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European Heart Journal Advance Access originally published online on February 7, 2009
European Heart Journal 2009 30(7):757-764; doi:10.1093/eurheartj/ehp005
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

Reperfusion ventricular arrhythmia ‘bursts’ predict larger infarct size despite TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction

Mohamed Majidi1,2, Andrzej S. Kosinski1,3, Sana M. Al-Khatib1,4, Miguel E. Lemmert2, Lilian Smolders2, Anton van Weert5, Johan H.C. Reiber5,6, Dan Tzivoni7, Frits W.H.M. Bär2, Hein J.J. Wellens8, Anton P.M. Gorgels2,8 and Mitchell W. Krucoff1,4,*

1 eECG Core Laboratory, Duke Clinical Research Institute, 508 Fulton Street, Room A3012, Durham, NC 27705, USA
2 Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands
3 Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
4 Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
5 Bio-Imaging Technologies, Leiden, The Netherlands
6 Leiden University Medical Centre, Leiden, The Netherlands
7 Shaare Zedek Medical Centre, Jerusalem, Israel
8 Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands

Received 14 April 2008; revised 29 December 2008; accepted 8 January 2009; online publish-ahead-of-print 7 February 2009.

* Corresponding author. Tel: +1 919 286 6860, Fax: +1 919 286 6861, Email: kruco001{at}mc.duke.edu

Aims: Successful epicardial reperfusion with primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) can paradoxically evoke myocardial reperfusion injury, which may be signalled by temporally associated ventricular arrhythmias (VAs). We correlated reperfusion VA ‘bursts’ with final infarct size (IS) in patients with restored TIMI 3 flow following PCI for anterior STEMI.

Methods and results: All 128 anterior STEMI patients with final TIMI 3 flow had continuous 24 h digital 12-lead ECG with simultaneous Holter recording initiated prior to PCI, and Day 7/discharge SPECT imaging IS assessment. Angiography, SPECT imaging, continuous ST recovery, and quantitative rhythm analyses were performed. Reperfusion VA bursts were defined against patient-specific background VA rates and timed as concomitant with or following first angiographic TIMI 3 flow restoration associated with ≥50% stable ST recovery; they were then correlated with IS and global left ventricular ejection fraction (LVEF) at Day 7/discharge. Bursts occurred in 81/128 (63%) patients and were significantly correlated with larger IS and worse LVEF (median: 21.0 vs. 10.0%, P < 0.001; 35.5 vs. 46.5%, P < 0.001, respectively). In multivariable analyses that adjusted for known predictors of IS, the association of bursts with larger IS remained significant; similar results were seen for worse LVEF.

Conclusion: Reperfusion VA bursts predict larger IS despite TIMI 3 flow restoration with ≥50% stable ST recovery following PCI for anterior STEMI. Well-characterized reperfusion VAs may provide a novel biomarker of reperfusion injury.

Key Words: ST-elevation myocardial infarction • Primary percutaneous coronary intervention • Continuous 12-lead ECG monitoring • Beat-to-beat Holter monitoring • Statistical outlier detection methodology • Reperfusion ventricular arrhythmia bursts


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