The American Journal of Cardiology - Vol. 107, Issue 4 (February 2011)

153 Pages·2011·6.05 MB·English

by  The American Journal of Cardiology

EDITOR IN CHIEF ASSOCIATE EDITORS
William C. Roberts, MD Vincent E. Friedewald
Baylor Heart & Vascular Institute Paul A. Grayburn
Baylor University Medical Center
ASSISTANT EDITORS
Wadley Tower No. 457
3600 Gaston Avenue Robert C. Kowal
Dallas, Texas 75246 Jeffrey M. Schussler
[phone]
Fax: [phone]
EDITORIAL BOARD
CARDIOVASCULAR Rodney H. Falk Joseph Lindsay, Jr. Robert J. Siegel
MEDICINE John A. Farmer Gregory Y.H. Lip Marc A. Silver
In Adults David P. Faxon Francisco Lopez-Jimenez Ross J. Simpson, Jr.
Ted Feldman Joseph Loscalzo Steven N. Singh
Antonio Abbate
Jack Ferlinz G.B. John Mancini Burton E. Sobel
J. Dawn Abbott
Jerome L. Fleg Francis E. Marchlinski John C. Somberg
George S. Abela
Gerald F. Fletcher Frank I. Marcus
Jamil Aboulhosn David H. Spodick
Joseph A. Franciosa Barry J. Maron
Joseph S. Alpert Lynne W. Stevenson
Gary S. Francis Martin S. Maron
Martin A. Alpert Gregory W. Stone
W. Bruce Fye Randolph P. Martin
Ezra A. Amsterdam John R. Stratton
William H. Gaasch Attilo Maseri
Jeffrey L. Anderson Jonathan M. Tobis
Julius M. Gardin Charles Maynard
Evan Appelbaum Eric J. Topol
Bernard J. Gersh Michael D. McGoon
Richard W. Asinger Byron F. Vandenberg
S. David Gertz Darren K. McGuire
Pablo Avanzas Hector O. Ventura
Mihai Gheorghiade Raymond G. McKay
Gary John Balady
D. Luke Glancy Jawahar L. Mehta George W. Vetrovec
Eric Bates
Stephen P. Glasser Bernard Meier Robert A. Vogel
Jeroen J. Bax
Michael R. Gold Franz H. Messerli Ron Waksman
George A. Beller
Samuel Z. Goldhaber Eric L. Michelson David D. Waters
William E. Boden
Robert E. Goldstein Richard V. Milani Nanette K. Wenger
Monty M. Bodenheimer
Sidney Goldstein Alan B. Miller Robert Wilensky
Robert O. Bonow
Steven A. Goldstein Wayne L. Miller James T. Willerson
Jeffrey S. Borer
J. Anthony Gomes Gary S. Mintz Clyde W. Yancy
Martial G. Bourassa
Antonio M. Gotto, Jr. Fred Morady Barry L. Zaret
Eugene Braunwald K. Lance Gould Lori Mosca
Douglas P. Zipes
Jeffrey A. Brinker Donald C. Harrison Arthur J. Moss
David L. Brown Philip D. Henry James E. Muller In Infants and Children
Michael E. Cain L. David Hillis Gerald B. Naccarelli Hugh D. Allen
Richard O. Cannon III David R. Holmes, Jr. Navin C. Nanda Bruce S. Alpert
Bernard R. Chaitman Mun K. Hong Robert A. O’Rourke Stanley J. Goldberg
Kanu Chatterjee William G. Hundley Erik Magnus Ohman Warren G. Guntheroth
John S. Child Ami S. Iskandrian Richard L. Page Howard P. Gutgesell
Robert J. Cody Allan S. Jaffe Sebastian T. Palmeri John D. Kugler
Lawrence S. Cohen Hani Jneid Seung-Yung Park
James E. Lock
Marc Cohen Greg L. Kaluza Eugene R. Passamani
John W. Moore
C. Richard Conti Joel S. Karliner Alan S. Pearlman
Lowell W. Perry
Michael H. Crawford John A. Kastor Carl J. Pepine
David J. Sahn
James P. Daubert Sanjiv Kaul Joseph K. Perloff
Richard M. Schieken
Gregory J. Dehmer Ellen C. Keeley Bertram Pitt
James A. de Lemos Kenneth M. Kent Philip J. Podrid CARDIOVASCULAR SURGERY
Anthony N. DeMaria Richard E. Kerber Don Poldermans Eugene H. Blackstone
Pablo Denes Dean J. Kereiakes Arshed A. Quyyumi Lawrence I. Bonchek
George A. Diamond Morton J. Kern Charles E. Rackley Lawrence H. Cohn
John P. DiMarco Spencer B. King III C. Venkata Ram John A. Elefteriades
Allen Dollar Robert E. Kleiger Nathaniel Reichek Hartzel V. Schaff
Michael J. Domanski George J. Klein Robert Roberts
RELATED SPECIALISTS
Gerald Dorros Lloyd W. Klein Jennifer G. Robinson
L. Maximilian Buja
Uri Elkayam Paul Kligfield Lynda E. Rosenfeld
Kenneth A. Ellenbogen Robert A. Kloner Melvin M. Scheinman Jean-Pierre Despres
Myrvin H. Ellestad John B. Kostis David J. Schneider Michael Emmett
Stephen G. Ellis Charles Landau John S. Schroeder Giovanni Filardo
