Prediction of Myocardial Salvage by

Modified Selvester QRS score in Patients

with ST-segment Elevation Myocardial
Infarction after Primary PCI
Thesis
Submitted for partial fulfillment of master degree
in cardiology

By
Amir Mahmoud Sammy Taher
M.B.,B.Ch., Faculty of Medicine
Ain Shams University

Under Supervision of
Doctor/ Sameh Saleh Thabet
Assistant Professor of Cardiology
Faculty of Medicine Ain Shams University

Doctor/ Ahmed Mohamed Elmahmoudy

Lecturer of Cardiology
Faculty of Medicine Ain Shams University

Faculty of Medicine
Ain Shams University
2013
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 Acknowledgement
First and foremost, thanks for ALLAH for guiding and
helping me to finish this work
I would like to express my sincere gratitude to
Dr. Sameh Saleh Thabet, Assistant professor of
Cardiology, Ain Shams University, for his
encouragement, support and kindness which enable
me to produce good valuable work.
I would like to express my deepest thanks to
Dr. Ahmed Mohamed Elmahmoudy, Lecturer of
Cardiology, Ain Shams University, for his
uninterrupted care and advice, his meticulous
supervision, precious remarks and continuous
encouragement.
I would also like to record my thanks and
sincere gratitude to my family, my colleagues,
physicians of the gamma camera lab., and nursing
staff in Ain Shams Cardiology department for their
sincere cooperation.
 DEDICATION

To my family and friends

I dedicate this work.
 List of Contents
Subject Page No.

List of Abbreviations ...........................................................i

List of Tables .....................................................................iii

List of Figures ....................................................................iv

Introduction...............................................................................1
Aim of the study ........................................................................3
Chapter (1): AMI ...................................................................4
Chapter (2): Myocardial reperfusion .....................................9
Chapter (3): Assessment of reperfusion...............................22
Chapter (4): Myocardial Perfusion Imaging (MPI) .............31
Chapter (5): QRS Score .......................................................39
Patients and Methods .............................................................54
Results ......................................................................................64
Discussion.................................................................................77
Study Limitations....................................................................82
Conclusion ...............................................................................83
Recommendations ...................................................................84
Summary..................................................................................85
References ................................................................................87
Arabic Summary.....................................................................
 List of Abbreviations

AIVR : Accelerated idioventricular rhythm

AMI : Acute myocardial infarction
ATP : Adenosine tri-phosphate
ATPase : Adenosine tri-phosphatase
CABG : Coronary artery bypass grafting
CAD : Coronary artery disease
CCU : Coronary care unit
CD : Cluster of differentiation
CK : Creatine kinase
CK-MB : Creatine kinase myocardial band
cTFC : Corrected TIMI frame count
cTnI : Cardiac troponin I
cTnT : Cardiac troponin T
ECG : Electrocardiographic, Electrocardiogram
ESC : European Society of Cardiology
FDA : Food and drug administration
FMC : First medical contact
GP : Glycoprotein
HLA : Horizontal long axis
IRA : Infarct related artery
IU : International unit
Kev : Kilo electron volt
LAD : Left anterior descending artery
LBBB : Left bundle branch block
LCX : Left circumflex artery
LV : Left ventricle, left ventricular
MAC : Membrane attack complex
MBG : Myocardial blush grade
MCE : Myocardial Contrast echocardiography
mCi : Milli Curie
mg : Milligram
mm : Millimeter
MPI : Myocardial perfusion imaging
 List of Abbreviations (Cont)

