The Predictive Value of P wave Dispersion in Determination of Infarct Ralated Artery Patency

Öz

Introduction: The value of P-wave dispersion (PWD) on the surface electrocardiogram (ECG) has been shown to increase in coronary ischemia. Previous studies demonstrated that PWD decreased with repefusion therapy in patients with STEMI. The aim of current study is to investigate whether PWD is able to be used as an additional parameter to predict successful reperfusion and infarct related artery patency in patients with STEMI who were admitted in the first 12 hours of myocardial infarction and received thrombolytic therapy.Patients and Methods: A total of 150 patients who referred to Dokuz Eylül University Cardiology Department with STEMI between 01 January 2012 and 01 December 2013 and received thrombolytic therapy in the first 12 hours of the symptoms were included in our study. Hospital records of each patient were evaluated retrospectively. Demographical features were noted. Standart 12-lead surface ECG of each patient which were recorded before and at 30, 60, 90 and 120 minutes after the start of thrombolytic therapy were obtained. Maximum, minimum P-wave duration and PWD were calculated on each electrocardiogram and ST segment resolution was determined. Coronary angiography images were also evaluated to determine TIMI flow grade and TIMI frame count of the infarct related artery. The relationship between PWD and ST segment resolution and infarct related artery patency was investigated.Results: While PWD at the start of the thrombolytic therapy was 50.79±14.12 ms, PWD at 90th minute of thrombolytic therapy was calculated as 48.34±15.60 and PWD at 120th minute of thrombolytic therapy was calculated as 47.85±10.87 ms; the difference was not statistically significant (p= 0.07). The comparison of PWD values with ST segment resolution groups demonstrated that PWD at 120th minute of thrombolytic therapy was found to be significantly lower in complete resolution group than incomplete and inadequate resolution groups (42.10±9.55, 49.65±10.60, 56.08±7.44 ms respectively; p

Anahtar Kelimeler

• P-wave dispersion, thrombolytic therapy, STEMI, ST segment resolution

P Dalga Dispersiyonunun İnfarkt İlişkili Aater Açıklığını Saptamadaki Prediktif Değeri

Öz

Giriş: Yüzey elektrokardiyografi (EKG) ile ölçülen P-dalga dispersiyonu (PDD) değerinin koroner iskemide uzadığı gösterilmiştir. ST elevasyonlu myokard infarktüs (STEMI) hastalarında da reperfüzyon tedavisi ile PDD değerlerinin başlangıç değerlere göre kısaldığı çeşitli çalışmalarla gösterilmiştir. Çalışmamızın amacı; STEMI tanısı ile ilk 12 saatte başvuran ve trombolitik tedavi uygulanan hastalarda, PDD değerinin başarılı reperfüzyonu ve infarkt ilişkili arter açıklığını öngördürmede ek bir parametre olarak kullanılıp kullanılamayacağını belirlemektir.Hastalar ve Yöntem: Çalışmamıza 01.01.2012 – 01.12.2013 tarihleri arasında Dokuz Eylül Üniversitesi Tıp Fakültesi Kardiyoloji AD'na STEMİ tanısıyla başvuran ve semptomların ilk 12 saati içinde trombolitik tedavi uygulanan ardışık 150 hasta alındı. Veriler geriye dönük olarak incelendi. Hastaların demografik özellikleri, rutin laboratuar parametreleri kaydedildi. Trombolitik tedavinin 0, 30, 60, 90 ve 120. dakikalarında çekilen 12 derivasyonlu EKG kayıtlarına ulaşıldı. Tüm EKG'lerde maksimum, minimum P dalga süreleri ve PDD hesaplandı, ST segment rezolüsyon oranları belirlendi. Ayrıca hastaların koroner anjiyografi görüntüleri değerlendirilip infarkt ilişkili arterdeki TIMI kan akımı ve TIMI kare sayısı hesaplandı. PDD değerleri ile ST segment rezolüsyonu ve infarkt ilişkili arter açıklığı arasındaki ilişki değerlendirildi.Bulgular: Trombolitik tedavi başlangıcında ölçülen PDD değeri 50.79±14.12 msn iken 90. dk PDD değeri 48.34±15.60 ve 120. dk'da ölçülen PDD değeri 47.85±10.87 msn olarak saptandı, aradaki fark istatistiksel olarak anlamlı değildi (p= 0.07). PDD değerleri, ST segment rezolüsyon grupları ile karşılaştırıldığında; 120. dk'da ölçülen PDD değerinin komplet rezolüsyon sağlanan grupta, inkomplet ve yetersiz rezolüsyon sağlanan gruplara göre anlamlı olarak daha düşük olduğu saptandı (sırasıyla; 42.10±9.55, 49.65±10.60, 56.08±7.44 msn; p

