Characteristics and mechanism of reciprocal ST-segment depression in acute ST segment elevation myocardial infarction

Background: At present, the mechanism of reciprocal ST-segment depression(RSTD) is still not clear.Methods: The electrocardiogram and angiography of 85 STEMI patients were retrospectively analyzed to summarize the characteristics of ST segment changes and explore the mechanism of RSTD.Results: A total of 85 patients were included, of which 75 were patients with RSTD (10 patients with anterior myocardial infarction had no RSTD), all 45 patients with inferior myocardial infarction had limb leads RSTD, and 37 of them had anterior lead ST segment depression.Thirty patients with anterior myocardial infarction were accompanied by mild ST segment changes in the limb leads. According to the characteristics of RSTD, it is speculated that the mechanism of RSTD is that the action potential of infarct area decreased , which could not offset the action potential in non-infarct area.Conclusion: the mechanism of RSTD in acute myocardial infarction maybe that the negative electrode action potential of the lead was weakened or disappeared, and the positive electrode action potential could not be completely offset, resulting in ST segment depression.

807 Wellens syndrome: a rare entity not to underestimate

Aims Abrupt oppressive chest pain is a common reason of emergency department’s access. An accurate assessment of the clinical setting is needed to ensure the patient the correct management. This includes a good anamnesis, physical examination, electrocardiogram (ECG) and cardiac biomarkers evaluation. Wellens syndrome is a clinical entity characterized by acute chest pain, normal or minimal elevation of cardiac biomarker, specific ECG changes with no ST elevation or Q-waves. The ECG modifications contemplate: biphasic T waves in lead V2 and V3 (type A) initially positive and subsequent negative or deep and symmetrically inverted T waves in anterior leads (Type B, more often V1–V4). Recognizing these patterns can be so challenging for physician in emergency departments, especially in Type A, and failure in diagnosis can lead to deleterious outcomes. In fact, Wellens syndrome can be considered as a pre-infarction state that needs immediate intervention: if not treated appropriately, about 75% of patients can suffer anterior myocardial infarction due to a stenosis of left anterior descending (LAD) artery. Methods A 55-year-old male with hyperlipidaemia and a family history of cardiovascular disease, presented to emergency department with abrupt oppressive chest pain after mild physical effort. At presentation he presented a typical ECG of Wellens syndrome type A with negative cardiac biomarkers. His GRACE (Global Registry of Acute Coronary Events) score was 72 and his thrombolysis in myocardial infarction (TIMI) was 2. At second blood sample cardiac biomarkers was mildly higher than upper limit of normal. Results Despite low grade on risk stratification he immediately underwent coronary angiography, who resulted in a subocclusive stenosis from ostium to the medium tract of LAD. PCI was subsequently taken with implantation of TWO drug eluting stent (DES). After 3 days he was discharged asymptomatic and in optical medical therapy. Conclusions Wellens syndrome is a rare clinical entity that must be considered as a pre- infarction state difficult to individuate. Conventional management in these patients utilizing typical risk stratification scores may not be appropriate. In this context an early diagnosis of ECG patterns it’s crucial, in order to provide an urgent percutaneous intervention. Failure in recognition of signs and symptoms of Wellens syndrome can lead to disastrous outcome due to a critical, vulnerable, stenosis on proxymal LAD and to a possible imminent large anterior myocardial infarction.

Extensive anterior myocardial infarction of an older non diabetic patient has better prognosis compared to a younger patient: a case report

ST elevation myocardial infarction (STEMI) incidence rates has been decreased inversely to non-STEMI (121 to 77, 126 to 132 per 100.000 case respectively). Diabetes as a risk factors of STEMI is found in 20% patients. The increment of fibrinogen level in diabetic patient may induce compact clots resistance to fibrinolysis that lead to hypercoagulable state problem. Percutaneous coronary intervention (PCI), a non-surgical invasive procedure, can be done to relieve the obstruction. We reported two case reports, patients with anterior extensive STEMI who had underwent primary PCI. Both patients were found a total occlusion at proximal segment of LAD. First case was presented type 2 diabetes mellitus as comorbid while the second case was without diabetes. High burden thrombus was found on the diabetic patient which had poor prognosis, but on the non diabetic patient was found only less thrombus which was more stable condition. There is a strong correlation between type 2 diabetes mellitus and cardiovascular disease (CVD). Glucose control is important for prevention of CVD. Dietary changes that are characterized by increased use of natural sources diets such as whole grains, vegetables, and fruit-based foods and increased physical activity is remarkably strong factors for diabetes prevention.

