|Year : 2019 | Volume
| Issue : 1 | Page : 28-31
Heart rate variability patterns in anterior st-segment elevation myocardial infarction versus inferior st-segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention
Department of Cardiology, Ainshams University, Cairo, Egypt
|Date of Web Publication||10-May-2019|
Dr. Mohamed Zahran
Cardiology Clinic, 3 Abdelazeem Awadallah Street, Higaz Square, Heliopolis, Cairo 11786
Source of Support: None, Conflict of Interest: None
Introduction: Heart rate variability (HRV) has been known as a measurable parameter of the cardiac autonomic function. The cardiac autonomic innervation is heterogeneous and hence leads to different patterns of autonomic modulation. The normal pattern of autonomic modulation is altered in the case of myocardial infarction, the pattern of alteration is not uniform, and it depends on the infarcted wall or region of the heart. Primary percutaneous coronary intervention (PCI) is the gold standard therapy for revascularization of ST-segment elevation myocardial infarction (STEMI) cases, but still conflicting and nonconclusive data are available on the modifications that happen to the cardiac autonomic function after a successful primary PCI with restoration of the Thrombolysis in Myocardial Infarction III flow in the infarct-related artery (IRA). Aim of The Work: Studying and comparing the pattern of autonomic modulation between anterior STEMI patients and inferior STEMI patients. Methods and Results: A total of 93 consecutive patients (56 males and 37 females) presented by STEMI and treated by primary PCI at our cath lab at Ainshams university hospitals (a 24/7 tertiary referral center for primary PCI) during the period between February 2016 and March 2017; 48 had an anterior wall STEMI (ANT) and 45 had an inferior wall STEMI (INF). Mean duration for hospital stay was 4 ± 2 days. Electrocardiogram and respiration were recorded within the day of admission (DA) and at day of discharge (DD). Cardiac autonomic modulation was evaluated using symbolic analysis (SA) of HRV. The first recording for HRV by SA (DA recording) was performed after 18 ± 6 h from primary PCI as soon as the IRA has been opened and the patient stabilized in the cardiac care unit (CCU) for 12 h at least. The second recording for HRV by SA (DD recording) was performed at the DD (duration of admission was 4 ± 2 days). SA recordings showed a significantly predominant of vagal modulation in anterior STEMI patients compared to inferior STEMI at DA, as indicated by 2LV% (10% [7–15] vs. 6% [2–9], P = 0.03). Moreover, at DA, inferior STEMI patients had a significantly higher 0V%, index of sympathetic modulation, compared to anterior STEMI patients (33% [18–47] vs. 19% [12–29], P = 0.02). The second recordings on the DD (DD recording) showed nonsignificant difference between the anterior STEMI and the inferior STEMI groups. Conclusion: After revascularization by primary PCI for STEMI patients, the group presenting by inferior STEMI were characterized by a sympathetic predominance, while those presenting by anterior STEMI were characterized by a predominant vagal modulation. This difference in the sympathetic modulation between the two groups disappeared at the time of discharge from the hospital.
Keywords: Heart rate variability, primary percutaneous coronary intervention, ST-segment elevation myocardial infarction
|How to cite this article:|
Zahran M. Heart rate variability patterns in anterior st-segment elevation myocardial infarction versus inferior st-segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention. J Indian coll cardiol 2019;9:28-31
|How to cite this URL:|
Zahran M. Heart rate variability patterns in anterior st-segment elevation myocardial infarction versus inferior st-segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention. J Indian coll cardiol [serial online] 2019 [cited 2019 May 19];9:28-31. Available from: http://www.joicc.org/text.asp?2019/9/1/28/257959
| Introduction|| |
Heart rate variability (HRV) has been known as a measurable parameter of the cardiac autonomic function. The cardiac autonomic innervation is heterogeneous and hence leads to different patterns of autonomic modulation. The normal pattern of autonomic modulation is altered in the case of myocardial infarction, the pattern of alteration is not uniform, and it depends on the infarcted wall or region of the heart. This altered autonomic modulation starts within a few hours after the acute event. In ST-segment elevation myocardial infarction (STEMI) patients, cardiac autonomic modulation is predominantly characterized by activated sympathetic and withdrawn parasympathetic activity in the early hours after STEMI. It is worth mentioning that this autonomic modulation shows a difference according to the location of the infarction, with the inferior/posterior/right ventricular infarctions showing a more pronounced vagal/vaso-depressive response while the anterior/anteroseptal/anterolateral infarctions showing a more pronounced sympathetic response. However, the effect of treatment of the acute MI whether by fibrinolysis or primary percutaneous coronary intervention (PCI) has not been adequately studied regarding its effect on recovery of the normal pattern of autonomic cardiac modulation., The importance of this point arises from the effect of the autonomic modulation on contributing to reperfusion injury and arrhythmias such as nonsustained ventricular tachycardia.
