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Background Newly designed computer-based applications and the development of wireless technology have allowed the transmission of 12-lead electrocardiogram (ECG) waveforms from remote locations to the hand-held computers of cardiologists. If these computer ECGs can be reliably interpreted, then the time to treatment for cardiac patients may be reduced. Methods and Results Twenty classic examples of cardiac abnormalities were chosen to test the efficacy of the hand-held computer's liquid crystal display (LCD) screen in the interpretation of 12-lead ECGs. Ten cardiologists interpreted these 20 ECGs on the hand-held computers and then twice later on traditional printed paper. The control intraobserver agreement between the sets of paper-displayed ECGs was measured against the agreement between each of the paper sets and the LCD-displayed set of ECGs. Eighty-nine percent (178/200) of the ECGs were interpreted identically by the participants between the 2 paper sets. When comparing the interpretations of the LCD-displayed ECGs with those of each of the paper sets of ECGs, 88.0% (176/200) and 87.5% (175/200) of identical diagnoses were noted. These differences of 1.0% and 1.5% in intraobserver agreement between paper-to-paper and each of the 2 paper-to-LCD comparisons were not significant ( P = .75 and P = .88, respectively). Conclusions The strong intraobserver agreement shows that cardiologists make the same diagnoses when viewing LCD-displayed ECGs as they do when viewing paper-displayed ECGs. A study to measure the intraobserver agreement of the decision regarding administration of reperfusion therapy after interpretation of ECGs of patients with acute chest pain is now underway. (Am Heart J 1999;138:765-70.)

We assessed predicting final infarct size (using predischarge Selvester score) by 3 electrocardiographic variables in 267 patients with first anterior wall acute myocardial infarction (AMI) undergoing (n = 86) or not undergoing (n = 181) thrombolysis. Patients with previous AMI or inverted T waves in leads with ST elevation were excluded. The sum (sigma) of ST elevation, the number of leads with ST elevation, and the initial electrocardiographic pattern were determined on the admission electrocardiogram (absence (QRS-) or presence (QRS+) of distortion of the terminal portion of the QRS inor =2 leads (J pointor =0.5 of the R-wave amplitude in leads I, aVL, V4 to V6, or presence of ST elevation without S waves in leads V1 to V3). There was no association between sigmaST elevation and final infarct size in patients who did or did not receive thrombolytic therapy. Analysis of covariance showed that the number of leads with ST elevation (F = 19.6), thrombolysis (F = 25.2), and QRS+ initial pattern (F = 19.5) were all associated with final infarct size (p0.0001 for all). Among patients who did not receive thrombolytic therapy, the average Selvester score was 19.7+/-9.9 for the QRS- patients and 26.1+/-10.4 for the QRS+ patients (p = 0.02). Among patients who received thrombolytic therapy, the average Selvester score was 11.7+/-9.8 for the QRS- patients and 24.2+/-10.1 for the QRS+ patients (p0.0001). Thrombolysis reduced final Selvester score only in the QRS- group (p0.00001), but not in the QRS+ group (p = 0.45). It is concluded that (1) final Selvester score in anterior wall AMI can be predicted by the number of leads with ST elevation, the initial electrocardiographic pattern, and thrombolysis, and (2) thrombolysis reduces final Selvester score only in patients with QRS- pattern.

Survey.To assess the association between patients' perceptions of responsibility for the injury and long term outcomes.Duke University Medical Center Spinal Injury Service.One hundred and forty patients, who suffered spinal cord injuries between 1985 and 1990, were selected to participate in the study, and 26 (19%), including eight with quadriplegia, completed a telephone interview. The mean age at interview was 39+/-12 years and 12% were women. The mean time from injury to completion of the study was 8.7+/-1.5 years. Attribution of cause of injury, the Craig Handicap Assessment Reporting Technique, and the SF36 mental health depression/vitality surveyed instruments attribution of responsibility for the injury, functional capacity, mental health depression, and vitality.The majority (18/26) of patients either totally blamed themselves or others for their injuries. Overall, there was no statistically significant association between attribution of injury and long-term outcomes. Outcomes were similar in patients who either totally blamed themselves or others for their predicament.In this study, long-term outcomes were not influenced by whether patients perceived themselves as being responsible for their injuries.