Toby R. Engel Richard L. Lange Patrick Washington Serruys Barry A. Franklin
Andrew E. Epstein Carl J. Lavie Pravin M. Shah Charles B. Higgins
N. A. Mark Estes, III Carl V. Leier Prediman K. Shah Jeffrey E. Saffitz
Michael Ezekowitz B. T. Liang Jamshid Shirani Renu Virmani
A5
THE AMERICAN JOURNAL OF CARDIOLOGY姞
CONTENTS VOL. 107, NO. 4 FEBRUARY 15, 2011
Coronary Artery Disease Comparison of Morbidity and Mortality in Diabetics
Versus Nondiabetics Having Isolated Coronary
An Early and Simple Predictor of Severe Left Main
Bypass Versus Coronary Bypass plus Valve
and/or Three-Vessel Disease in Patients With
Operations Versus Isolated Valve Operations ....535
Non–ST-Segment Elevation Acute Coronary
Serenella Castelvecchio, Lorenzo Menicanti,
Syndrome ......................................................495
Ekaterina Baryshnikova, Carlo de Vincentiis,
Masami Kosuge, Toshiaki Ebina, Kiyoshi Hibi,
Alessandro Frigiola, and Marco Ranucci, for the
Satoshi Morita, Mitsuaki Endo, Nobuhiki Maejima,
Surgical and Clinical Outcome Research (SCORE)
Noriaki Iwahashi, Kozo Okada, Toshiyuki Ishikawa,
Group
Satoshi Umemura, and Kazuo Kimura
Reperfusion by Primary Percutaneous Coronary Heart Failure
Intervention in Patients With ST-Segment Elevation
Relation of Bundle Branch Block to Long-Term
Myocardial Infarction Within 12 to 24 Hours of the
(Four-Year) Mortality in Hospitalized Patients With
Onset of Symptoms (from a Prospective National
Systolic Heart Failure ......................................540
Observational Study [PL-ACS]) .........................501
Alon Barsheshet, Ilan Goldenberg, Moshe Garty,
Marek Gierlotka, Mariusz Gasior, Krzysztof Wilczek,
Shmuel Gottlieb, Amir Sandach,
Michal Hawranek, Janusz Szkodzinski, Piotr Paczek,
Avishag Laish-Farkash, Michael Eldar, and
Andrzej Lekston, Zbigniew Kalarus, Marian Zembala,
Michael Glikson
and Lech Polonski
Review Characteristics of Depression Remission and Its
Relation With Cardiovascular Outcome Among
Percutaneous Coronary Intervention for Non
Patients With Chronic Heart Failure (from the
ST-Elevation Acute Coronary Syndromes: Which,
SADHART-CHF Study) ......................................545
When and How? ............................................509
Wei Jiang, Ranga Krishnan, Maragatha Kuchibhatla,
Robert K. Riezebos, Jan G.P. Tijssen,
Michael S. Cuffe, Carolyn Martsberger,
Freek W.A. Verheugt, and Gerrit J. Laarman
Rebekka M. Arias, and Christopher M. O’Connor, for
the SADHART-CHF Investigators
Coronary Artery Disease
Long-Term Follow-Up of Patients With First-Time
Warfarin Use and Outcomes in Patients With
Chest Pain Having 64-Slice Computed
Advanced Chronic Systolic Heart Failure Without
Tomography ...................................................516
Atrial Fibrillation, Prior Thromboembolic Events, or
Fabiola B. Sozzi, Filippo Civaia, Philippe Rossi,
Prosthetic Valves .............................................552
Jean-Francois Robillon, Stephane Rusek,
Marjan Mujib, Abu-Ahmed Z. Rahman, Ravi V. Desai,
Frederic Berthier, Francois Bourlon, Laura Iacuzio,
Mustafa I. Ahmed, Margaret A. Feller,
Gilles Dreyfus, and Vincent Dor
Inmaculada Aban, Thomas E. Love, Michel White,
Usefulness of Cooling and Coronary Catheterization Prakash Deedwania, Wilbert S. Aronow,
to Improve Survival in Out-of-Hospital Cardiac Gregg Fonarow, and Ali Ahmed
Arrest ............................................................522
Dion Stub, Christopher Hengel, William Chan, Editorial
Damon Jackson, Karen Sanders, Anthony M. Dart,
Andrew Hilton, Vincent Pellegrino, James A. Shaw, The Risk of Thromboembolism in Heart Failure:
Stephen J. Duffy, Stephen Bernard, and David M. Kaye Does It Merit Anticoagulation Therapy? ............558
Eduard Shantsila and Gregory Y.H. Lip
Two-Year Safety and Effectiveness of Sirolimus-