mv : Millivolt
NAD : Nicotine amide adenine dinucleotide
PCI : Percutaneous coronary intervention
PDH : Pyruvate dehydrogenase
pH : Power of hydrogen
PIS : Pre-infarction syndrome
PMNs : Polymorph nuclear leukocytes
PTCA : Percutaneous transluminal coronary angioplasty
PTP : Permeability transition pore
RCA : Right coronary artery
RISK : Reperfusion injury salvage kinase
r-PA : Reteplase
S : Second
SD : Standard deviation
SK : Streptokinase
SPECT : Single photon emission computed tomography
STEMI : ST segment elevation myocardial infarction
Tc : Technetium
TIMI : Thrombolysis in myocardial infarction
TNF : Tumor necrosis factor
TNK-tPA : Tenecteplase
tPA : Tissue plasminogen activator
VLA : Vertical long axis
Vs. : Versus
 List of Tables
Table No. Title Page No.
Table (1): Distribution of ECG changes in STEMI. ......................6
Table (2): Doses of fibrinolytics. .................................................11
Table (3): Fibrinolytics commonly used in STEMI.....................12
Table (4): Contraindications of fibrinolytics...................................12
Table (5): MBG and TIMI myocardial perfusion grade. .............29
Table (6): Complete 54-Criteria, 32-Point QRS Scoring
System .........................................................................41
Table (7): Modified Selvester QRS Scoring System ..................42
Table (8): Modified Selvester QRS Scoring System ...................57
Table (9): Basic characteristics of the whole study
population....................................................................65
Table (10): Population angiographic data......................................66
Table (11): Descriptive statistics quantitative data......................67
Table (12): Univariate analysis for categorical variable................69
Table (13): Bivariate correlation between myocardial
salvage index and other variables ...............................70
Table (14): Bivariate correlation between QRS score
before procedure and initial infarct size......................71
Table (15): Bivariate correlation between QRS score after
procedure and final infarct size...................................72
Table (16): Multiple regression model for prediction of
myocardial salvage index............................................74
Table (17): Multiple regression model for prediction of
myocardium at risk......................................................75
Table (18): Multiple regression model for prediction of
final infarct size...........................................................75
 List of Figures
Figure No. Title Page No.
Figure (1): Reperfusion strategies ................................................20
Figure (2): Thrombus aspirated from an occluded
coronary artery during primary PCI............................21
Figure (3): Primary PCI for inferior STEMI ................................21
Figure (4): Standard tomographic heart slices, orientated
at 90 angles to each other ..........................................35
Figure (5): Standard segmental myocardial display for
semi quantitative visual analysis in a 17-
segment model, with corresponding vascular
territory schematic.......................................................61
Figure (6): Scatter plot of change in QRS score and
myocardial salvage index............................................70
Figure (7): Scatter plot for correlation between QRS score
before procedure and myocardium at risk...................71
Figure (8): Scatter plot showing correlation between QRS
score after procedure and final size of
infarction .....................................................................72
Figure (9): The calculation of the initial and final size of
infarction in patient number 16. ..............................73
Figure (10): Receiver-operating characteristic (ROC) curve
for prediction of successful thrombolysis
using change in QRS score .........................................76
 Introduction

Introduction

A
cute myocardial infarction remains a leading cause of
morbidity and mortality worldwide. Myocardial infarction
occurs when irreversible myocardial cell damage or death occur (1).

ST segment elevation myocardial infarction is the most

serious presentation of atherosclerotic coronary artery disease
carrying the most hazardous consequences (2).

ST segment elevation myocardial infarction is caused by

occlusion of major coronary artery.

Primary PCI is the preferred reperfusion strategy especially

when performed by an experienced team within the shortest
possible time from first medical contact (3).

Over the past decade, methods to estimate myocardial

infarct size from the standard 12 lead ECG have been developed
using a QRS scoring system (4). QRS scores have been shown to
correlate with pathologic infarct size such that a high QRS score
is associated with a large myocardial infarction (5). QRS scores
have also been shown to correlate with left ventricular function
after initial myocardial infarction (6).

The Selvester QRS score measures infarct size with each of

the 31 points in the score corresponding to 3% of the left
ventricular (LV) mass (7). Failure to achieve ST-segment recovery
in the presence of patent infarct related arteries indicates failed
microvascular reperfusion.