Over the past several years, the editors of leading international cardiovascular journals have met to form the HEART Group and to discuss areas of growing, common interest. Recently, the HEART Group has developed a document that addresses general ethical principles in the conduct of the scientific process with which all of the editors concur. Published essentially simultaneously in all of the participating journals, including this journal, this document presents the ethical tenets accepted by all of the undersigned editors that will (continue to) guide their decisions in the editorial process. These are the general principles on which the HEART Group is based and by which we, as a group, abide; however, please note that individual journal members and their respective societies may have their own rules and regulations that supersede the guidelines of the HEART Group. Acta Cardiologica Hugo Ector, MD, PhD Editor-in-Chief Patrizio Lancellotti, MD Editor-in-Chief American Journal of Cardiology William C. Roberts, MD Editor-in-Chief American Journal of Geriatric Cardiology Nanette K. Wenger, MD Editor-in-Chief Annals of Noninvasive Electrocardiology Arthur J. Moss, MD Editor-in-Chief Canadian Journal of Cardiology Eldon R. Smith, MD Editor-in-Chief Cardiology Jeffrey S. Borer, MD Editor-in-Chief Cardiosource Review Journal Kim A. Eagle, MD Editor-in-Chief Cardiovascular Drug Reviews Jane Freedman, MD Incoming Editor-in-Chief Henry Krum, PhD Incoming Editor-in-Chief Chim Lang, MD Incoming Editor-in-Chief Cardiovascular Drugs and Therapy Willem J. Remme, MD, PhD Editor-in-Chief Cardiovascular Research Hans Michael Piper, MD, PhD Editor-in-Chief Catheterization and Cardiovascular Interventions Christopher J. White, MD Editor-in-Chief Circulation Joseph Loscalzo, MD, PhD Editor-in-Chief Circulation Research Eduardo Marban, MD, PhD Editor-in-Chief Coronary Artery Disease Burton E. Sobel, MD Editor Current Opinion in Cardiology Robert Roberts, MD Editor Current Problems in Cardiology Shahbudin H. Rahimtoola, MD Editor Europace A. John Camm, MD Editor-in-Chief European Heart Journal Frans Van de Werf, MD Editor-in-Chief European Journal of Heart Failure Karl Swedberg, MD, PhD Editor-in-Chief Heart Adam D. Timmis, MD Editor Heart & Lung: The Journal of Acute and Critical Care Kathleen S. Stone, PhD, RN Editor-in-Chief Heart Rhythm Douglas P. Zipes, MD Editor-in-Chief International Journal of Interventional Cardioangiology David G. Iosseliani, MD Editor-in-Chief Journal of Cardiovascular Computed Tomography Allen J. Taylor, MD Editor-in-Chief Journal of Cardiovascular Pharmacology Michael R. Rosen, MD Editor Journal of Interventional Cardiology Cindy L. Grines, MD Editor-in-Chief Journal of the American College of Cardiology Anthony N. DeMaria, MD Editor-in-Chief JACC: Cardiovascular Imaging Jagat Narula, MD, PhD Editor-in-Chief JACC: Cardiovascular Interventions Spencer B. King III, MD Editor-in-Chief Journal of Electrocardiology Galen S. Wagner, MD Editor-in-Chief Journal of Interventional Cardiac Electrophysiology Sanjeev Saksena, MD Editor-in-Chief Journal of the American Society of Echocardiography Alan S. Pearlman, MD Editor-in-Chief Journal of Heart Valve Disease Endre Bodnar, MD, PhD Editor-in-Chief Robert W. Emery, MD Incoming Editor-in-Chief Journal of Thoracic and Cardiovascular Surgery Lawrence H. Cohn, MD Editor-in-Chief Netherlands Heart Journal Ernst E. van der Wall, MD Editor-in-Chief Pediatric Cardiology Ra-id Abdulla, MD Editor-in-Chief Progress in Cardiovascular Diseases Michael Lesch, MD Editor Revista Espanola de Cadiologia Fernando Alfonso, MD, PhD Editor-in-Chief Scandinavian Cardiovascular Journal Rolf Ekroth, MD Chief Editor