Eluting Stents (from a Prospective Registry) .......528 Heart Failure
Bimmer E. Claessen, Roxana Mehran, Martin B. Leon,
Eric A. Heller, Giora Weisz, George Syros, Trials on the Effect of Cardiac Resynchronization on
Gary S. Mintz, Theresa Franklin-Bond, Arterial Blood Pressure in Patients With Heart
Irene Apostolidou, Jose P.S. Henriques, Failure ...........................................................561
Gregg W. Stone, Jeffrey W. Moses, and Sameer Ather, Sripal Bangalore, Srinath Vemuri,
George D. Dangas Long B. Cao, Biykem Bozkurt, and Franz H. Messerli
A6 THE AMERICAN JOURNAL OF CARDIOLOGY姞 VOL. 107 FEBRUARY 15, 2011
Patient Perception Versus Medical Record Entry of Cardiomyopathy
Health-Related Conditions Among Patients With
Relation of Pulse Pressure to Blood Pressure
Heart Failure ..................................................569
Response to Exercise in Patients With Hypertrophic
Adnan S. Malik, Grigorios Giamouzis,
Cardiomyopathy .............................................600
Vasiliki V. Georgiopoulou, Lucy V. Fike,
Kevin S. Heffernan, Martin S. Maron,
Andreas P. Kalogeropoulos, Catherine R. Norton,
Eshan A. Patvardhan, Richard H. Karas, and
Dan Sorescu, Sidra Azim, Sonjoy R. Laskar,
Jeffrey T. Kuvin, the Vascular Function Study Group
Andrew L. Smith, Sandra B. Dunbar, and Javed Butler
Editorial
Effectiveness of Serial Increases in Amino-Terminal
Clinical Challenges of Genotype Positive
Pro–B-Type Natriuretic Peptide Levels to Indicate the
(ⴙ)–Phenotype Negative (ⴚ) Family Members in
Need for Mechanical Circulatory Support in
Hypertrophic Cardiomyopathy .........................604
Children With Acute Decompensated Heart
Barry J. Maron, Laura Yeates, and
Failure ...........................................................573
Christopher Semsarian
Derek T.H. Wong, Kristen George, Judith Wilson,
Cedric Manlhiot, Brian W. McCrindle, Khosrow Adeli,
Miscellaneous
and Paul F. Kantor
Usefulness of Repeated N-Terminal Pro-B-Type
Arrhythmias and Conduction Natriuretic Peptide Measurements as Incremental
Disturbances Predictor for Long-Term Cardiovascular Outcome
After Vascular Surgery ....................................609
Relation of Obesity to Recurrence Rate and Burden Dustin Goei, Jan-Peter van Kuijk, Willem-Jan Flu,
Sanne E. Hoeks, Michel Chonchol,
of Atrial Fibrillation .........................................579
Hence J.M. Verhagen, Jeroen J. Bax, and
Maya Guglin, Kuldeep Maradia, Ren Chen, and
Don Poldermans
Anne B. Curtis
Usefulness of At Rest and Exercise Hemodynamics
Roundtable Discussion (CME)
to Detect Subclinical Myocardial Disease in Type 2
Diabetes Mellitus .............................................615
The Editor’s Roundtable: Implantable Cardioverter-
Christine L. Jellis, Tony Stanton, Rodel Leano,
Defibrillators in Primary Prevention of Sudden
Jennifer Martin, and Thomas H. Marwick
Cardiac Death and Disparity-Related Barriers to
Implementation ...............................................583
Specific Characteristics of Sudden Death in a
Vincent E. Friedewald, Gregg C. Fonarow,
Mediterranean Spanish Population ...................622
Brian Olshansky, Clyde W. Yancy, and
M. Teresa Subirana, Josep O. Juan-Babot,
William C. Roberts
Teresa Puig, Joaqu´ın Lucena, Antonio Rico,
Manuel Salguero, Juan C. Borondo, Jorge Ordo´ñez,
Valvular Heart Disease
Josep Arimany, Rafael Va´zquez, Lina Badimon,
Gaetano Thiene, and Antonio Baye´s de Luna
Comparison of the Effectiveness and Safety of Low-
Molecular Weight Heparin Versus Unfractionated
Clinical and Prognostic Relevance of
Heparin Anticoagulation After Heart Valve
Echocardiographic Evaluation of Right Ventricular
Surgery ..........................................................591
Geometry in Patients With Idiopathic Pulmonary
Claudia Bucci, William H. Geerts, Andrew Sinclair,
Arterial Hypertension ......................................628