HRV is an easy, noninvasive and reliable tool that has been widely used for the assessment of cardiac autonomic control in health and diseases, with several methods of recording and analysis now available and even included within wearable smartwatches and mobile applications.
Symbolic analysis (SA), a newer tool has been introduced during the past decade as a substitute to the classical linear spectral tools. SA has been previously tested in heart failure studies and proved to be a highly reliable tool for the assessment of autonomic control in health and disease.
| Methods|| |
The aim of this study was to assess the effect of revascularization by primary PCI on the recovery of the autonomic cardiac modulation using SA of HRV as the measurable parameter of the cardiac autonomic function. The location of the infarction whether its anterior/anterolateral STEMI or inferior/posterior/right ventricular STEMI is considered for comparison. We evaluated 93 consecutive patients diagnosed by STEMI according to the ESC guidelines, then treated accordingly by primary PCI at our cath lab at Ainshams university hospitals (a 24/7 tertiary referral center for primary PCI) during the period between February 2016 and March 2017. All patients gave their informed written consent and the protocol of the study was approved by the ethical committee of the hospital. We excluded patients with atrial fibrillation, pacemaker rhythm, markedly dyspneic/tachypneic patients and those with periodic breathing, all of which will hamper an adequate HRV recording.
Patients were evaluated for HRV within the first 24 h day of admission (DA) and at the day of discharge (DD) with an average hospital stay of 4 ± 2 days. HRV was measured by the recording of the patient's electrocardiogram (ECG) (lead II) and respiration using a thoracic piezoelectric belt with the patient in the supine position for 15 min. During the recording, patients were breathing normally but they were not allowed to stand up, sit, or talk. ECG and respiration were recorded using the CCU monitors transferring the data to the central station computer where it was stored then transferred on a USB for offline analysis. The ECG sample frequency was 1 KHz. After the detection of QRS complex on the ECG traces, the apex of R wave was located using parabolic interpolation, thus allowing the calculation of R-R interval on a beat-to-beat basis. Only recorded segments with regular breathing were considered, and those with ectopics or irregular breathing were not considered for calculations. RR interval time series were then analyzed and stationary segments of 150–300 beats, characterized by regular breathing, were used to calculate the HRV at DA and DD.
Symbolic analysis (SA) is a method to measure HRV by detecting changes of sympathetic and parasympathetic modulations on heart period time series.,,, SA is based on the transformation of time series into a sequence of symbols, which is used to construct patterns (i.e., words), these patterns are categorized four families, and then, calculating their frequency of occurrence. All patterns are grouped without any loss into four families: 0V family, zero variation, pattern with no variation (i.e., all the symbols are equal or within the same level), 1V family, one variation pattern (2 consecutive symbols are equal and the remaining one is different), 2LV family, two like variation patterns (the 3 symbols form an ascending or descending ramp) and the 2UV family, two unlike variation pattern (the three symbols form a peak or a valley). The frequency of occurrence of each pattern is expressed in percentage, i.e., 0V%, 1V%, 2LV%, and 2UV%. It has been demonstrated from previous studies that 0V% is a marker of sympathetic modulation, while 2LV% and 2UV% are markers of vagal/vasodepressor modulation.,
All data were summarized and displayed as the mean ± standard deviation for continuous variables and as number (percentage) of patients in each group for categorical variables. The P values for the categorical variables were calculated using the Chi-square test. Continuous variables were compared using the independent sample t-test. A two-tailed P < 0.05 was considered statistically significant for all analyses. All analyses were performed with the SPSS software (SPSS Inc., Chicago, Illinois, USA).
| Results|| |
Demographic and clinical characteristics of the 93 studied patients are described in [Table 1]. Fifty-six patients were male and mean age was 63 ± 14 years, 48 patients presented by an anterior/anteroseptal/anterolateral STEMI and 45 patients presented by an inferior/inferoposterior/inferolateral wall STEMI, no patient in the study had a right ventricular infarction. There were no statistical differences in baseline characteristics between both groups. No significant difference regarding medications whether before admission or in-hospital medications including beta blockers or calcium channel blockers.