Anahtar Kelimeler

• P-dalga dispersiyonu, trombolitik tedavi, STEMİ, ST segment rezolüsyonu

Kaynakça

1. Braunwald E. Myocardial reperfusion, limitation of infarct size, reduction of left ventricular dysfunction and improved survival. Should the paradigm be expanded? Circulation. 1989;97:441-4.
2. Grancer CB, Califf RM, Topol EJ. Thrombolytic therapy for acute myocardial infarction. Drugs. 1992;44:293-325.
3. The GUSTO angiografic investigators. The effect of tissue plasminogen activator, streptokinase, or both on coronary artery patency, ventricular function, and survival after acute myocardial infarction. N Eng J Med. 1993;329:1615-22.
4. Popovic AD, Nescovich NA, Babic R, Obradovic V, Bozinovic L, Marinkovic J, et al. Independent impact of thrombolytic therapy and vessel patency on left ventricular dilatation. Circulation. 1994;90:800-7.
5. Ross A, Lundergan C, Rohrbeck S, Boyle D, Brand M, Buller C, et al. Rescue angioplasty after failed thrombolysis: technical and clinical outcomes in a large thrombolysis trial. J Am Coll Cardiol. 1998; 31:1511-7.
6. Ellis S, Da Silva ER, Heyndrickx G, Talley JD, Cernigliaro C, Steg G, et al. Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for acute myocardial infarction. Circulation. 1994;90:2280-4.
7. Stewart J, French J, Theroux P, Ramanathan K, Solymoss B, Johnson R, et al. Early noninvasive identification of failed reperfusion after intravenous thrombolytic therapy in acute myocardial infarction. J Am Coll Cardiol. 1998;31:1499-505.
8. Laperche T, Steg P, Dehoux M, Benessiano I, Grollier G, Aliot E, et al. A study of biochemical markers of reperfusion early after thrombolysis for acute myocardial infarction. Circulation. 1995;92:2079-86.

9. Wehrens XH, Doevendans PA, Ophuis TJ, Wellens HJ. A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous coronary angioplasty. Am Heart J. 2000;139:430-6.
10. Vaturi M, Birnbaum Y. The use of electrocardiogram to identify epicardial coronary and tissue reperfusion in acute myocardial infarction. J Thromb Thrombolysis. 2000;10:137-47.
11. de Lemos JA, Antman EM, Giugliano RP, McCabe CH, Murphy SA, Van de Werf F, et al. for the TIMI 14 Investigators. ST segment resolution and infarct-related artery patency and flow after thromblytic therapy. Am J Cardiol. 2000;85:299-304.
12. Dissmann R, Schroder R, Busse U, Appel M, Brüggemann T, Jereczek M, et al. Early assessıment of outcome by ST-segment analysis after thromıbolytic therapy in acute myocardial infarction. Am Heart J. 1994;128:851-7.
13. Schroder R, Dissmann R, Brüggemann T, Wegscheider K, Linderer T, Tebbe U, et al. Extent of early ST segment elevation resolution, a simple but strong predictor of outcome in patients with acute myocardial in-farction. J Am Coll Cardiol. 1994;24:384-91.
14. Zeymer U, Schröder R, Tebbe U, Molhoek GP, Wegscheider K, Neuhaus KL. Noninvasive detection of early infarct vessel patency by resolution of ST-segment elevation in patients with thrombolysis for acute myocardial infarction: results of the angiographic substudy of the Hirudin for Improvement of Thrombolysis (HIT)-4 trial. Eur Heart J. 2001;22:769-75.
15. Özmen F, Atalar E, Aytemir K, Ozer N, Acil T, Ovunc K, et al. Effect of balloon-induced acute ischaemia on P wave dispersion during percutaneous transluminal coronary angioplasty. Europace. 2001;3:299-303.
16. Guyton RA, McClenathan JH, Michaelis LL. Evolution of regional ischemia distal to a proximal coronary stenosis. Am J Cardiol. 1977;40:381-92.
17. Sigwart U, Grbic M, Goy JJ, Kappenberger L. Left atrial function in acute transient left ventricular ischemia produced during percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery. Am J Cardiol. 1990;65:282-6.
18. Yılmaz R, Demirbag R. P-wave dispersion in patients with stable coronary artery disease and its relationship with severity of the disease. J Electrocardiol. 2005;38:279-84.
19. Akdemir R, Ozhan H, Gunduz H, Tamer A, Yazici M, Erbilen E, et al. Effect of reperfusion on P-wave duration and P-wave dispersion in acute myocardial infarction: primary angioplasty versus thrombolytic therapy. Ann Noninvasive Electrocardiol. 2005;10:35-40.
20. Karabağ T, Dogan SM, Aydin M, Sayin MR, Buyukuysal C, Gudul NE, et al. The value of P wave dispersion in predicting reperfusion and infarct related artery patency in acute anterior myocardial infarction. Clin Invest Med. 2012;35:12-19.
21. Celik T, Iyisoy A, Kursaklioglu H, Kilic S, Kose S, Amasyali B, et al. Effects of Primary Percutaneous Coronary Intervention on P Wave Dispersion. Ann Noninvasive Electrocardiol. 2005;10:342-7.
22. Somitsu Y, Nakamura M, Degawa T, Yamaguvhi T. Prognostic value of slow resolution of ST-segment elevation following successful direct percutaneous transluminal coronary angioplasty for recovery of left ventricular function. Am J Cardiol. 1997;80:406-10.
23. van’t Hof AW, Liem A, de Boer M-J, Fijlstra F. Clinical value of 12-lead electrocardiogram after successful reperfusion therapy foracute myocardial infarction. Lancet. 1997;350(9078):615-9.
24. Santoro GM, Valenti R, Buonamici P, Bolognese L, Cerisano G, Moschi G, et al. Relation between ST-segment changes and myocardial perfusion evaluated by myocardial contrast echocardiography in patients with acute myocardial infarction treated with direct angioplasty. Am J Cardiol. 1998;82:932-7.
25. Sutton AG, Campbell PG, Grech ED, Price D, Davies A, Hall J, et al. Failure of thrombolysis: Experience with a policy of early angiography and rescue angioplasty for electrocardiographic evidence of failed thrombolysis. Heart. 2000;84:197-204.
26. Wijeysundera HC, Vijayaraghavan R, Nallamothu BK, Foody JM, Krumholz HM, Phillips CO, et al. Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction: A metaanalysis of randomized trials. J Am Coll Cardiol. 2007;49:422-30.