and Stephen E. Fremes
Stefano Ghio, Anna Sara Pazzano, Catherine Klersy,
Laura Scelsi, Claudia Raineri, Rita Camporotondo,
Congenital Heart Disease Andrea D’Armini, and Luigi Oltrona Visconti
Seeking Optimal Relation Between Oxygen Clinically Significant Incidental Findings Among
Saturation and Hemoglobin Concentration in Adults Human Immunodeficiency Virus-Infected Men
With Cyanosis from Congenital Heart Disease ...595 During Computed Tomography for Determination of
Craig S. Broberg, Ananda R. Jayaweera, Coronary Artery Calcium .................................633
Gerhard P. Diller, Sanjay K. Prasad, Swee Lay Thein, Nancy Crum-Cianflone, James Stepenosky,
Bridget E. Bax, John Burman, and Sheila Medina, Dylan Wessman, David Krause, and
Michael A. Gatzoulis Gilbert Boswell
CONTENTS A11
Case Report Long-Term Follow Up of Atrioventricular Block in
Transcatheter Aortic Valve Implantation ............641
Self-Terminated Ventricular Fibrillation and
Recurrent Syncope ..........................................638
Instructions to Authors can be found at the AJC
Yuval Konstantino, Angela Morello,
website: www.AJConline.org
Peter J. Zimetbaum, and Mark E. Josephson
Classifieds on pages A10, A37
Readers’ Comments
Comparison of 600 Versus 300-mg Clopidogrel
Loading Dose in Patients With ST-Segment Elevation
Full Text: www.ajconline.org
Myocardial Infarction Undergoing Primary
Coronary Angioplasty .....................................641
A18 THE AMERICAN JOURNAL OF CARDIOLOGY姞 VOL. 107 FEBRUARY 15, 2011
An Early and Simple Predictor of Severe Left Main and/or
Three-Vessel Disease in Patients With Non–ST-Segment
Elevation Acute Coronary Syndrome
Masami Kosuge, MD*, Toshiaki Ebina, MD, Kiyoshi Hibi, MD, Satoshi Morita, PhD,
Mitsuaki Endo, MD, Nobuhiki Maejima, MD, Noriaki Iwahashi, MD, Kozo Okada, MD,
Toshiyuki Ishikawa, MD, Satoshi Umemura, MD, and Kazuo Kimura, MD
Clopidogrel should be initiated as soon as possible in patients with non–ST-segment
elevation acute coronary syndrome (NSTE-ACS) except those who urgently require coro-
nary artery bypass grafting (CABG). The present study assessed the ability to predict
severe left main coronary artery and/or 3-vessel disease (LM/3VD) that would most likely
require urgent CABG based on only clinical factors on admission in 572 patients with
NSTE-ACS undergoing coronary angiography. Severe LM/3VD was defined as >75%
stenosis of LM and/or 3VD with >90% stenosis in >2 proximal lesions of the left anterior
descending coronary artery and other major epicardial arteries. Patients were divided into
the 3 groups according to angiographic findings: no LM/3VD (n ⴝ 460), LM/3VD but not
severe LM/3VD (n ⴝ 57), and severe LM/3VD (n ⴝ 55). Severe LM/3VD was associated
with a higher rate of urgent CABG compared to no LM/3VD and LM/3VD but not severe
LM/3VD (46%, 2%, and 2%, p <0.001). On multivariate analysis, degree of ST-segment
elevation in lead aVR was the strongest predictor of severe LM/3VD (odds ratio 29.1,
p <0.001), followed by positive troponin T level (odds ratio 1.27, p ⴝ 0.044). ST-segment
elevation >1.0 mm in lead aVR best identified severe LM/3VD with 80% sensitivity, 93%
specificity, 56% positive predictive value, and 98% negative predictive value. In conclusion,
ST-segment elevation >1.0 mm in lead aVR on admission electrocardiogram is highly
suggestive of severe LM/3VD in patients with NSTE-ACS. Selected patients with this
finding might benefit from promptly undergoing angiography, withholding clopidogrel to
allow early CABG. © 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;107:
495–500)
Dual antiplatelet therapy with clopidogrel and aspirin require urgent CABG, using only clinical factors on admis-
should be initiated as soon as possible in patients with sion in patients with NSTE-ACS.
