Diagnosis and Prognosis of Clinical Course of Acute Myocardial Infarction

I.Ye. Belaya, V.I. Kolomiyets, Ye.K. Musayeva

Abstract


About one third of all acute coronary events is ST elevated myocardial infarction (MI). Prehospital mortality of patients in Europe and Ukraine is 30–50 %, in-hospital — 8–13 %. Therefore, the problem of MI diagnosis is of current interest. Although we have highly informative methods such as myocardial perfusion scintigraphy, emission computed tomography and magnetic resonance tomography, echocardiography, ultrasound and contrast coronary angiography, in fact the only method of instrumental diagnostics in practice is medical electrocardiogram (ECG). However, atypical pain or no changes on the standard ECG can complicate the diagnosis of acute coronary disease. Especially when you consider that markers of myocardial necrosis are not absolutely specific and sensitive, depending on the disease and comorbidity. First of all it concerns the posterior basal MI when ECG can show only indirect signs of myocardial damage. Therefore, the introduction of a new noninvasive method of electromotive forces of the heart research on cardiodiagnostic polygraph MTM-SCM allows not only to clarify the localization of necrobiotic processes in the myocardium, but also to obtain additional information about the electrical activity of the heart, including the «dead» zone, which is especially important in «mute» ECG It should be noted that foreign researchers study electrical instability of myocardium in MI using vector analysis, but electrophysiological features of this localization are not reflected in the available literature.
The purpose is to identify vectorcardiographic (VCG) signs of acute MI with posterior-inferior Q wave with the spread to the posterior basal part of the left ventricle (LV) and to define its main prognostic factors.
Materials and Methods. The work includes 17 patients with primary posterior-inferior MI and 14 patients with primary massive posterior LV MI with the average age of 69 ± 3 and 66 ± 3 years. Patients were hospitalized in the first 24 hours of onset. Instrumental studies included the routine ECG, V7–9, Dorsalis according to Nab, V3R and V4R and VCG in five projections (VA1–5) according to Akulinichev, conducted on the MTM-SCM cardiodiagnostic multifunctional complex.
Results. Acute posterior-inferior MI with the spread to the high parts of the posterior wall of LV in VCG is characterized by QRS loops shift to the right (forward in space) from the myocardial injury zone; 1.2–1.3 times reduction of the maximum vector in the first, second (p < 0.05) and fifth (p < 0.01) projections and three times reduction of the QRS loop area in the first three projections (p < 0.001), and the slowing of excitation spread speed over QRS loops in all projections (p < 0.01). Unlocked QRS loops with downward injury vector ST that is directed downwards, to the left and back, 2–3 times reduction of the T loops maximum vector (p < 0.01–0.001) and multidirectional changes of QRS-T loops angular divergence (with 1.2–8.4 times change, p < 0.01–0.001) in the first, third and fifth projections and slow pulse spread over T loops in all projections (p < 0.001), when they are located outside QRS loops, reflect repolarization disorder in the necrosis zone. Outside the necrosis area we can see the growth in the excitation spread speed in the upper interior part of the left ventricular and the posterior part of both ventricles (the first, fourth and fifth projections of VCG (p < 0.001), as well as P loops maximum vector reduction (p < 0.05) with the violation of internal atrial conduction over all P loops (p < 0.001) and repolarization in the form of multidirectional changes of angular divergence of QRS-P loops in the third, fourth and fifth VCG projections in 2.8–7.6 times (p < 0.01–0.001). The use of an adequate method of predicting the consequences of LV posterior basal part damage, viz. «Decision Tree» Data Mining algorithm, has allowed to find a significant factor of probable death, that is the speed of the excitation spread over T loop in the end part of BA5. If this figure is less than 2.525 mV/s, then death can be predicted with 93% accuracy. If the speed is above this figure or equal, then the prognosis is favourable.
Conclusions. The «Decision Tree» algorithm has been used to predict the outcomes of posterior-basal left ventricle injury on the basis of vectorcardiography study results. The significant factor of probable death was revealed — the speed of excitation spread in the end part of T loop in the fifth projection. So important for prognosis is the degree of late posterior-basal repolarization abnormality in basal parts of the ventricles.