We assessed the prognostic significance of negative T waves on admission in leads with ST elevation in 2,853 patients with acute myocardial infarction treated with thrombolysis. Patients were classified into 2 groups based on the presence of negative (T–) or positive (T+) T waves in the leads with ST elevation on admission. T+ and T– waves on admission were detected in 2,601 (91%) and 252 (9%) patients, respectively. T– waves were observed in 6.7 and 9.6% of patients admitted ≤2 and 2–6 h after onset of infarction, respectively. There was a difference in prognosis between patients admitted ≤2 and >2 h after symptom onset. T– patients admitted ≤2 h after onset had no hospital mortality (0/52 patients), as compared to a 5.0% mortality rate in T+ patients (36/726 patients; p = 0.19). T– patients treated >2 h after onset suffered higher mortality (20/196 patients; 10.2%) than T+ patients (100/1,836 patients; 5.4%; p = 0.01). Multivariate analysis of the data on patients treated >2 h after onset demonstrated T– waves to be associated with mortality (OR 1.86; 95% CI 1.07–3.25; p = 0.017). T– waves in leads with ST elevation upon admission are associated with adverse prognosis in patients presenting >2 h after symptom onset, whereas in patients presenting ≤2 h after first symptoms, T– waves may be associated with better prognosis.

Objectives The purpose of this study was to determine the prognostic capacity of a single electrocardiogram (ECG) obtained early after admission to the hospital in patients suspected of non-Q-wave myocardial infarction and unstable angina pectoris. Methods Six hundred twenty-nine patients from the TRIM study were included. The patients were divided into subgroups on the basis of ST-segment changes in the inclusion ECG. Death, acute myocardial infarction, or refractory angina (despite treatment) were registered during a follow-up period of 30 days. Results Patients with ST depression had a significantly higher event rate compared with patients with other ECG changes or with normal ECG results. The difference in event rates between patients with ST depression and patients without ST depression regarding the composite of death and acute myocardial infarction was highly significant ( P = .0008). A significant association between the magnitude of the ST-segment depression (in millimeters) and the risk of cardiac events was also demonstrated. Multivariate analysis proved ST depression early after admission to be an independent predictor of high risk. Conclusion In patients with unstable coronary artery disease, ST-segment depression at admission is a strong predictor of early (30 days) cardiac events and the extent of ST depression carries important prognostic information as well.(Am Heart J 1999;137:24-33.)

This study assessed whether differences in the underlying mechanisms for various patterns of precordial ST-segment depression with inferior acute myocardial infarction (AMI) are associated with poorer prognoses. We studied 1,155 patients with inferior AMI who underwent thrombolysis in the Global Utilization of Streptokinase and TPA for Occluded arteries (GUSTO-I) angiographic substudy: those without precordial ST depression (n = 412; 35.7%), those with maximum ST depression in leads V1 to V3 (n = 547; 47.4%), and those with maximum ST depression in leads V4 to V6 (n = 196; 17.0%) on admission electrocardiogram. We compared the infarct-related artery, presence of left anterior descending or multivessel coronary artery disease, and left ventricular function among groups. Patients with maximum ST depression in leads V4 to V6 more often had 3-vessel disease (26.0%) than those without precordial ST depression (13.5%) or those with ST depression in leads V1 to V3 (15.7%; p = 0.002), and they had a lower ejection fraction (median 54% vs 60% and 55%, respectively; p

patients with coronary artery disease, those with chest pain and ST-segment depression during atrial pacing had an increase in the left ventricular end-diastolic pressure (LVEDP), whereas those without ischemia showed no increase. This indicates that ST-segment depression was caused by an increase in LVEDP. Extensive supply ischemia, for example, caused by sudden obstruction of the left main coronary artery, impairs the relaxatio n of the left ventr icle. 3 The resultin g increase in LVEDP induces severe subendocardial ischemia. In animals, a constriction of the left main coronary artery, causing global left ventricular ischemia, resulted in a significant decrease in the endocardial-to-epicardial flow ratio and a significant incre ase of end-diasto lic left ventricul ar trans mura l press ure. 4 Nikus et al have shown that the ECG pattern of STsegment depression and inverted T waves, maximally in leads V4 to V5, was strongly associated with left main or severe 3-vess el disea se ( Fig. 2). 5 ST-segment elevation in

