricular function
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References
- 1. ISIS‐2 (Second International Study of Infarct Survival) Collaborative Group : Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS‐2. Lancet 1988; ii: 349–360 [PubMed] [Google Scholar]
- 2. GISSI (Gruppo Italiano per lo Studio della Streptochinasi nell Infarto Miocardico) : Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; i: 397–402 [PubMed] [Google Scholar]
- 3. GUSTO Investigators : An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329: 679–682 [DOI] [PubMed] [Google Scholar]
- 4. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group : Indications for fibrinolytic therapy in suspected acute myocardial infarction: Collaborative trials of more than 1000 patients. Lancet 1994; 343: 311–322 [PubMed] [Google Scholar]
- 5. Hochman JS, Choo H: Limitation of myocardial infarct expansion by reperfusion independent of myocardial salvage. Circulation 1987; 75: 299–306 [DOI] [PubMed] [Google Scholar]
- 6. Hale SL, Kloner RA: Left ventricular topographic alterations in the completely healed rat infarct caused by early and late coronary artery reperfusion. Am Heart J 1988; 116: 1508–1513 [DOI] [PubMed] [Google Scholar]
- 7. Force T, Kemper A, Leavitt M, Parisi AF: Acute reduction in functional infarct expansion with late coronary reperfusion: Assessment with quantitative two‐dimensional echocardiography. J Am Coll Cardiol 1988; 11: 192–200 [DOI] [PubMed] [Google Scholar]
- 8. Braunwald E, Kim CB: Late establishment of patency of the infarct‐related artery In Management of Acute Myocardial Infarction (Eds. Julian D, Braunwald E.), p. 147–162. London: WB Saunders Ltd., 1994. [Google Scholar]
- 9. Jeremy RW, Hackworthy RA, Bautovich G, Hutton BF, Harris PJ: Infarct artery perfusion and changes in left ventricular volume in the month after acute myocardial infarction. J Am Coll Cardiol 1987; 9: 989–995 [DOI] [PubMed] [Google Scholar]
- 10. Kim CB, Braunwald E: Potential benefits of late reperfusion of infarcted myocardium. The open artery hypothesis. Circulation 1993; 88: 2426–2436 [DOI] [PubMed] [Google Scholar]
- 11. Meijer A, Verheugt FWA, van Eenige MJ, Werter CPJP: Left ventricular function at 3 months after successful thrombolysis. Impact of reocclusion without reinfarction on ejection fraction, regional function and remodeling. Circulation 1994; 90: 1706–1714 [DOI] [PubMed] [Google Scholar]
- 12. Nijland F, Kamp O, Verheugt FWA, Veen G, Visser CA: Long‐term implications of reocclusion on left ventricular site and function after successful thrombolysis for first anterior myocardial infarction. Circulation 1997; 95: 111–117 [DOI] [PubMed] [Google Scholar]
- 13. Leung WH, Lau CP: Effects of severity of the residual stenosis of the infarct‐related coronary artery on left ventricular dilation and function after acute myocardial infarction. J Am Coll Cardiol 1992; 20: 307–313 [DOI] [PubMed] [Google Scholar]
- 14. Zijlstra F, de Boer MJ, Hoorntje JCA, Reiffers S, Reiber JHC, Suryapranata H: A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993; 328: 680–684 [DOI] [PubMed] [Google Scholar]
- 15. Gibbons RJ, Holmes DR, Reeder GS, Bailey KR, Hopfensperger MR, Gersh BJ: Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993; 328: 685–691 [DOI] [PubMed] [Google Scholar]
- 16. Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O'Keefe J, Overlie P, Donohue B, Chelliah N, Timmis GC, Vlietstra RE, Strrzelecki M, Puchrowicz‐Ochocki S, O'Neill WW, for the Primary Angioplasty in Myocardial Infarction Study Group : A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993; 328: 673–679 [DOI] [PubMed] [Google Scholar]
- 17. Lange RA, Hillis LD: Should thrombolysis or primary angioplasty be the treatment of choice for acute myocardial infarction? N Engl J Med 1996; 355: 1311–1312 [DOI] [PubMed] [Google Scholar]
- 18. Grines CL: Primary angioplasty—the strategy of choice. N Engl J Med 1996; 355: 1313–1316 [PubMed] [Google Scholar]
- 19. Every NR, Parsons LS, Hlatky M, Martin JS, Weaver WD, for the Myocardial Infarction Triage and Intervention Investigators : A comparison of thrombolytic therapy with primary angioplasty for acute myocardial infarction. N Engl J Med 1996; 335: 1253–1260 [DOI] [PubMed] [Google Scholar]
- 20. Ellis S: The GUSTO IIb angioplasty substudy. Presented at the American College of Cardiology Scientific Sessions, March 27, 1996.