1
 Introduction

On the basis of the available scientific evidence, SPECT

imaging with Technetium-99m Sestamibi is the best available
measurement tool for infarct size in clinical medicine.
Technetium-99m Sestamibi scintigraphy is considered a reliable
method to assess myocardial salvage (difference between the
initial and final perfusion defect (8).

2
 Aim of the Work

Aim of the study

To assess the ability of modified Selvester QRS score to
predict myocardial salvage measured by Tc99m-Sestamibi scan as
a gold standard in patients with acute ST-elevation myocardial
infarction after primary coronary intervention.

3
 Review of Literature

Chapter (1)
AMI
Definition:
Detection of rise and/or fall of cardiac biomarkers with at
least one value above the 99th percentile of the upper reference
limit (URL) together with evidence of myocardial ischemia
with at least one of the following:
Any symptom of ischemia.
Electrocardiographic (ECG) changes indicative of new
ischemia (new ST-T changes or new left bundle branch
block (LBBB)).
Development of pathological Q waves in the ECG.
Imaging evidence of new loss of viable myocardium or
new regional wall motion abnormality.
Identification of intracoronary thrombus by angiography
or autopsy
Cardiac death with symptoms suggestive of myocardial
ischemia and presumed new ischemic ECG changes or
new LBBB, but death occurred before cardiac biomarkers
were obtained, or before cardiac biomarker values would
be increased.
Percutaneous coronary intervention (PCI) related MI is
arbitrarily defined by elevation of cTn values (>5 x 99th
percentile URL) in patients with normal baseline values
(99th percentile URL) or a rise of cTn values >20% if
4
 Review of Literature

the baseline values are elevated and are stable or falling.

In addition, either (i) symptoms suggestive of myocardial
ischaemia or (ii) new ischaemic ECG changes or (iii)
angiographic findings consistent with a procedural
complication or (iv) imaging demonstration of new loss
of viable myocardium or new regional wall motion
abnormality are required.
Stent thrombosis associated with MI when detected by
coronary angiography or autopsy in the setting of
myocardial ischemia and with a rise and/or fall of cardiac
biomarker values with at least one value above the 99th
percentile URL.
Coronary artery bypass grafting (CABG) related MI is
arbitrarily defined by elevation of cardiac biomarker
values (>10 x 99th percentile URL) in patients with
normal baseline cTn values (99th percentile URL). In
addition, either (i) new pathological Q waves or new
LBBB, or (ii) angiographic documented new graft or new
native coronary artery occlusion, or (iii) imaging
evidence of new loss of viable myocardium or new
regional wall motion abnormality(9).

Clinical classification of different types of myocardial

infarction* Type 1: spontaneous myocardial infarction related
to ischemia caused by a primary coronary event, such as plaque
fissuring or rupture.*Type 2: myocardial infarction secondary
to ischemia resulting from an imbalance between oxygen
supply and demand.*Type 3: sudden death from cardiac disease

5
 Review of Literature

with symptoms of myocardial ischemia, accompanied by new

ST-elevation or LBBB, or verified coronary thrombus at
angiography and/or autopsy.*Type 4: myocardial infarction
associated with PCI.*Type 5: myocardial infarction associated
with CABG (10).

Diagnosis of STEMI
*ECG: ST elevation at the J point in 2 contiguous leads
with the cutoff points: 0.2 millivolt (mV) in men or 0.15 mV
in women in leads V2 through V3 and/or 0.1 mV in other
leads (11).

Table (1): Distribution of ECG changes in STEMI (12).

LAD: Left anterior descending artery

*Cardiac biomarkers:
Cardiac enzymes: Among the three isoenzyme forms of
creatine kinase (CK), creatine kinase myocardial band (CK-
MB) is highly sensitive in diagnosis of AMI and had been
regarded as the gold standard through the 1980s until about
1995. Its diagnostic specificity is limited because CK-MB is
also present in skeletal muscle. Once released into the blood
stream, CK-MB doubles its concentration within 56 hours
6