non–ST-segment elevation acute coronary syndrome
1,2
(NSTE-ACS). However, such combination therapy can
Methods
increase perioperative bleeding in patients undergoing early
3–7
coronary artery bypass grafting (CABG). Therefore, one We studied 572 consecutive patients (mean age 67 ⫾ 11
might consider with-holding clopidogrel until coronary an- years, range 30 to 92, 397 men and 175 women) who were
8
giography and definition of the coronary anatomy. The admitted to Yokohama City University Medical Center
proportion of patients with NSTE-ACS who undergo (Yokohama, Japan) coronary care unit and fulfilled the
4,5,8–12
CABG during hospitalization is 9% to 21%. CABG following criteria: (1) typical chest discomfort attributed to
can often be deferred for several days, and few patients cardiac ischemia, lasting ⱖ5 minutes, occurring within 24
require urgent CABG. Ideally, clopidogrel should be with- hours before hospital admission, and involving an unstable
held in the minority of patients who urgently require CABG pattern of pain including pain at rest, new onset, severe or
and should be given to the remaining majority of patients. frequent angina, or accelerating angina14; (2) no conditions
We previously examined clinical factors related to left main precluding evaluation ST-segment changes on electrocar-
coronary artery and/or 3-vessel disease (LM/3VD) that diogram (ECG) such as left or right bundle branch block,
would most likely lead to CABG in patients with NSTE- left ventricular hypertrophy, or ventricular pacing; (3) fully
ACS but did not evaluate severity of coronary lesions in that assessable ECGs on admission; and (4) fully assessable
13
study. In the present study, we assessed the ability to angiographic data during hospitalization. We excluded pa-
predict “severe” LM/3VD, which would most likely to tients with nonischemic or atypical pain, persistent new
ST-segment elevation in leads other than lead aVR, recent
(⬍6 months) percutaneous coronary intervention, or previ-
Division of Cardiology, Yokohama City University Medical Center,
Yokohama, Japan. Manuscript received August 28, 2010; revised manu- ous CABG. All patients gave informed consent. The study
script received and accepted October 1, 2010. protocol was approved by the internal review board of
*Corresponding author: Tel: [phone]; fax: [phone]. Yokohama City University Medical Center.
E-mail address:
496 The American Journal of Cardiology (www.ajconline.org)
Table 1
Clinical characteristics
LM/3VD p
Value
No LM/3VD Nonsevere Severe
(n ⫽ 460) (n ⫽ 57) (n ⫽ 55)
Age (years) 66 ⫾ 11 69 ⫾ 10 68 ⫾ 11 0.06
Men 322 (70%) 39 (68%) 36 (66%) 0.78
Systolic blood pressure on admission (mm Hg) 150 ⫾ 25 150 ⫾ 32 141 ⫾ 26 0.07
Heart rate on admission (beats/min) 76 ⫾ 17 81 ⫾ 20 89 ⫾ 23 ⬍0.001
Killip class ⱖII on admission 26 (6%) 9 (16%) 17 (31%) ⬍0.001
Symptom onset ⱕ6 hours 356 (78%) 43 (75%) 49 (89%) 0.13
Previous myocardial infarction 86 (19%) 18 (32%) 12 (22%) 0.07
Previous percutaneous coronary intervention 90 (20%) 15 (26%) 5 (9%) 0.06
Risk factors
Hypertension 304 (66%) 42 (74%) 38 (69%) 0.49
Diabetes mellitus 136 (30%) 29 (51%) 30 (55%) ⬍0.001
Smoking 229 (50%) 22 (39%) 23 (42%) 0.18
Hyperlipidemia* 230 (50%) 25 (44%) 29 (53%) 0.61
Family history of coronary artery disease 120 (26%) 13 (23%) 16 (29%) 0.75
Hemoglobin on admission (g/dl) 14 ⫾ 2 13 ⫾ 2 13 ⫾ 2 0.033
High-sensitivity C-reactive protein on admission (mg/dl) 0.131 (0.061–0.323) 0.180 (0.079–0.453) 0.253 (0.099–0.801) 0.005
Positive troponin T on admission 135 (29%) 28 (49%) 33 (60%) ⬍0.001
Creatine kinase-MB on admission (IU/L) 14 ⫾ 16 18 ⫾ 24 27 ⫾ 36 ⬍0.001
2
Estimated glomerular filtration rate on admission (ml/min/1.73 m ) 68 ⫾ 25 58 ⫾ 28 58 ⫾ 26 0.004
†
Brain natriuretic peptide on admission (pg/ml) 67 (26–179) 187 (81–429) 230 (67–571) ⬍0.001
(n ⫽ 297) (n ⫽ 32) (n ⫽ 31)
Cardiac procedures and outcomes at 30 days
Death 1 (0.2%) 1 (2%) 2 (4%) 0.010
Myocardial (re)infarction 14 (3%) 3 (5%) 5 (9%) 0.23
Death/myocardial (re)infarction 15 (3%) 4 (7%) 7 (13%) 0.004
Urgent percutaneous coronary intervention 29 (6%) 7 (12%) 5 (9%) 0.22
Urgent coronary artery bypass surgery 7 (2%) 1 (2%) 25 (46%) ⬍0.001
Urgent revascularization (percutaneous coronary intervention or 36 (8%) 8 (14%) 30 (55%) ⬍0.001
coronary artery bypass surgery)
Cardiac procedures
Percutaneous coronary intervention 272 (59%) 36 (63%) 14 (25%) ⬍0.001
Coronary artery bypass surgery 27 (6%) 13 (23%) 40 (73%) ⬍0.001
Any revascularization (percutaneous coronary intervention or 291 (63%) 49 (86%) 54 (98%) ⬍0.001
coronary artery bypass surgery)
Data are presented as mean ⫾ SD, median (interquartile range), or number of patients (percentage).