The 32-point, 54-criteria Selvester QRS scoring system has been successfully used to estimate the size of nonacute myocardial infarction (MI). Three criteria of the system have been shown to be sensitive for the identification of nonacute MI and specific in normal control subjects. The validity of the system has not been tested in patients with cardiomyopathy of nonischemic origin. The purpose of this study was to examine the electrocardiographs (ECGs) of patients with abnormal left ventricular function but no presence of coronary disease to determine the diagnostic specificity of the MI screening criteria subset of the Selvester QRS scoring system.Six hundred ninety patients were considered. Exclusion criteria included age10 years, cardiac transplantation, thrombolytic therapy, any angiographic evidence of coronary disease, left ventricular ejection fraction (LVEF)60%, or history of myocardial revascularization. ECG exclusion criteria included left ventricular hypertrophy, right ventricular hypertrophy, left bundle branch block, right bundle branch block, ventricular pacing, left anterior fascicular block, left posterior fascicular block, ventricular preexcitation, and low voltage, because these confounding factors could mimic an infarct on the ECG. The 261 remaining patients were then examined for the presence of the MI screening criteria subset: (1) inferior location: Qor =30 msec in aVF, (2) anterior location: either any Q or Ror =0.1 mV andor =10 msec in V2, and (3) posterior location: Ror =40 msec in V1. Thirty-two of the 261 patients falsely met at least 1 of the 3 MI screening criteria, resulting in an overall specificity of 88% (vs 95% in normal control subjects, P=.0006). A specificity of 98% (n = 256) was achieved for the inferior MI screening criterion alone, whereas the anterior and posterior MI screening criteria alone achieved significantly lower specificities: 94% (n = 245) and 95% (n = 249), respectively. When the patient population was divided into LVEF30% and LVEFor =30%, no significant association was found between MI screening criteria and LVEF with specificities of 87% and 88%, respectively, for the 2 groups (P= .34).The MI screening criteria subset is relatively specific in patients with nonischemic cardiomyopathy, falsely identifying only 12% with nonacute MI. However, this specificity is lower than the 95% achieved in normal subjects. Regional accumulation of scarring caused by cardiomyopathy could result in false-positive indication of MI in the present population. Another possibility could be that some patients could have hypertrophy of the myocardium insufficient to produce positive ECG criteria for left ventricular hypertrophy or right ventricular hypertrophy but sufficient to mimic infarction.

In this work we studied ST-T complex changes in the ECG as result of induced ischemia. The principal aim was to determine whether global changes in the ST-T complex were more sensitive markers of ischemic alterations than those based on measurements of changes at specific locations on ST segment or T wave. High-resolution ECGs from patients undergoing percutaneous transluminal coronary angioplasty in one of the major coronary arteries were analyzed to give a description of the period from the end of active depolarization (QRS complex) to the end of active repolarization (T wave). During artery occlusion traditional local measurements of the ST-T complex were compared to global measurements based on the Karhunen-Loève transform. An ischemic change sensor parameter was estimated for each of the studied indexes showing that global measurements detected changes better in the repolarization period in a larger number of leads and with higher sensitivity (more than 85%) than was done using local measurements (sensitivity of 64% with ST level, 33% with T-wave maximum position, and 37% with T-wave maximum amplitude). Using these global indexes it was found that most cases of ST-segment changes were accompanied by T-wave changes (72% of patients). With the use of traditional indexes 23% of patients showed no changes in the repolarization period, whereas with global indexes this percentage decreased to 8%. Thus a global representation of the entire ST-T complex appears to be more suitable than local measurements when studying the initial stages of myocardial ischemia.

The present study compares the on-site interpretation of an admission electrocardiogram (ECG) with core laboratory results in a large, multicenter trial of 516 patients diagnosed with unstable angina pectoris or non-Q-wave myocardial infarction. The local investigators evaluated the admission ECG regarding ST-T changes before the ECGs were sent to the core laboratory for blinded interpretation. The strength of agreement between the observations was described by kappa statistics. There was a poor agreement regarding identification of ST-segment elevation, with 17 patients identified by the local investigator versus 92 by the core laboratory (kappa = 0.05). There was a fair agreement on ST-segment depression with 158 patients diagnosed on-site versus 64 by the core laboratory (kappa = 0.38). Identification of T-wave inversion demonstrated good agreement with 306 patients diagnosed on-site versus 280 by the core laboratory (kappa = 0.63). A moderate agreement regarding identification of a normal ECG was found with 101 patients on-site versus 135 in the core laboratory (kappa = 0.42). Independent variables, including peak creatine kinase-MB and 30-day outcome, were more closely related to core laboratory results than the local investigator's interpretation of the admission ECG. Thus, in the present study, considerable differences were demonstrated between the on-site interpretation of the admission ECG and the blinded evaluation performed in the core laboratory regarding relatively simple electrocardiographic variables. The results suggest that more widespread use of independent evaluation of clinical data should be incorporated in future clinical trials.

