Terminal QRS Distortion in Inferior Acute Myocardial Infarction Predicts High-degree Atrioventricular Block
Abstract
Background. ST elevation in acute myocardial infarction can predict the size of infarction, response to reperfusion therapy, and prognosis. Birnbaum et al. showed that early QRS distortion is a reliable prediction of the devel-opment of advanced AV block among patients receiving thrombolytic therapy for inferior wall acute myocardial infarction. Distortion of the ter-minal portion of the QRS in inferior wall acute myocardial infarction based on J point / R wave ratio of more than 50% in at least two leads of the inferior leads (II, III, and aVF). Although transient, development of heart block during inferior infarction is associated with a high in-hospital mortal-ity rate, even they received thrombolytic therapy. Some studies showed ethnic differences in electrocardiogram amplitudes. The aims of this study is to evaluate the correlation between early QRS terminal distortion and high degree AV block among our patients with inferior acute myocardial infarction treated by thrombolytic.Methods and results. This study is a cross-sectional study on patients with inferior wall acute myocardial infarction treated by thrombolytic at National Cardiovascular Center – Harapan Kita, Jakarta during January 2000 until December 2004, that fulfill inclusion and exclusion criteria. They were divided into two groups, those with QRS distortion and without QRS dis-tortion. Correlation between the two groups were analyzed by t test, chi-square and multivariate regression analysis. There are 186 patients, ages between 37 until 72 years old, mostly men (89%) which are 93 patients with QRS distortion and 93 patients without QRS distortion. Those two groups were comparable. With univariate analysis, the group with QRS distortion have higher ST segment deviation (9,61±3,67 vs 7,76±3,53, p=0,001) and higher risk of failed thrombolytic (74,2%vs60,2%, p=0,042).
With multivariate regression analysis, there is a significant correlation be-tween QRS distortion and high-degree AV block (OR 2,5; 95% CI 1,04-6,01; p=0,04), most AV block happened during hospitalization.
Conclusions. Patients with distortion of the QRS terminal portion in in-ferior acute myocardial infarction and treated by thrombolytic have a higher risk of high-degree AV block during hospitalization, compared to patients without QRS distortion.
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References
Birnbaum Y, Kloner RA , Sclarovsky S, Cannon CP, McCabe CH, Davis VG, Zaret BL, Wackers FJ, Braunwald E, Distortion of the terminal portion of the QRS on the admission electrocar-diogram in acute myocardial infarction and correlation with inf-arct size and long-term prognosis (Thrombolysis In Myocardial Infarction 4 Trial), Am J Cardiol 1996: 78: 396-403
Birnbaum Y, Drew BJ, The electrocardiogram in ST elevation acute myocardial infarction:correlation with coronary anatomy and prognosis,PMJ2003;79:490-504
Wagner GS, Terminal QRS distortion on admission is better than ST-segment measurements in predicting final infarct size and assessing the potential effect of thrombolytic therapy in anterior wall acute myocardial infarction, Am J Cardiol 1999;84:530-34
Berger PB, Ryan TJ. Inferior Myocardial Infarction, High-risk subgroup. Circulation 1989: 81:401-11
Schweitzer P, Keller S, The role of the initial 12-lead ECG in risk stratification of patients with acute coronary syndrome, Bratisl Lek Listy 2001:102 (9):406-11
Birnbaum Y, Sclarovsky S, Herz I, Zlotikamien B, Chetrit A, Olmer L, Barbash GI, Admission clinical and electrocardio-graphic characteristics predicting in-hospital development of high-degree atrioventricular block in inferior wall acute myo-cardial infarction, Am J Cardiol 1997;80:1134-8
Berger P, Ruocco N, Ryan T, Frederick M, Jacobs A, Faxon D, Investigator at T. Incidence and prognostic implications of heart block complicating inferior myocardial infarction treated with thrombolytic therapy: results from TIMI II, J Am Coll Cardiol 1992: 20:533-40.
Clemmensen P, Bates E, Califf R, Hlatky M, Aronson L, George B, Lee K, Kereiakes D, Gacioch G, Berrios E, Topol EJ, and the TAMI Study Group. Complete atrioventricular block complicating inferior wall acute myocardial infarction treated with reperfusion therapy. Am J Cardiol 1991; 67: 225-30
Sclarovsky S, Strasberg B, Hishberg A, Arditi A, Lewin R, Agmon J, Advanced early and late atrioventricular block in acute inferior wall myocardial infarction, Am Heart J 108:19-24
Birnbaum Y, Herz I, Sclarovsky S, et.al. Admission clinical and electrocardiographic characteristics predicting an increased risk for early reinfarction after thrombolytic therapy, Am Heart J, 1998; 135:805-12
Christian T, Gibbons R, Clements I, et.al. Estimates of myo-cardium at risk and collateral flow in acute myocardial infarc-tion using electrocardiograhic pattern in patients with inferior wall acute myocardial infarction, Clin Cardiol 1996: 19:31-6
Lee CW, Hong MK, Yang HS, Choi SW, Kim JJ, Park SW, Park SJ, Determinants and Prognostic Implications of terminal QRS complex distortion in patients treated with primary angioplasty for acute myocardial infarction, Am J Cardiol 2001; 88:210-2
Tamura A, Nagase K, Watanabe T, Nasu M, Relationship be-tween terminal QRS distortion on the admission electrocar-diogram and the time course of left ventricular wall motion in anterior wall acute myocardial infarction,Jpn Circ J 2001;65:63-6
Birnbaum Y, Herz I, Sclarovsky, et al, Prognostic significance of the admission electrocardiogram in acute myocardial infarc-tion, J Am Coll Cardiol 1996;27:1128
Birnbaum Y, Criger DA, Wagner GS, et al, Prediction of the extent and severity of left ventricular dysfunction in anterior acute myocardial infarction by the admission electrocardiogram, Am Heart J, 2001; 141: 915-24
Rautaharju PM, Zhou SH, Calhoun HP. Ethnic differences in ECG amplitudes in North American white, black, and His-panic men and women: effect of obesity and age, J Electrocardiol. 1994:27(suppl):20-31
Adam-Hamoda MG, Caldwell MA, Stotts NA, Drew BJ, Fac-tors to consider when analyzing 12-lead electrocardiograms for evidence of acute myocardial ischemia, American Journal of Critical Care, 2003;12:9-16.