Keywords


vectorcardiogram; acute myocardial infarction; prediction; «Decision Tree» algorithm

References


Бєлая І.Є. Векторкардіографічні ознаки гострого інфаркту міокарда із зубцем Q задньо-нижньої локалізації в перші 24 години захворювання // Серце і судини. — 2012. — № 3. — С. 62-71.

Бабушкина А.В. Инфаркт миокарда: от фундаментальных исследований — к практическим достижениям (по материалам X Национального конгресса кардиологов Украины) // Укр. мед. часопис. — 2009. — № 5(73). — С. 10-13.

Барсегян А.А., Куприянов М.С., Степаненко В.В., Холод И.И. Методы и модели анализа данных: OLAP и Data Mining. — СПб.: БХВ-Петербург, 2004. — 336 с.

Коломиец В.И., Белая И.Е. Электрофизиологические особенности ранних этапов сердечной недостаточности при гипертонической болезни, сочетанной с язвенной болезнью двенадцатиперстной кишки // Укр. мед. альманах. — 2007. — Т. 10, № 1. — С. 230-236.

Копица Н.П., Литвин Е.И. Быстрая идентификация и прогноз у пациентов с острым коронарным синдромом // Укр. терапевт. журн. — 2011. — № 1. — С. 102-106.

Патологическая физиология / Под ред. А.И. Воложина, Г.В. Порядина. — Т. 2. — М.: Медпресс, 2000. — 528 с.

Рекомендации ESC по ведению больных с инфарктом мио­карда с подъемом сегмента ST (2008) // Кардиол. альманах. — 2009. — С. 5-20.

Целуйко В.И. Сложный клинический случай. Как поставить правильный диагноз? // Здоров’я України. — 2009, вересень. — № 17(222). — С. 18.

Cetin M., Kocaman S.A., Kiris T. et al. Absence and Resolution of Fragmented QRS Predict Reversible Myocardial Ischemia With Higher Probability of ST Segment Resolution in Patients With ST Segment Elevation Myocardial Infarction // Korean Circ. J. — 2012. — Vol. 42, Is. 10. — P. 674-83.

Nikus K., Pahlm O., Wagner G. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology // J. Electrocardiol. — 2010. — Vol. 43, Is. 2. — P. 91-103.

Ottander P., Nilsson J.B., Jensen S.M., Näslund U. Ischemic ST-segment episodes during the initial 24 hours of ST elevation myocardial infarction predict prognosis at 1 and 5 years // J. Electrocardiol. — 2010. — Vol. 43, Is. 3. — P. 224-229.

Patel N., Azemi T., Zaeem F., Fram D. Acute inferior myocardial infarction complicated by a very large ventricular septal rupture and cardiogenic shock // JACC Cardiovasc. Interv. — 2012. — Vol. 5, Is. 11. — P. e35-e36.

Pentti M. Rautaharju. Dispersed measures of dispersed repolarization and depolarization: Scalars, vectors, angles, maps, and prospects for improved clinical utility // J. Electrocardiol. — 2010. — Vol. 43, Is. 4. — P. 283-287.

Van de Werf F. The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology / Van de Werf F., Bax J., Betriu A. et al. // Eur. Heart J. — 2008. — Vol. 29, Is. 23. — P. 2909-2945.

Yanga H., Bukkapatnamb S.T., Leb T., Komanduric R. Identification of myocardial infarction (MI) using spatio-temporal heart dynamics // Medical Engineering & Physics. — 2012. — Vol. 34, Is. 4. — P. 485-497.




DOI: https://doi.org/10.22141/2224-0586.5.52.2013.88916

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