Increased T-wave amplitude is one of the earliest electrocardiographic (ECG) changes following coronary artery occlusion. Therefore, higher T waves in the presenting electrocardiogram should represent earlier time to treatment and thus be associated with lower mortality following thrombolytic therapy. However, T-wave amplitude has never been evaluated as a prognostic marker in this setting. We examined clinical outcomes in 3,317 patients with acute myocardial infarction (AMI) who underwent thrombolysis in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) Study. Patients were classified as either those with high T waves or those with low T waves. Higher T waves were defined as those >98th percentile of the upper limit of normal. T-wave amplitude was also evaluated as a continuous variable according to infarct location (maximum T-wave amplitude) and as the amount of excess T-wave amplitude above normal (excess T-wave amplitude). Patients with higher T waves had lower 30-day mortality than those without (5.2% vs 8.6%, p = 0.001) and were less likely to develop congestive heart failure (15% vs 24%, p

It is clinically important to estimate the size of a myocardial infarction (MI) to predict patient prognosis, to determine the ability of a therapy to limit its size, and to evaluate its effect on left ventricular function. Various electrocardiographic methods have been used for these purposes but their accuracies have not been compared with each other using an identical reference population of anatomically measured infarcts. The capability of 4 electrocardiographic scoring methods (the Selvester score, the Minnesota code, the Novacode, and the Cardiac Infarction Injury Score) to estimate MI size was compared using anatomic MI size in a group of 100 deceased patients. All patients had a standard 12-lead electrocardiogram of sufficient quality to perform manual waveform measurements and without confounding factors such as ventricular hypertrophy, fascicular block, or bundle branch block. The location and size of the left ventricular infarction was measured postmortem using the anatomic method of Ideker et al. All methods' size estimates correlated best with anatomic MI size in the anterior location (r = 0.65 to 0.89). The Selvester score was superior in estimating the sizes of inferior (r = 0.70) and posterolateral (r = 0.74) infarcts. For multiple infarcts all methods performed poorly (r = 0.18 to 0.44).

Objectives. We sought to assess the outcome of patients with acute myocardial infarction (MI) and bundle branch block in the thrombolytic era.Background. Studies of patients with acute MI and bundle branch block have reported high mortality rates and poor overall prognosis.Methods. The North American population with acute MI and bundle branch block enrolled in the Global Utilization of Streptokinase and t-PA [tissue-type plasminogen activator] for Occluded Coronary Arteries (GUSTO-I) trial was matched by age and Killip class with an equal number of GUSTO-I patients without conduction defects.Results. Of all 26,003 North American patients in GUSTO-I, 420 (1.6%) had left (n = 131) or right (n = 289) bundle branch block. These patients had higher 30-day mortality rates than matched control subjects (18% vs. 11%, p = 0.003, odds ratio [OR] 1.8) and were more likely to experience cardiogenic shock (19% vs. 11%, p = 0.008, OR 1.78) or atrioventricular block/asystole (30% vs. 19%, p < 0.012, OR 1.57) and to require ventricular pacing (18% vs. 11%, p = 0.006, OR 1.73). Bundle branch block also carried an independent 53% higher risk for 30-day mortality. Thirty-day mortality rates for patients with complete, partial and no reversion of the bundle branch block were 8%, 12% and 20%, respectively (two-tailed chi-square test for trend 5.61, p = 0.02, OR 0.34 for complete reversion, OR 0.55 for partial reversion).Conclusions. Bundle branch block at hospital admission in patients with acute MI predicts in-hospital complications and poor short-term survival.

To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI).Baseline Q-waves are useful in predicting clinical outcomes after MI.3589 STEMI patients were assessed from a multi-centre study.1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥40ms for inferior and ≥20ms for lateral/apical MI in all patients (n=3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54-3.85), p0.001) and the composite (HR: 2.32, 95% CI (1.70-3.16), p0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02-0.29), p=0.027).The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥40ms in inferior and ≥20ms for lateral/apical MI enhances prognostic insight beyond current criteria.

