Electrocardiography remains the most widely used method for detecting myocardial ischemia. ST segment abnormalities in the resting 12-lead electrocardiogram in subjects with angina and coronary risk factors seem to definitely indicate ischemic heart disease and an adverse prognosis. ST depression during exercise testing is the first line provocative test for ischemic heart disease although it has a mean sensitivity of only 68% and a slightly higher specificity (77%). The presence or absence of chest pain in patients with an ischemic ST response to exercise testing does not change the risk of future ischemic events. However, ST depression during the recovery period is associated with increased risk both for acute coronary events and coronary death, whereas silent ischemia during recovery is an even stronger predictor than during exercise. The amplitude of ST depression has not been documented to reflect the magnitude of ischemia. Therefore, new methods are under investigation such as adding R and Q wave amplitude criteria, maximal ST/heart rate slope, linear regression analysis of the heart rate related change in ST depression and a score integrating ST segment amplitude and slope changes. The demonstration of episodic ST segment depressions in the ambulatory setting, even without accompanying chest pain, are an expression of transient ischemia and such episodes seem to represent a poor prognosis. In the hospital setting, ST depression detected by continuous monitoring is related to the clinical outcome. ST segment monitoring during the first 6-9 hours after coronary care unit admission provides important prognostic information on-line and considerably improves early risk stratification. Such continuous ST monitoring overcomes some of the limitations of static monitoring, as it improves the likelihood of capturing the maximal point of ST deviation, as well as early episodes of reocclusion that are manifest as recurrent ST elevation.

Electrocardiography↗

PubMed1998

Quantification of Atherosclerotic Burden in the Descending Aorta by Transesophageal Echocardiography: Inter- and Intraobserver Variability.

Atherosclerotic plaques had been imaged but not quantitated in the thoracic aorta using transesophageal echocardiography. The aim of this study was to describe a method for measuring the atherosclerotic plaque area in the descending aorta by transesophageal echocardiography (TEE) and to evaluate its reproducibility. TEE examinations were performed by two independent sonographers, in 21 patients with angiographically proven coronary artery disease. Two hundred fifty-six transverse segments (mean 12 +/- 3 patient) of the descending aorta were adequately recorded. In each segment the plaque and the lumen areas in the half of the aortic segment distant from the transesophageal probe were measured by one reader in the two studies (intersonographer reproducibility). Interreader reproducibility was also evaluated. The correlation coefficient between the first and second study (intersonographer reproducibility) was 0.81. The standard deviation of the difference between examinations equaled 0.137 cm(2) and the mean absolute difference between examinations was 0.003 cm(2) (95% CI: -0.015; 0.021; P = 0.75). The correlation coefficient between the two readers was 0.86, the standard deviation of the difference between readers was 0.175 cm(2) and the mean absolute difference was 0.006 cm(2) (95% CI: -0.029; 0.018; P = 0.63). A method for quantitative measurement of aortic atherosclerotic plaque area was evaluated and found to have high intersonographer and intereader reproducibilities. This method might be used in the future for noninvasive evaluation of regression or progression of aortic atherosclerosis.

Journal Article↗

PubMedDate not supplied

Presenting symptoms, admission electrocardiogram, management, and prognosis in acute coronary syndromes: differences by age.

In a nationwide survey conducted in all 26 hospitals in Israel during February and March 2000, data were collected on 2133 consecutive acute coronary syndrome patients. The patients were divided into three age subgroups: <65 years (n=974), 65-74 years (n=500), and > or =75 years (n=639). The frequency of no anginal pain/atypical symptoms on presentation increased with age for all acute coronary syndrome patients (14%, 21%, and 32%, in the three age subgroups, respectively; p for trend <0.0001). The frequency of ST-elevation on admission electrocardiogram decreased with advancing age (59%, 46%, and 42%, in the three age subgroups, respectively; p for trend <0.0001), whereas ST-depression gradually increased (14%, 24%, and 28%, respectively; p for trend <0.0001). In multivariate analysis, variables associated with no anginal pain/atypical symptoms on presentation (in decreasing order) were: history of heart failure, age, lack of past angina, diabetes, and nonsmoking. ST-elevation was inversely associated with no anginal pain/atypical symptoms on admission (odds ratio, 0.48; 95% confidence interval, 0.37-0.63). The use of acute reperfusion therapy significantly declined with advancing age. Seven-day, 30-day, and 1-year mortality increased with advancing age. No anginal pain/atypical symptoms on presentation were associated with an increased early and late mortality in all three age subgroups.

Adult↗