Left ventricular function

Left ventricular function is one of the major determinants of long term risk. There is now clear evidence that specific treatment with angiotensin converting enzyme (ACE) inhibitors (probably also P blockers) can reduce that risk, and coronary bypass surgery may be particularly beneficial when left ventricular dysfunction is associated with multivessel coronary artery disease. For many patients clinical criteria are sufficient to exclude significant left ventricular dysfunction, and an analysis of data from the GUSTO 1 trial confirmed that in patients presenting with a first infarct, absence of anterior infarction, left bundle branch block, or acute phase pulmonary oedema accurately

Figure 4.3. Kinetics of creatine kinase (CK) release (left) and ST resolution (right) in response to coronary reperfusion. Sequential coronary arteriograms 90 minutes apart in 41 patients presenting with acute coronary syndromes and ST elevation permitted identification of three groups: group 1—patency of infarct related artery at first arteriogram before thrombolytic treatment (n = 12); group 2—early recanalisation of the infarct related artery within 90 minutes of thrombolytic treatment (n = 10); group 3—persistent occlusion of infarct related artery (n = 19). Serial CK analysis showed early peaking in groups with coronary recanalisation (groups 1 and 2). Cumulative CK release was considerably greater in patients with failed recanalisation (group 3). Serial ECGs showed rapid resolution of ST segment elevation in patients in groups 1 and 2, while in those patients with persistent coronary occlusion (group 3), ST elevation persisted considerably longer. Reproduced from Timmis et al6 with permission of bMj Publishing Group.

Clinical criteria associated with an ejection fraction > 40% in acute myocardial infarction

• First myocardial infarction in the absence of:

-anterior infarction -left bundle branch block -acute phase pulmonary oedema identified 94% of all patients with an ejection fraction > 40%.9 For the remainder, noninvasive evaluation of left ventricular function by echocardiography or radionuclide angiography is recommended in order to determine appropriate risk management.

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