In patients with ST-elevation myocardial infarction (STEMI) the amount of myocardial area at risk (MaR) indicates the maximal potential loss of myocardium if the coronary artery remains occluded. During the time course of infarct evolution ischemic MaR is replaced by necrosis, which results in a decrease in ST segment elevation and QRS complex distortion. Recently it has been shown that combining the electrocardiographic (ECG) Aldrich ST and Selvester QRS scores result in a more accurate estimate of MaR than using either method alone. Therefore, we hypothesized that the combined Aldrich and Selvester score, indicating MaR, is stable until myocardial reperfusion therapy. In a retrospective analysis of a study population of 114 patients, 33 patients were included. The combined Aldrich and Selvester score was determined in ECGs recorded in the ambulance (ECG1) and in the hospital before reperfusion (ECG2). The combined Aldrich and Selvester score was considered stable if the difference between ECG1 and ECG2 was

Objectives. This study assessed prospectively the correlation between the conal branch of the right coronary artery and the pattern of ST segment elevation in leads V1and V3R during anterior wall acute myocardial infarction (AMI).Background. The traditional electrocardiographic (ECG) definition of anteroseptal AMI—ST segment elevation in leads V1to V3—has recently been challenged. The significance of ST segment elevation in lead V1during anterior wall AMI is unclear.Methods. The admission 12-lead ECG with additional lead V3R and the coronary angiograms performed within 10 days of hospital admission were evaluated in 28 consecutive patients (mean age ± SD 62 ± 9 years) admitted to the coronary care unit with anterior wall AMI. Patients were classified into two groups according to the magnitude of ST segment elevation in lead V1: group A (elevation ≥1.5 mm, n = 12) and group B (elevation

Objectives. We assessed the outcomes of patients with a first myocardial infarction with ST segment elevation, with and without the development of abnormal Q waves after thrombolysis. Background. Prethrombolytic era studies report conflicting short- versus long-term mortality in the overall non-Q wave population, probably related to its heterogeneity. Methods. Patients with no electrocardiographic (ECG) confounding factors or evidence of previous infarction were included. Q wave infarction was defined as a Q wave duration ≥30 ms in lead aVF; R wave ≥40 ms in lead V1; any Q wave or R wave ≤10 ms and ≤0.1 mV in lead V2; or Q wave ≥40 ms in at least two of the following leads: I, aVL, V4, V5or V6. In-hospital clinical events and mortality at 30 days and 1 year were assessed. Results. No Q waves developed in 4,601 (21.3%) of the 21,570 patients. This group comprised more women and had a lower Killip class, lower weight and less anterior baseline ST elevation. The non-Q wave group had less in-hospital cardiogenic shock (2.1% vs. 3.3%, p < 0.0001), less heart failure (8.5% vs. 13.9%, p < 0.0001) and a trend toward less stroke (0.7% vs. 1.0%, p = 0.07) but an increased use of angioplasty (28% vs. 24%, p = 0.0001). The unadjusted mortality rate in the non-Q wave group was lower at 30 days (0.9% vs. 1.8%, p = 0.0001) and 1 year (2.7% vs. 4.2%, p = 0.0001), as was the adjusted 30-day mortality rate (4.8% vs. 5.3%, p < 0.0001). Conclusions. Patients with no ECG confounding factors or evidence of previous infarction who do not develop Q waves after thrombolysis have a better 30-day and 1-year prognosis than patients with a Q wave infarction. (J Am Coll Cardiol 1997;29:770–7)

The present study was performed to test the hypothesis that patients with a large amount of ischemic (hibernating) myocardium are most likely to develop a perioperative myocardial infarction undergoing coronary artery bypass grafting (CABG). Furthermore, we evaluated the Selvester QRS scoring system as a postoperative prognostic tool. A relationship between a high amount of hibernating myocardium determined by ventriculographic and electrocardiographic investigations and an increased risk of perioperative myocardial infarction was found. The Selvester QRS scoring system used in diagnosing and prognosing after acute myocardial infarction was proven valid in predicting prognosis after CABG as well.

There is conflicting evidence with regard to the value of electrocardiographic left ventricular hypertrophy (LVH) in myocardial infarction. Of 5,951 patients in the ASSENT-3 trial, 273 (5%) had LVH on baseline electrocardiograms and had significantly higher mortality rates at 30 days (11% vs 6%, p = 0.001) and 1 year (13% vs 8%, p = 0.007). After adjustment for differences in baseline parameters, LVH remained an independent predictor of 30-day (hazard ratio 2.3, 95% confidence interval 1.4 to 3.9) and 1-year (hazard ratio 1.8, 95% confidence interval 1.1 to 2.8) mortality rates. Thus, electrocardiographic LVH is a prognostic tool in identifying short- and long-term mortality rates in patients who have ST-elevation myocardial infarction and receive fibrinolysis.

