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. 2016 Jul-Aug;31(4):E10-9.
doi: 10.1097/JCN.0000000000000310.

Among Unstable Angina and Non-ST-Elevation Myocardial Infarction Patients, Transient Myocardial Ischemia and Early Invasive Treatment Are Predictors of Major In-hospital Complications

Michele M Pelter  1 , Denise L Loranger, Teri M Kozik, Anita Kedia, Richard P Ganchan, Deborah Ganchan, Xiao Hu, Mary G Carey
Affiliations

Among Unstable Angina and Non-ST-Elevation Myocardial Infarction Patients, Transient Myocardial Ischemia and Early Invasive Treatment Are Predictors of Major In-hospital Complications

Michele M Pelter et al. J Cardiovasc Nurs. 2016 Jul-Aug.

Abstract

Background: Treatment for unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) is aimed at plaque stabilization to prevent infarction. Two treatment strategies are (1) invasive (ie, cardiac catheterization laboratory <24 hours after admission) or (2) selectively invasive (ie, medications with cardiac catheterization laboratory >24 hours for recurrent symptoms). However, it is not known if the frequency of transient myocardial ischemia (TMI) or complications during hospitalization varies by treatment.

Purpose: We aimed to (1) examine occurrence of TMI in UA/NSTEMI, (2) compare frequency of TMI by treatment pathway, and (3) determine predictors of in-hospital complications (ie, death, myocardial infarction [MI], pulmonary edema, shock, dysrhythmia with intervention).

Methods: Hospitalized patients with coronary artery disease (ie, history of MI, percutaneous coronary intervention/stent, coronary artery bypass graft, >50% lesion via angiogram, or positive troponin) were recruited, and 12-lead electrocardiogram Holter initiated. Clinicians, blinded to Holter data, decided treatment strategy; offline analysis was done after discharge. Transient myocardial ischemia was defined as more than 1-mm ST segment ↑ or ↓, in more than 1 electrocardiographic lead, more than 1 minute.

Results: Of 291 patients, 91% were white, 66% were male, 44% had prior MI, and 59% had prior percutaneous coronary intervention/stent or coronary artery bypass graft. Treatment pathway was early in 123 (42%) and selective in 168 (58%). Forty-nine (17%) had TMI: 19 (15%) early invasive, 30 (18%) selective (P = .637). Acute MI after admission was higher in patients with TMI regardless of treatment strategy (early: no TMI 4% vs yes TMI 21%; P = .020; selective: no TMI 1% vs yes TMI 13%; P = .0004). Predictors of major in-hospital complication were TMI (odds ratio, 9.9; 95% confidence interval, 3.84-25.78) and early invasive treatment (odds ratio 3.5; 95% confidence interval, 1.23-10.20).

Conclusions: In UA/NSTEMI patients treated with contemporary therapies, TMI is not uncommon. The presence of TMI and early invasive treatment are predictors of major in-hospital complications.

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Conflict of interest statement

Conflicts of interest: none

Figures

Figure 1
Figure 1
Illustrates a patient treated with a selectively invasive strategy. Top figure A shows an ST-segment trend (Y-axis electrocardiographic (ECG) leads; X-axis time). This trend was recorded in a 67 year old male presenting to the emergency department at 0345 with pain between his shoulder blades and in his right arm. His cardiac history included paroxysmal atrial fibrillation treated with metoprolol and Coumadin, the latter was discontinued for unknown reasons one month prior. His initial troponin I was normal and his 12-lead ECG was unremarkable for acute ischemia. A CT scan ruled out aortic aneurysm, and he was admitted to the telemetry unit for further workup. At 0300 (23 hours post admission) abrupt ST elevation is seen in leads V1–V4, and concomitant ST depression in leads V6, I, II, aVF and III. At 0345 the patient complained of back and right arm pain. The nurse gave the patient a sublingual nitroglycerin, IV morphine and obtained a 12-lead ECG. The hospital 12-lead ECG was obtained after the ST changes resolved; hence ischemia was not diagnosed. The patient went back to sleep. At 0555 the patient contacted the nurse complaining of 10/10 chest pain in his back and both arms. A hospital 12-lead ECG obtained by the nurse showed ST elevation in leads V2 and V3. The cardiologist was phoned and the patient was taken urgently to the cardiac catheterization laboratory where a stent was placed in the left anterior descending coronary artery. Of note, are the small ST segment changes during the day at 1320, 1800, and 2345, likely indicating acute but brief coronary occlusion followed by reperfusion. Figure A. ST-segment Trend with time on X-axis and ECG Leads on Y axis. Figure B. Left figure shows leads V1 to V3 (#1 in above figure), was obtained before transient myocardial ischemia. Right figure shows leads V1 to V3 (#2 in above figure), was obtained during transient myocardial ischemia and illustrates ST elevation indicative of complete coronary occlusion.
Figure 1
Figure 1
Illustrates a patient treated with a selectively invasive strategy. Top figure A shows an ST-segment trend (Y-axis electrocardiographic (ECG) leads; X-axis time). This trend was recorded in a 67 year old male presenting to the emergency department at 0345 with pain between his shoulder blades and in his right arm. His cardiac history included paroxysmal atrial fibrillation treated with metoprolol and Coumadin, the latter was discontinued for unknown reasons one month prior. His initial troponin I was normal and his 12-lead ECG was unremarkable for acute ischemia. A CT scan ruled out aortic aneurysm, and he was admitted to the telemetry unit for further workup. At 0300 (23 hours post admission) abrupt ST elevation is seen in leads V1–V4, and concomitant ST depression in leads V6, I, II, aVF and III. At 0345 the patient complained of back and right arm pain. The nurse gave the patient a sublingual nitroglycerin, IV morphine and obtained a 12-lead ECG. The hospital 12-lead ECG was obtained after the ST changes resolved; hence ischemia was not diagnosed. The patient went back to sleep. At 0555 the patient contacted the nurse complaining of 10/10 chest pain in his back and both arms. A hospital 12-lead ECG obtained by the nurse showed ST elevation in leads V2 and V3. The cardiologist was phoned and the patient was taken urgently to the cardiac catheterization laboratory where a stent was placed in the left anterior descending coronary artery. Of note, are the small ST segment changes during the day at 1320, 1800, and 2345, likely indicating acute but brief coronary occlusion followed by reperfusion. Figure A. ST-segment Trend with time on X-axis and ECG Leads on Y axis. Figure B. Left figure shows leads V1 to V3 (#1 in above figure), was obtained before transient myocardial ischemia. Right figure shows leads V1 to V3 (#2 in above figure), was obtained during transient myocardial ischemia and illustrates ST elevation indicative of complete coronary occlusion.
See this image and copyright information in PMC

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