* Fasting total cholesterol concentration ⱖ220 mg/dl, fasting triglyceride concentration ⱖ150 mg/dl, or use of antihyperlipidemic therapy.
†
Available for 360 patients.
Table 2
Electrocardiographic findings
Variable LM/3VD p Value
No LM/3VD Nonsevere Severe
(n ⫽ 460) (n ⫽ 57) (n ⫽ 55)
ST-segment depression ⱖ0.5 mm 288 (63%) 53 (93%) 55 (100%) ⬍0.001
Maximal ST-segment depression (mm) 0.8 ⫾ 1.0 1.7 ⫾ 1.1 2.6 ⫾ 1.7 ⬍0.001
Sum of ST-segment depressions (mm) 2.6 ⫾ 3.6 6.7 ⫾ 5.1 10.5 ⫾ 7.3 ⬍0.001
Number of leads with ST-segment depression ⱖ0.5 mm 2.5 ⫾ 2.5 5.1 ⫾ 2.6 6.1 ⫾ 2.2 ⬍0.001
ST-segment elevation ⱖ0.5 mm in lead aVR 68 (15%) 39 (68%) 50 (91%) ⬍0.001
ST-segment elevation in lead aVR (mm) 0.1 ⫾ 0.3 0.6 ⫾ 0.5 1.2 ⫾ 0.7 ⬍0.001
Data are presented as mean ⫾ SD or number of patients (percentage).
paper speed of 25 mm/s and an amplification of 10 mm/mV. ms after this point for ST-segment elevation using the preced-
15
All ECGs were examined by a single investigator who was ing TP segment as a baseline. ST-segment deviation was
14
blinded to all other clinical data. ST-segment shifts were mea- considered present if deviation was ⱖ0.5 mm in any lead.
sured 80 ms after the J-point for ST-segment depression and 20 A qualitative assay for cardiac-specific troponin T (de-
Coronary Artery Disease/Prediction of Severe LM/3VD in NSTE-ACS 497
tection limit 0.1 ng/ml of cardiac-specific troponin T; Roche
Diagnostics, Tokyo, Japan) was performed on admission.
Troponin T ⱖ0.1 ng/ml was defined as positive. Blood
samples for measuring hemoglobin, plasma high-sensitivity
C-reactive protein levels, and estimated glomerular filtra-
tion rate were also taken on admission. Japanese equations
were used to calculate estimated glomerular filtration rate
16
from serum creatinine level. Brain natriuretic peptide was
simultaneously measured in 360 patients. Creatine ki-
nase-MB levels were measured on admission, at 3-hour
intervals during the first 24 hours, and in any patient with
suspected reinfarction.
All patients underwent cardiac catheterization a median
of 3 days after admission. Urgent cardiac catheterization
was performed in patients with unstable hemodynamics
from ischemic attacks or with ischemic attacks that could
not be controlled by intensive drug treatment. Type and
timing of revascularization were left to the discretion of the
treating physician. All coronary angiograms were evaluated
by a single investigator who was blinded to all other clinical
data. Stenosis ⱖ50% in the diameter of the LM or stenosis
of ⱖ75% in ⱖ1 major epicardial vessel or its main branches
was considered clinically significant. Severe LM/3VD was
defined as (1) ⱖ75% stenosis of the LM, (2) 3VD with
ⱖ90% stenosis of the proximal portion of the left anterior
descending coronary artery and ⱖ90% stenosis of the right
coronary artery and/or left circumflex coronary artery, and
(3) definitions 1 and 2. Patients were categorize according to
presence (n ⫽ 112) or absence (n ⫽ 460) of LM/3VD, and
the former group was subdivided according to severity of
coronary lesions: nonsevere LM/3VD (n ⫽ 57) and severe
LM/3VD (n ⫽ 55).
