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      Does Chronic ST Segment Elevation following Q Wave Myocardial Infarction Exclude Tissue Viability?

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          Abstract

          Purpose: Electrocardiographic (ECG) ST segment elevation lasting 2 or more weeks following Q wave myocardial infarction has been associated with ‘ventricular aneurysm’ and absence of tissue viability. Regional systolic dysfunction may reflect either viable myocardium or scar. Positron emission-tomographic (PET) imaging can distinguish viable from nonviable tissue. We hypothesized that patients with chronic ST segment elevation after Q wave infarction might demonstrate salvageable myocardium in the infarct region. Methods: The ECGs of 1,229 sequential patients undergoing PET scans for viability assessment were reviewed by an electrocardiographer to identify individuals with chronic anteroseptal Q wave infarctions with persistent ST segment elevation exceeding 1 mV. Patients with QRS duration longer than 0.14 ms or rhythm other than sinus were excluded. Viability was considered present if either a reversible stress-induced perfusion defect (ischemia) or a resting perfusion-metabolism mismatch (hibernation) was identified. Results: Anteroseptal ECG Q wave infarction was identified in 132 subjects (74% male, age 61 ± 12 years). Chronic ST segment elevation was present in 84 subjects (64%) and absent in 48. Baseline clinical characteristics and left ventricular systolic function were similar in both groups. 63% of those with and 56% of those without chronic ST elevation had viable myocardium. No relationship was noted between chronic ST segment elevation and the presence or absence of myocardial viability. Conclusions: Chronic ST segment elevation after anteroseptal Q wave myocardial infarction does not exclude myocardial viability in the ‘infarct zone’. Evaluation of residual tissue viability is indicated to assess the benefit of revascularization in patients with Q wave infarction and chronic ST segment elevation.

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          Most cited references 4

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          Value of metabolic imaging with positron emission tomography for evaluating prognosis in patients with coronary artery disease and left ventricular dysfunction.

          Patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction have a high but variable annual mortality and some may benefit from myocardial revascularization. This study aimed to evaluate the prognostic value of positron emission tomography (PET), and its interrelation with the choice of medical therapy or revascularization for predicting survival and improvement in symptoms of heart failure in patients with CAD and LV dysfunction. Ninety-three consecutive patients with angiographic CAD and a mean LV ejection fraction of 0.25 who underwent cardiac PET studies for assessment of hypoperfused yet viable myocardium ("mismatch pattern") using N-13 ammonia and 18-F deoxyglucose were followed up for an average of 13.6 months. Fifty patients underwent medical treatment and 43 underwent revascularization. The Cox model analysis showed that the extent of mismatch had a negative effect (p = 0.02), whereas revascularization had a positive effect on survival (p = 0.04). The annual survival probability of patients with mismatch receiving medical therapy was lower than of those without mismatch (50 vs 92%, p = 0.007). Patients with mismatch who underwent revascularization had a higher survival rate than those treated medically (88 vs 50%, P = 0.03). The presence of mismatch also predicted improvement in heart failure symptoms after revascularization (p < 0.001). These results suggest that the presence of mismatch in patients with CAD and severe LV dysfunction is associated with poor annual survival with medical therapy. Revascularization in patients with PET mismatch appears to be associated with improved survival and heart failure symptoms.
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            Prediction by postexercise fluoro-18 deoxyglucose positron emission tomography of improvement in exercise capacity after revascularization.

            The extent of ischemic and hibernating myocardium, which may be detected by increased postexercise uptake of fluoro-18 deoxyglucose (FDG) using positron emission tomography, may determine the degree of functional benefit after revascularization. This study examined the influence of the amount of this FDG-avid myocardium on changes in left ventricular function and exercise parameters after revascularization. Echocardiography and exercise testing were performed before and after intervention in 23 patients who had undergone positron emission tomography for the evaluation of myocardial perfusion (using rubidium-82), and postexercise FDG imaging in the fasting state. Follow-up echocardiography (22 +/- 14 weeks after revascularization) was compared with preoperative FDG activity in 7 myocardial regions per patient. Systolic function improved after intervention in 19 of 26 malperfused, dysfunctional FDG-avid regions (73%), and did not improve in 35 of 47 dysfunctional regions without increased FDG uptake (74%). The influence of the amount of FDG-avid tissue on changes in functional state was examined by comparing 9 patients with multiple (greater than or equal to 2) FDG-avid regions with the remainder. Those with multiple FDG-avid regions demonstrated improvement in peak rate-pressure product (20 +/- 4 to 26 +/- 4 x 10(3), p less than 0.02), and percentage of maximal heart rate achieved at peak (84 +/- 10% to 93 +/- 6%, p = 0.04), neither of which changed significantly in the remaining patients. Exercise capacity increased from 5.6 +/- 2.7 to 7.5 +/- 1.7 METS in the group with multiple FDG-avid regions; this increase of 55 +/- 18% exceeded the increase of 13 +/- 10% in the remainder (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)
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              Natural history of S-T segment elevation after acute myocardial infarction

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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2003
                September 2003
                22 September 2003
                : 100
                : 1
                : 11-16
                Affiliations
                Departments of aInternal Medicine, bCardiovascular Medicine, cMolecular and Functional Imaging and dBiostatistics, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
                Article
                72386 Cardiology 2003;100:11–16
                10.1159/000072386
                12975540
                © 2003 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 4, Tables: 3, References: 24, Pages: 6
                Categories
                General Cardiology

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