Blood-clot formation that results in the complete occlusion of a blood vessel (thrombosis) often leads to serious life-threatening events, such as strokes and heart attacks. As the composition of a thrombus changes as it matures, new imaging methods that are capable of distinguishing new clots from old clots may yield important diagnostic and prognostic information. To address this need, an activatable magnetic resonance (MR) probe that is responsive to a key biochemical process associated with recently formed clots has been developed.

Low left ventricular ejection fraction (LVEF) increases risk for both sudden cardiac death (SCD) and for heart failure (HF) death; however, implantable cardioverter-defibrillators (ICDs) reduce the incidence of SCD, not HF death. Distinguishing individuals at risk for HF death (non-SCD) versus SCD could improve ICD patient selection.This study evaluated whether electrocardiogram (ECG) quantification of myocardial infarction (MI) could discriminate risk for SCD versus non-SCD.Selvester QRS scoring was performed on 995 MADIT-II trial subjects' ECGs to quantify MI size. MIs were categorized as small (0-3 QRS points), medium (4-7) or large (≥ 8). Mortality, SCD and non-SCD rates in the conventional medical therapy (CMT) arm and mortality and ventricular tachycardia/fibrillation (VT/VF) rates in the ICD arm were analyzed by QRS score group. Both arms were analyzed to determine ICD efficacy by QRS score group.In the CMT arm, mortality, SCD and non-SCD rates were similar across QRS score groups (P = 0.73, P = 0.92, and P = 0.77). The ICD arm showed similar rates of mortality (P = 0.17) and VT/VF (P = 0.24) across QRS score groups. ICD arm mortality was lower than CMT arm mortality across QRS score groups with greatest benefit in the large scar group.Recently, QRS score was shown to be predictive of VT/VF in the SCD-HeFT population consisting of both ischemic and nonischemic HF and having a maximum LVEF of 35% versus 30% for MADIT-II. Our study found that QRS score did not add prognostic value in the MADIT-II population exhibiting relatively more severe cardiac dysfunction.

Background The prognosis of patients hospitalized with acute myocardial ischemia is quite variable. We examined the value of serum levels of cardiac troponin T, serum creatine kinase MB (CK-MB) levels, and electrocardiographic abnormalities for risk stratification in patients with acute myocardial ischemia. Methods We studied 855 patients within 12 hours of the onset of symptoms. Cardiac troponin T levels, CK-MB levels, and electrocardiograms were analyzed in a blinded fashion at the core laboratory. We used logistic regression to assess the usefulness of base-line levels of cardiac troponin T and CK-MB and the electrocardiographic category assigned at admission — ST-segment elevation, ST-segment depression, T-wave inversion, or the presence of confounding factors that impair the detection of ischemia (bundle-branch block and paced rhythms) — in predicting outcome. Results On admission, 289 of 801 patients with base-line serum samples had elevated troponin T levels (>0.1 ng per milliliter). Mortality with...

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 V1 to V3 only (n = 5,850 [35.4%]), those with ST segment depression in leads V4 to V6 only (n = 876 [5.3%]) and those with ST segment depression in both leads V1 to V3 and leads V4 to V6 (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 < 0.001), regardless of whether ST segment depression was noted in leads V1 to V6 or in leads V4 to V6. The magnitude of precordial ST segment depression (sum of leads V1 to V6) 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.

Background The presence of left bundle-branch block on the electrocardiogram may conceal the changes of acute myocardial infarction, which can delay both its recognition and treatment. We tested electrocardiographic criteria for the diagnosis of acute infarction in the presence of left bundle-branch block. Methods The base-line electrocardiograms of patients enrolled in the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial who had left bundle-branch block and acute myocardial infarction confirmed by enzyme studies were blindly compared with the electrocardiograms of control patients who had chronic coronary artery disease and left bundle-branch block. The electrocardiographic criteria for the diagnosis of infarction were then tested in an independent sample of patients presenting with acute chest pain and left bundle-branch block. Results Of 26,003 North American patients, 131 (0.5 percent) with acute myocardial infarction had left bundle-b...