Electrocardiographic Predictors of Primary Ventricular Fibrillation and 30-Day Mortality in Patients Presenting with
Alberto Cipriani1, Gianpiero D'Amico2, Giulia Brunetti1
1Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy.
Insights
The TW-Lambda electrocardiogram pattern in ST-elevation myocardial infarction (STEMI) patients predicts early primary ventricular fibrillation (PVF) before percutaneous coronary intervention (PCI) and 30-day mortality, primarily through reduced left ventricular ejection fraction (LVEF).
Area of Science:
- Cardiology
- Medical Diagnostics
- Electrocardiography
Background:
- Primary ventricular fibrillation (PVF) is a critical early complication of ST-elevation myocardial infarction (STEMI) occurring before reperfusion therapy.
- Specific electrocardiographic (ECG) patterns, including tombstone, Lambda, and triangular QRS-ST-T waveform (TW), are associated with PVF and mortality in STEMI patients.
Purpose of the Study:
- To compare the predictive value of distinct ECG patterns in STEMI for PVF and 30-day mortality.
- To identify specific ECG markers for early risk stratification in STEMI patients.
Main Methods:
- A cohort of 407 STEMI patients presenting within 12 hours of symptom onset was analyzed.
- ECG patterns, including a combined TW-Lambda group, were assessed for association with PVF and 30-day mortality.
- Multivariable and mediation analyses were performed to identify independent predictors and pathways.
Main Results:
- The TW-Lambda ECG pattern, characterized by a giant R-wave and downsloping ST-segment, was present in 3% of patients.
- Patients with the TW-Lambda pattern had significantly higher rates of PVF (50% vs. 8%) and 30-day mortality (43% vs. 6%) compared to those without.
- Killip class ≥3 and the TW-Lambda pattern were independent predictors of PVF, while LVEF and PVF predicted mortality. The TW-Lambda pattern's effect on mortality was mediated by reduced LVEF.
Conclusions:
- The TW-Lambda ECG pattern is a significant predictor of both PVF before primary PCI and 30-day mortality in STEMI patients.
- This ECG pattern can aid in the early risk stratification of STEMI patients, guiding timely intervention and management.
- Reduced LVEF is a key mediator in the association between the TW-Lambda pattern and mortality.
Abstract:
Primary ventricular fibrillation (PVF) may occur in the early phase of ST-elevation myocardial infarction (STEMI) prior to primary percutaneous coronary intervention (PCI). Multiple electrocardiographic STEMI patterns are associated with PVF and short-term mortality including the tombstone, Lambda, and triangular QRS-ST-T waveform (TW). We aimed to compare the predictive value of different electrocardiographic STEMI patterns for PVF and 30-day mortality. We included a consecutive cohort of 407 STEMI patients (75% males, median age 66 years) presenting within 12 h of symptoms onset. At first medical contact, 14 (3%) showed the TW or Lambda ECG patterns, which were combined in a single group (TW-Lambda pattern) characterized by giant R-wave and downsloping ST-segment. PVF prior to primary PCI occurred in 39 (10%) patients, significantly more often in patients with the TW-Lambda pattern than those without (50% vs. 8%, p < 0.001). For the multivariable analysis, Killip class ≥3 (OR 6.19, 95% CI 2.37-16.1, p < 0.001) and TW-Lambda pattern (OR 9.64, 95% CI 2.99-31.0, p < 0.001) remained as independent predictors of PVF. Thirty-day mortality was also higher in patients with the TW-Lambda pattern than in those without (43% vs. 6%, p < 0.001). However, only LVEF (OR 0.86, 95% CI 0.82-0.90, p < 0.001) and PVF (OR 4.61, 95% CI 1.49-14.3, p = 0.042) remained independent predictors of mortality. A mediation analysis showed that the effect of TW-Lambda pattern on mortality was mediated mainly via the reduced LVEF. In conclusion, among patients presenting with STEMI, the electrocardiographic TW-Lambda pattern was associated with both PVF before PCI and 30-day mortality. Therefore, this ECG pattern may be useful for early risk stratification of STEMI.
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