Demographic data, risk factors for coronary artery dis-
ease, and data from physical examination on admission
were collected. Major adverse events such as death, myo-
cardial (re)infarction, or urgent revascularization were also
recorded for all patients. Myocardial infarction was diag-
nosed according to cardiac enzyme levels or electrocardio-
graphic criteria. Enzymatic evidence of myocardial infarc-
tion was defined as an increase of creatine kinase-MB to
higher than the upper limit of normal if the previous creatine
kinase-MB level was in the normal range or 50% above the
previous level if the previous level was above the normal
17
range. Electrocardiographic evidence of myocardial in-
farction was defined as new clinically significant Q waves in
ⱖ2 contiguous leads distinct from the enrollment myocar-
17
dial infarction. Patients were followed for 30 days after
admission.
Figure 1. Representative electrocardiogram of a patient with severe left
Results are expressed as mean ⫾ SD or as frequency main coronary artery and/or 3-vessel disease. Troponin T was positive on
(percentage), and high-sensitivity C-reactive protein and admission. ST-segment elevation in lead aVR was 4.5 mm on admission
brain natriuretic peptide levels are expressed as median and electrocardiogram. Urgent coronary angiography showed 90% stenosis of
interquartile range. Data were compared by 1-way analysis the left main trunk.
of variance, Kruskal-Wallis test, and chi-square analysis.
Differences were considered statistically significant at p
tified on multivariate analysis were determined. SPSS sta-
value ⬍0.05. Multivariate logistic regression analysis was
tistical software (SPSS, Inc., Chicago, Illinois) was used for
used to identify clinical predictors of severe LM/3VD
all analyses.
among the variables associated (p ⬍0.05) with this diagno-
sis on univariate analysis. Odds ratios and 95% confidence
Results
intervals were calculated. In addition, sensitivity, specific-
ity, positive predictive value, negative predictive value, and Baseline characteristics are listed in Table 1. Patients
predictive accuracy of predictors of severe LM/3VD iden- with LM/3VD, especially severe LM/3VD, had a more
498 The American Journal of Cardiology (www.ajconline.org)
Table 3
Univariate and multivariate predictors of severe left main coronary artery and/or three-vessel disease
Variable Odds Ratio (95% CI) p Value
Univariate Multivariate
Systolic blood pressure 0.020 0.07
Heart rate ⬍0.001 0.29
Killip class ⱖII ⬍0.001 0.29
Previous percutaneous coronary intervention 0.045 0.80
Diabetes mellitus 0.001 0.08
High-sensitivity C-reactive protein ⬍0.001 0.30
Positive troponin T 1.27 (1.10–2.78) ⬍0.001 0.044
Creatine kinase-MB ⬍0.001 0.33
Estimated glomerular filtration rate ⬍0.001 0.32
Maximal ST-segment depression ⬍0.001 0.053
Sum of ST-segment depressions ⬍0.001 0.055
Number of leads with ST-segment depression ⱖ0.5 mm ⬍0.001 0.24
Degree of ST-segment elevation in lead aVR 29.1 (9.54–49.8) ⬍0.001 ⬍0.001
CI ⫽ confidence interval.
Table 4 and predictive accuracy of ST-segment elevation in lead
Comparison of ST-segment elevation in lead aVR and positive troponin
aVR and positive troponin T for severe LM/3VD are pre-
T for predicting severe left main coronary artery and/or three-vessel
sented in Table 4. ST-segment elevation ⱖ1.0 mm in lead
disease
aVR best identified severe LM/3VD.
Sensitivity Specificity PPV NPV Predictive
Accuracy
Discussion
ST-segment elevation
in lead aVR Our study showed that ST-segment elevation ⱖ1.0 mm
† † †
ⱖ0.5 mm 91% 79% 32% 99% 80% in lead aVR and positive troponin T on admission (espe-
ⱖ1.0 mm 80% 93% 56% 98% 92% cially the former) were highly suggestive of severe LM/
† † †
ⱖ1.5 mm 27% 98% 58% 93% 91% 3VD, and the converse was also true, i.e., absence of these
† † † †
Positive troponin T 60%* 69% 17% 94% 68%
findings was rarely associated with severe LM/3VD. To our
knowledge, this is the first study to establish a reliable
NPV ⫽ negative predictive value; PPV ⫽ positive predictive value.