Kaul U, Diagnosis and management of unsuccessful throm-bolysis after acute myocardial infarction, JK-Practitioner, 2001;8(4):206-9
Birnbaum Y, Criger DA, Gates KB, et al. Grade 3 ischemia on resentation with acute myocardial infarction predicts rapid progression of necrosis and less myocardial salvage with throm-bolysis (abstr), J Am Coll Cardiol 2001;37:115A (suppl A).
Birnbaum Y, Drew BJ, The electrocardiogram in ST elevation acute myocardial infarction:correlation with coronary anatomy and prognosis,PMJ2003;79:490-504
Wagner GS, Terminal QRS distortion on admission is better than ST-segment measurements in predicting final infarct size and assessing the potential effect of thrombolytic therapy in anterior wall acute myocardial infarction, Am J Cardiol 1999;84:530-34
Berger PB, Ryan TJ. Inferior Myocardial Infarction, High-risk subgroup. Circulation 1989: 81:401-11
Schweitzer P, Keller S, The role of the initial 12-lead ECG in risk stratification of patients with acute coronary syndrome, Bratisl Lek Listy 2001:102 (9):406-11
Birnbaum Y, Sclarovsky S, Herz I, Zlotikamien B, Chetrit A, Olmer L, Barbash GI, Admission clinical and electrocardio-graphic characteristics predicting in-hospital development of high-degree atrioventricular block in inferior wall acute myo-cardial infarction, Am J Cardiol 1997;80:1134-8
Berger P, Ruocco N, Ryan T, Frederick M, Jacobs A, Faxon D, Investigator at T. Incidence and prognostic implications of heart block complicating inferior myocardial infarction treated with thrombolytic therapy: results from TIMI II, J Am Coll Cardiol 1992: 20:533-40.
Clemmensen P, Bates E, Califf R, Hlatky M, Aronson L, George B, Lee K, Kereiakes D, Gacioch G, Berrios E, Topol EJ, and the TAMI Study Group. Complete atrioventricular block complicating inferior wall acute myocardial infarction treated with reperfusion therapy. Am J Cardiol 1991; 67: 225-30
Sclarovsky S, Strasberg B, Hishberg A, Arditi A, Lewin R, Agmon J, Advanced early and late atrioventricular block in acute inferior wall myocardial infarction, Am Heart J 108:19-24
Birnbaum Y, Herz I, Sclarovsky S, et.al. Admission clinical and electrocardiographic characteristics predicting an increased risk for early reinfarction after thrombolytic therapy, Am Heart J, 1998; 135:805-12
Christian T, Gibbons R, Clements I, et.al. Estimates of myo-cardium at risk and collateral flow in acute myocardial infarc-tion using electrocardiograhic pattern in patients with inferior wall acute myocardial infarction, Clin Cardiol 1996: 19:31-6
Lee CW, Hong MK, Yang HS, Choi SW, Kim JJ, Park SW, Park SJ, Determinants and Prognostic Implications of terminal QRS complex distortion in patients treated with primary angioplasty for acute myocardial infarction, Am J Cardiol 2001; 88:210-2
Tamura A, Nagase K, Watanabe T, Nasu M, Relationship be-tween terminal QRS distortion on the admission electrocar-diogram and the time course of left ventricular wall motion in anterior wall acute myocardial infarction,Jpn Circ J 2001;65:63-6
Birnbaum Y, Herz I, Sclarovsky, et al, Prognostic significance of the admission electrocardiogram in acute myocardial infarc-tion, J Am Coll Cardiol 1996;27:1128
Birnbaum Y, Criger DA, Wagner GS, et al, Prediction of the extent and severity of left ventricular dysfunction in anterior acute myocardial infarction by the admission electrocardiogram, Am Heart J, 2001; 141: 915-24
Rautaharju PM, Zhou SH, Calhoun HP. Ethnic differences in ECG amplitudes in North American white, black, and His-panic men and women: effect of obesity and age, J Electrocardiol. 1994:27(suppl):20-31
Adam-Hamoda MG, Caldwell MA, Stotts NA, Drew BJ, Fac-tors to consider when analyzing 12-lead electrocardiograms for evidence of acute myocardial ischemia, American Journal of Critical Care, 2003;12:9-16.
Kaul U, Diagnosis and management of unsuccessful throm-bolysis after acute myocardial infarction, JK-Practitioner, 2001;8(4):206-9
Birnbaum Y, Criger DA, Gates KB, et al. Grade 3 ischemia on resentation with acute myocardial infarction predicts rapid progression of necrosis and less myocardial salvage with throm-bolysis (abstr), J Am Coll Cardiol 2001;37:115A (suppl A).
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How to Cite
Sewianto, A., Kasim, M., & Yusak, M. (1). Terminal QRS Distortion in Inferior Acute Myocardial Infarction Predicts High-degree Atrioventricular Block. Indonesian Journal of Cardiology, 28(1), 36-43. https://doi.org/10.30701/ijc.v28i1.265
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Clinical Research
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