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VKG-vid akuta koronara syndrom Docent Sven V Eriksson Hemsida:

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Presentation on theme: "VKG-vid akuta koronara syndrom Docent Sven V Eriksson Hemsida:"— Presentation transcript:

1 VKG-vid akuta koronara syndrom Docent Sven V Eriksson Hemsida:

2 Docent Sven V Eriksson Åre 1999

3 SVE-99 History 1  ECG - (Waller 1887, Einthoven 1893)  ST-elevation MI - (Smith 1918)  Monocardiogram - (Mann 1920)  AHA V1-6, 1938  12-lead ECG, (Goldberger 1942)  VCG - (Schmitt 1955)

4 SVE-99 History 2  Standard VCG-leads (Frank 1956/60)  VCG MI criteria (Hoffman 1964, Young 1968)  Continuous VCG (cVCG) (Hodges 1974)  cVCG during acute MI (Sederholm 1984)  On-line cVCG (Gröttum 1985)  MIDA 1986  EASI-MIDA 2001

5 SVE-99 Myter 1  VKG används nästan bara i Sverige  VKG används nästan bara i Sverige  Det krävs ingen genuin kunskap i fysiologi för att lära sig VKG  Det är enkelt att inkludera VKG-analyser i t.ex. läkemedelsstudier  Av multiavlednings-EKG-metoderna är bara VKG utvärderade vid akut IHD  VKG används idag nästan bara i MIDA-systemen  Det krävs minst 8 avledningar för beräkning av VKG

6 SVE-99 Myter 2  Icke-Q-vågs-infarkt = icke-transmural infarkt  Icke-Q-vågsinfarkt har annan prognos än Q-vågs infarkt  Icke-Q-vågs infarkt har icke ockluderat koronarkärl i motsats till Q-våginfarkt (22% skillnad).  Om cVKG är u.a. och pat. är smärtfri = ej MI  cVKG ger ingen information vid grenblock  Om cVKG/Holter visar ischemi = myokard-ischemi

7 SVE-99 Q Versus Non-Q  Prinzmetal. Q-wave=Transmural MI. Am J Med 1954;16:  Pipberger/Prinzmetal. Admitting errors of method..”there was no reason to suppose that subendocardial infarcts could not generate Q-waves”. Am Heart J 1957;54:  Approximately 50 % of all subendocardial infarcts are accompanied by Q-waves. Circulation 1958;18:600-11, Circulation 1958;18:  Review of prognosis in non-Q versus Q in 9 studies. No difference! Table 1. JACC 1999;33:

8 SVE-99 Frank X-, Y- and Z-leads Y Z X Z X Y

9 SVE-99 ST-Vector Magnitude- ST-VM X Y Z ST x ST y ST z – ST –x–x –y–y –z–z –=–= –+–+ –+–+ –2–2 –2–2 –2–2 – ST-VM

10 SVE-99 ST-Vector

11 SVE-99 ST Change Vector Magnitude STC-VM Present ST-vector Y X Z In i t i a l ST-vector STC-V M

12 SVE-99 QRS-Vector Difference QRS-VD A X Y Z

13 SVE-99

14

15 Why use more/other than 12-lead ECG?  Matetzky S et al. Significance of ST Segment Elevations in Posterior Chest Leads (V7 to V9) in Patients with Acute Inferior Myocardial Infarction: JACC 1998;31:  Jai B et al. Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12- lead electrocardiogram. Am J Cardiol 1999;83:  Addition of right precordial leads to standard exercise electrocardiography improves sensitivity. N Engl J Med 1999;340:

16 SVE-99 Limits:  QRS-VD >15 uVs  ST-VM > 0.05 mV

17 SVE-99 QRS-VD känslig för:  Ändrat kroppsläge (ofta typisk bild)  Ischemi  Ändring i volym  Ledningshinder

18 SVE-99 ST-VM känslig för:  Ischemi (relativt spec./män)  Digitalis  Frekvens  Vänsterkammarhypertrofi

19 SVE-99 ECG/VCG difficult in patients with:  Bundle branch block?  Ventricular pacing  Left ventricular hypertrophy?  Atrial fibrillation?

20 SVE-99 VCG can give information regarding:  Ischemia (predischarge exercise test)  Prognosis (MI/Unstable angina)  Reperfusion  Reocclusion  Diagnosis (bundle branch block)

21 SVE-99 Value of clinical and VCG data for prediction of ST depression at exercise test X2 valueP value STC-VM episodes31.5<0.001 ST-X maximum depression16.2<0.001 ST-Z value elevation9.4<0.01 Rest pain episodes5.5<0.05 Lundin P, Eriksson SV et al. J of Electrocardiol 1995;28:

22 SVE-99 Prognostic information   Lundin P, Eriksson SV, Strandberg L, Rehnqvist N. Prognostic Information from on-line vectorcardiography in acute myocardial infarction. Am J Cardiol, 1994;74:   Lundin P, Eriksson SV, Fredriksson M, Rehnqvist N. Prognostic information from on-line vectorcardiography in patients with unstable angina pectoris. Cardiology, 1995;86:   Andersen K, Eriksson P, Dellborg M. Ischaemia detected by continuous on-line vectorcardiographic monitoring predicts unfavourable outcome in patients admitted with probable unstable coronary disease. Coron Artery Dis 1996;7:   Andersen K, Eriksson P, Dellborg M. Non-invasive risk stratification within 48 h of hospital admission in patients with unstable coronary disease. Eur Heart J 1997;18:   Holmvang L et al. Relative contributions of a single-admission 12-lead electrocardiogram and early 24-hour continuous electrocardiographic monitoring for early risk stratification in patients with unstable coronary artery disease. Am J Cardiol 1999;83:

23 SVE-99 Comparison between 167 survivors and 36 non- survivors  Variable  Age  Performed ex-test  VF during hospitalization  STC-VM episodes  QRS-end value  VCG sign of reperfusion  Dead (n=36)Alive (n=167)  **  42%92%**  19%4%**  3(2-5)0(0-2)**  25(17-36)19(15- 30)*  22%46%* Lundin P, Eriksson SV et al. Am J Cardiol 1995;74: *p<0.05, **p<0.01

24 SVE-99 Markers of reperfusion 35-50% of patients have multiple periods of both ST recovery and reelevation, reflecting cyclic variations in infarct artery flow Symptoms ECG Relief of pain a 5 point reduction on a 1 to 10 scale Abrupt increase of Troponin-T/I CK-MB Myoglobin Combination Serum markers A “snapshot” > 50% reduction of of ST elevation On-line VCG/ECG % ST recovery Accuracy 80%

25 SVE-99 Signs of reperfusion:  > 50% reduction of ST-VM within 90 min  Early “plateau” of QRS-VD

26 SVE-99 Chest pain + Thrombolytic drug On-line VCG 90 min (n=96) “Open” by VCG (n=65) Actually open (n=12) 5 + collateral 1 - collaterals Actually Closed (n=19) 12 - collaterals 7 + collateral's Closed by VCG (n=31) Actually closed (n=7) Actually open (n=58) VCG monitoring to assess early vessel patency Dellborg et al. Eur Heart J 1995;16:21-29

27 SVE-99 Selected publications   Lundin P, Eriksson SV et al. Ischemia monitoring with on-line vectorcardiography compared with results from a predischarge exercise test in patients with acute ischemic heart disease. J of Electrocardiol 1995;28:   Lundin P, Eriksson SV et al. Ischemia monitoring with on-line vectorcardiography during dobutamine stress-echocardiography in patients with unstable coronary artery disease. J Int Med., 1998;244:61-70   Jensen J, Eriksson SV et al. Systolic deterioration in basal segments of the left ventricle is related to myocardial ischemia during angioplasty: A tissue Doppler echocardiographic and vectorcardiographic study. Clinical Science 2001;100:   Jensen J, Eriksson SV, Lindvall B, Lundin P. Sylvén C. Women react with more myocardial ischemia and angina pectoris during elective percutaneous transluminal coronary angioplasty. Cor Art Disease 2000:11;   Eriksson SV. Vectorcardiography: a tool for the non-invasive detection of reperfusion and reocclusion? Thrombosis and Haemostasis 1999;82:64-67

28 SVE-99 VCG-studies DS/HS/USA/Germany for more details  VCG during acute MI 210 pat. DS, Thesis 1995  VCG in unstable angina 160 pat. DS  PEGHIRUID 210 pat. DS “core-lab”, Berlin, Germany  VCG-registration during PTCA 209 pat. HS, Thesis 2000  VCG during dialysis DS. 120 registrations  VCG-in Chest pain unit, 1918 pat. Chattanooga, USA  EASI/Frank-MIDA during PTCA 108 pat.  EASI/Frank-MIDA during thallium 90 pat.

29 The Erlanger/DS VCG-study The Erlanger/DS VCG-study Assistant Professor, Francis M. Fesmire UT College of Medicine Assistant Professor, Sven V Eriksson, Danderyds Hospital, Karolinska Institutet

30 SVE pat. Patients in VCG-study 210 with BBB with VCG consecutive pat

31 Characteristics in patients with and without LVH on ECG With LVHWithout LVH N=196 N=1 722 N=196 N=1 722 Age Male 99 (50.5%) 889 (51.6%) Race Caucasian86 (43.9%)1326 (77.0%)*** African American107 (54.6%) 379 (22.0%)*** Other3 (1.5%)17 (1.0%) Previous MI 65 (33.2%)496 (28.8%) Previous PTCA/CABG 47 (24.0%)410 (23.8%)

32 SVE-99 Patients without LVH Patients without LVH

33 SVE-99 Patients with LVH

34 SVE-99 Conclusions: – VCG registration improves identification of patients with high risk of an acute MI – The optimal cut-off value for patients without left ventricular hypertrophy is 100 uV – In pat. with LVH, VCG-monitoring has limited power for detection of acute MI


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