* p ⬍0.05; † p ⬍0.01 versus ST-segment elevation ⱖ1.0 mm in lead technique for early identification of patients with severe
aVR. LM/3VD who are most likely to require urgent CABG in
patients with NSTE-ACS. Our findings have important im-
plications for identification of high-risk patients and selec-
rapid heart rate, higher prevalences of Killip class ⱖII, tion of optimal treatment strategy in the setting of NSTE-
diabetes mellitus, positive troponin T, and higher levels of ACS.
high-sensitivity C-reactive protein, creatine kinase-MB, and The standard 12-lead ECG, which is an inexpensive,
brain natriuretic peptide than did patients without LM/3VD. noninvasive, and readily available clinical tool, has a central
LM/3VD was associated with lower levels of hemoglobin role in diagnosis and immediate triage for NSTE-ACS and
and estimated glomerular filtration rate. There were no sig- provides important prognostic information. In particular,
nificant differences in other clinical variables among the 3 presence of ST-segment depression on admission ECG has
groups. been recognized to be a strong predictor of adverse out-
14,17–20
Urgent CABG was more frequently done in patients with comes in patients with NSTE-ACS. The Global Uti-
severe LM/3VD (46%). In contrast, urgent CABG was done lization of Strategies to Open Occluded Arteries in Acute
in only 2% of patients with LM/3VD but not severe LM/ Coronary Syndrome IV (GUSTO-IV ACS) trial of 7,800
3VD. patients with NSTE-ACS has highlighted the striking prog-
Electrocardiographic findings are presented in Table 2. nostic value of ST-segment depression on admission com-
Compared to patients without LM/3VD, those with LM/ pared to expanded biomarker profiles and traditional risk
18
3VD, especially severe LM/3VD, had a higher prevalence factors. However, most previous studies assessing the
and a larger amount of ST-segment depression, a larger clinical significance of admission ECG in patients with
number of leads other than lead aVR with ST-segment NSTE-ACS have focused on ST-segment deviation in leads
depression, and a higher prevalence and greater magnitude other than lead aVR; i.e., clinicians have used an “11-lead”
of ST-segment elevation in lead aVR. Figure 1 shows a ECG, neglecting lead aVR.
representative ECG of a patient with severe LM/3VD. Several studies have found that analysis of lead aVR is
13,15,21,22
In multivariate models, degree of ST-segment elevation useful for evaluation of NSTE-ACS. Gorgels et
21
in lead aVR was the strongest predictor of severe LM/3VD, al reported that ST-segment elevation in lead aVR accom-
followed by positive troponin T (Table 3). Sensitivity, spec- panied by ST-segment depression in leads I, II, and V to V
4 6
ificity, positive predictive value, negative predictive value, during episodes of angina strongly suggests LM/3VD in
Coronary Artery Disease/Prediction of Severe LM/3VD in NSTE-ACS 499
15
patients with angina at rest. Barrabés et al demonstrated ST-segment depression in other leads in patients with
that presence of ST-segment elevation in lead aVR predicts NSTE-ACS.
risk of in-hospital death in patients with a first non–ST- Recently approved antiplatelet agents such as prasugrel
segment elevation acute myocardial infarction. In that and ticagrelor, a new reversible agent, have been shown to
study, ST-segment elevation in lead aVR was also related to decrease ischemic events compared to clopidogrel, but the
7
LM/3VD; however, coronary angiography was performed former increased the risk of perioperative bleeding and the
26
in only 56% of subjects within 6 months after infarction. We latter did not decrease the risk of perioperative bleeding.
previously demonstrated that presence of ST-segment ele- Until an antiplatelet agent that decreases ischemic events
vation ⱖ0.5 mm in lead aVR on admission ECG strongly and decreases perioperative bleeding compared to clopi-
suggested LM/3VD and had a higher prognostic value than dogrel becomes available, some patients will be exposed to
ST-segment depression in other leads in patients with a risk of urgent CABG-related bleeding caused by upstream
NSTE-ACS who underwent coronary angiography in the dual antiplatelet therapy.
13,22
acute phase. However, previous studies, including ours, This study was retrospective, performed at a single cen-
did not consider severity of LM/3VD, which has clinical ter, and included a small number of patients who underwent
implications for timing of CABG in relation to dual anti- coronary angiography during hospitalization. However, the
platelet therapy. An increased risk of perioperative bleeding proportion of patients undergoing CABG during hospital-
events due to early clopidogrel administration is clinically ization in this study (14%) was similar to that in previous
4,10,12
problematic in patients with LM/3VD who urgently require studies. Moreover, because our subjects underwent
CABG. In such patients, postponing CABG for several days cardiac catheterization a median of 3 days after admission,
might seriously compromise outcomes. Timing of CABG our data on clinical outcomes according to angiographic
depends on many factors including severity of coronary findings cannot be generalized to hospitals that provide
lesions, risk of ongoing ischemia, general condition of a early invasive strategies. Further studies in larger numbers
patient, bleeding risk associated with upstream antithrom- of patients are needed to verify our results.
botic therapies, and local logistic factors such as collocation
of cardiac surgical services and surgical waiting lists. The 1. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey
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