European Heart Journal Advance Access originally published online on May 11, 2007
European Heart Journal 2007 28(15):1911; doi:10.1093/eurheartj/ehm160
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Long-term outcomes of patients with acute myocardial infarction
Medical Division
Manchester Medical Society
c/o John Ryland University Library
Oxford Road
Manchester
M13 9PP
Tel: +44 1612736048 E-mail address: oscarjolobe{at}yahoo.co.uk
One of the successes of the PRAGUE-2 trial was to delineate the time frame for optimization of transfer of patients with suspected myocardial infarction (MI) to an interventional facility.1 Unlike its predecessor trial, which was equally successful in this regard,2 the PRAGUE-2 trial included suspected MI patients with left bundle branch block (LBBB), although only restricting the enrolment to those with LBBB deemed to be new.1 The exclusion of suspected MI patients with ‘old’ LBBB was, however, a missed therapeutic opportunity given the fact that, even in the presence of ezymatically authenticated MI, only a minority of instances of ‘new’ LBBB are characterized by additional ECG stigmata, such as concordant ST-segment deviation, capable of distinguishing new from old LBBB,3 and that thrombolysis confers a mortality rate which (rather tantalizingly) ‘tends’ to be lower (P = 0.067) in LBBB patients lacking those stigmata than the mortality rate in counterparts characterized by those stigmata.3 Accordingly, given the fact that the onset of MI may, in the majority of instances, fail to distinguish new LBBB from old LBBB, and the fact that reperfusion therapy significantly reduces mortality in MI patients with BBB,4 the recommendation that thrombolysis should be offered to all LBBB patients with suspected MI regardless of whether LBBB is deemed to be old or new5 should have, as its corollary, the use of primary angioplasty in all LBBB patients with suspected MI regardless of whether LBBB is old or new.6 For the purpose of early triage (i.e. within the 3 h time window) for primary angioplasty, rather than categorize LBBB into old and new, such patients should be categorized into those with and without early enzyme markers such as myoglobin,7 CK-MB,7 and heart fatty acid binding protein,8 the diagnostic accuracy of the biomarkers being potentially enhanced by serial sampling7 and by using a combination of tests,9 so as further to explore issues such as the possibility that, in the absence of concordant ST-segment deviation, LBBB patients with enzymatically validated MI might indeed have a significantly lower mortality rate, following reperfusion therapy, than their counterparts who have those ECG stigmata.
References
- Widimsky P, Bilkova D, Penicka M, Novak M, Lanikova M, Porizka V, Groch L, Zelizko M, Budesinsky T, Aschermann M, on behalf of the PRAGUE Study Investigators. Long-term outcomes of patients with acute myocardial infraction presenting to hospitals without catheterisation laboratory and randomised to immediate thrombolysis or interhospital transport for primary percutaneous coronary intervention. Five years' follow-up of the Prague-2 trial. Eur Heart J (2007) 28:679–684.
[Abstract/Free Full Text] - Andersen HR, Nielsen, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. New Engl J Med (2003) 349:733–742.
[Abstract/Free Full Text] - Wong C-K, French JK, Aylward PEG, et al. Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogenous outcomes depending on the presence of ST-segment changes. J Am Coll Cardiol (2005) 46:29–38.
[Abstract/Free Full Text] - Fibrinolytic Therapy Trialists Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet (1994) 343:311–322.[CrossRef][Web of Science][Medline]
- Shlipak MG, Lyons WL, Go AS, Chou TM, Evans GT, Browner WS. Should the electrocardiogram be used to guide therapy for patients with left bundle branch block and suspecte myocardial infarction? J Am Med Assoc (1999) 281:714–719.
[Abstract/Free Full Text] - Guerrero M, Harjari K, Stone GW, Brodie B, Cox D, Boura J, Grines L, O'Neill W, Grines C. Comparison of the prognosis of left versus right versus no bundle branch block on presenting electrocardiogram in acute myocardial infarction patients treated with primary angioplasty in the primary angioplasty in myocardial infarction trials. Am J Cardiol (2005) 96:482–488.[CrossRef][Web of Science][Medline]
- Balk EM, Ioannidis JPA, Salem D, Chew PW, Lau J. Accuracy of biomarkers to diagnose acute cardiac ischemia in the emergency department: a meta-analysis. Ann Emergency Med (2001) 37:478–494.[CrossRef][Web of Science][Medline]
- Mad P, Domanovits H, Fazelnia C, Stiassny K, Russmuller G, Cseh A, Sodeck G, Binder T, Christ G, Szekeres T, Laggner A, Herkner H. Human heart-type fatty-acid binding protein as a point-of-care test in the early diagnosis of acute myocardial infarction. Quart J Med (2007) doi:10:1093/qmed/hcm007.
- Ng SM, Krishnaswamy P, Morrisey R, Clapton P, Fitzgerald R, Maisel AS. Mitigation of the clinical significance of spurious elevation of cardiac troponin I in the settings of coronary ischemia using serial testings of multiple cardiac markers. Am J Cardiol (2001) 87:994–999.[CrossRef][Web of Science][Medline]
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