- 21. Yoshino H, Taniuchi M, Kachi E, Shimizu H, Kajiwara T, Ohguchi M, Okada M, Ishikawa K: Asynergy of the noninfarcted left ventricular inferior wall in anterior wall acute myocardial infarction secondary to isolated occlusion of the left anterior descending artery. Am J Cardiol 1998; 81: 828–833 [DOI] [PubMed] [Google Scholar]
- 22. Birnbaum Y, Sclarovsky S, Solodky A, Tschori J, Herz I, Sulkes J, Mager A, Rechavia E: Prediction of the level of left anterior descending coronary artery obstruction during anterior wall acute myocardial infarction by the admission electrocardiogram. Am J Cardiol 1993; 72: 823–826 [DOI] [PubMed] [Google Scholar]
- 23. Myers GB, Klein HA, Hiratzka T: II. Correlation of electrocardiographic and pathologic findings in large anterolateral infarcts. Am Heart J 1948; 36: 838–881 [DOI] [PubMed] [Google Scholar]
- 24. Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, Dodge HT, Francis CK, Hillis D, Ludbrook P, Markis JE, Mueller H, Passamani ER, Powers ER, Rao AK, Robertson T, Ross A, Ryan TJ, Sobel BE, Willerson J, Williams DO, Zaret L, Braunwald E: Thrombolysis in Myocardial Infarction (TIMI) trial, phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Circulation 1987; 76: 142–154 [DOI] [PubMed] [Google Scholar]
- 25. The Principal Investigators of CASS and The Associates : The National Heart, Lung and Blood Institute Coronary Artery Surgery Study (CASS). Circulation 1981; 63 (suppl I): I‐1–88 [Google Scholar]
- 26. AHA Committee Report : A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for grading of coronary artery disease, Council on Cardiovascular Surgery, American Heart Association. News from the American Heart Association. Circulation 1975; 51: 5–40 [DOI] [PubMed] [Google Scholar]
- 27. Rentrop KP, Feit F, Sherman W, Thornton JC: Serial angiographic assessment of coronary artery obstruction and collateral flow in acute myocardial infarction. Circulation 1989; 80: 1166–1175 [DOI] [PubMed] [Google Scholar]
- 28. Iwasaki K, Kusachi S, Kita T, Taniguchi G: Prediction of isolated first diagonal branch occlusion by 12‐lead electrocardiography: ST segment shift in leads I and aVL. J Am Coll Cardiol 1994; 23: 1557–1561 [DOI] [PubMed] [Google Scholar]
- 29. The GUSTO Angiographic Investigators : The effects of tissue plasminogen activator, streptokinase, or both on coronary artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med 1993; 329: 1615–1622 [DOI] [PubMed] [Google Scholar]
- 30. Pizzetti G, Belotti G, Margonato A, Cappelletti A, Chierchia SL: Coronary recanalization by elective angioplasty prevents ventricular dilation after anterior myocardial infarction. J Am Coll Cardiol 1996; 28: 637–645 [DOI] [PubMed] [Google Scholar]