The Role of Cardiac Magnetic Resonance in Assessment of Myocardial Contractile Function After Exercise Training Based Cardiac Rehabilitation Program in Anterior ST-Elevated Myocardial Infarction Patients Treated with Primary Percutaneous Coronary Intervention

Back ground Regular exercise training program has been shown to reduce mortality, improve functional capacity and control risk factors in myocardial infarcted patients. Wall motion score index (WMSI) is a strong independent mortality predicator in patient with previous MI AIM The main objective of this study was to investigate the impact of exercise training on regional left ventricular systolic function, in patients post anterior myocardial infarction. using cardiac magnetic resonance imaging Methods We recruited twenty-six adult patients on optimal medical therapy one month after an anterior myocardial infarction underwent successful percutaneous coronary intervention (PCI) were assigned to a three-month exercise training program group or to a control group, (control group: n = 10, training group: n = 16). Symptom limited treadmill exercise (Modified Bruce Protocol) test was done to exercise training group before and repeated after finishing the CR program. Cardiac Magnetic Resonance (CMR) was performed for all patients 4 weeks after PCI and was repeated after completion of the study period that was lasted for 12 weeks. Results A total number of patients, included 26 (100%) males, assigned to control group n:10 without an exercise mean age 50± 8 years, weigh 84 ±17 kg, height 175±7.7 cm and EF was 36.62 ±14.23 and to training group n:16 with 3-months exercise training program, the mean age, weight, height and EF were 50.19±8.68 years, 82.69±16 kg, 172.81±7.74 cm, 36.62±14.32% respectively While there was significant improvement in EF (P < 0.0008), WMSI (P < 0.00003) without significant change in LVESV and LVEDV in exercise training group, there was no significant change in EF, WMSI, LVESV and LVEDV in control group. Conclusion CMR revealed that exercise training in post-myocardial infarction patients could have beneficial effects on LV global and regional function without adversely affecting LV remodeling or causing serious cardiac complications with significant improvement in exercise capacity after 3 months of exercise training program.

Arrhythmogenic anterior myocardial infarction with QRS-complex fragmentations and Passing phenomenon or Yasser’s phenomenon; the risk and serious implications

Rationale: The arrhythmias associated with myocardial infarction may be serious. Increasing morbidity and mortality in myocardial infarction-induced arrhythmias will be expected. The term “fragmentation of the QRS complex” denotes the existence of high-frequency potentials (spikes) in the QRS-complex. It is either a marker for cardiac structural diseases inducing biventricular hypertrophy or any condition interfering with the normally homogeneous depolarization status inside the myocardium. An associated Passing phenomenon or “Yasser’s phenomenon” may have an apparent hemodynamic impact. Patient concerns: A 68-year-old married, housewife, Egyptian female patient presented to the physician outpatient clinic with acute chest pain and anterior myocardial infarction with QRS-complex fragmentations and Passing phenomenon or “Yasser’s phenomenon”. Diagnosis: Arrhythmogenic acute extensive anterior infarction with QRS-complex fragmentations and Passing phenomenon or Yasser’s phenomenon. Interventions: Electrocardiography, oxygenation, streptokinase intravenous infusion, echocardiography, and percutaneous transluminal coronary angioplasty. Outcomes: Dramatic response of acute arrhythmogenic anterior ST-segment elevation myocardial infarction with QRS-complex fragmentations to streptokinase and percutaneous transluminal coronary angioplasty. Lessons: The presence of runs of ventricular tachycardia, multiform frequent premature ventricular contractions, and QRS-complex fragmentations, elderly, female sex are prognostic factors for the severity of the disease. Dramatic clinical and electrocardiographic response signifying the role of streptokinase, fibrinolytic, and percutaneous transluminal coronary angioplasty. The presence of fragmentation of the QRS-complex may have a bidirectional impact from seriousness to complications. Passing phenomenon or “Yasser’s phenomenon” should be directed at the disease progression.