The first recording for HRV by SA (DA recording) was performed after 18 ± 6 h from primary PCI as soon as the infarct-related artery (IRA) has been opened and the patient stabilized in the CCU for 12 h at least. The second recording for HRV by SA (DD recording) was performed at the DD (duration of admission was 4 ± 2 days) [Table 2]. SA recordings showed a predominance of vagal modulation in anterior STEMI patients compared to inferior STEMI at DA, as indicated by 2LV% (10% [7–15] vs. 6% [2–9], P = 0.03). Moreover, at DA, inferior STEMI patients had a higher 0V%, index of sympathetic modulation, compared to anterior STEMI patients (33% [18–47] vs. 19% [12–29], P = 0.02). The second recordings on the DD (DD recording) showed nonsignificant difference between the anterior STEMI and the inferior STEMI groups [Table 3] and [Table 4].
|Table 2: Difference in heart rate variability between day of admission and day of discharge for all ST segment elevation myocardial infarction patients|
Click here to view
|Table 3: Difference in heart rate variability between day of admission and day of discharge for anterior ST segment elevation myocardial infarction patients|
Click here to view
|Table 4: Difference in heart rate variability between day of admission and day of discharge for inferior ST segment elevation myocardial infarction patients|
Click here to view
| Discussion|| |
Previous studies referred to autonomic alterations in STEMI patients with very few actually studying the effect of revascularization on the pattern of autonomic modulation., Vagal overactivity is well known to be more frequent in inferior STEMI compared to sympathetic overactivity in anterior STEMI, this can be explained by the preferential distribution of vagal afferents to the inferoposterior wall of the left ventricle. Thus, the effect of revascularization whether by primary PCI or by fibrinolysis is supposed to be associated with different cardiac autonomic patterns of recovery depending on the site of STEMI. Primary PCI offers the gold standard therapy by restoring the flow in the IRA according to the guidelines of treatment of STEMI, while its effect on restoring the normal autonomic modulation pattern remains unclear. This study showed that the pattern of an early sympathetic modulation is predominantly present after primary PCI for patients with inferior STEMI while an early vagal modulation is predominantly present after primary PCI for patients with anterior STEMI and that this pattern becomes nonsignificant by the time of discharge from the hospital.
This study showed that reperfusion of the infarcted wall achieved by primary PCI in STEMI cases and restoring the flow in the IRA is able to acutely reverse the cardiac autonomic modulatory pattern. For inferior STEMI patients, usually associated with a vagal predominance, sympathovagal balance was shifted toward a sympathetic predominance within the first 24 h; on the other hand, higher vagal modulation was prevalent in patients with anterior STEMI in the first 24 h, usually known to have a prevalent sympathetic modulation.
Previous studies have investigated the pattern of autonomic modulations in patients treated with fibrinolysis, conflicting data have been reported on when this modulation accurately starts after the initiation of treatment., Few studies are available on the effects of revascularization by primary PCI in STEMI patients, and the difference when taking into account whether its anterior STEMI or inferior STEMI.
Lotze et al. studied HRV changes using time domain method, they showed that inferior STEMI treated with thrombolysis showed an autonomic modulatory pattern characterized by initial vagal hyperactivity then followed by sympathetic predominance within few hours. In the case of anterior STEMI, the autonomic modulation pattern is usually characterized by a reduction of total variability, either after fibrinolysis or revascularization by primary PCI.,,
| Conclusion and Study Limitations|| |
Data from this study show two major important results, first, that SA can detect differences in cardiac autonomic modulation after primary PCI as an applicable and noncomplicated method, and second that the pattern of autonomic modulation after revascularization by primary PCI shows a predominant sympathetic activity in inferior STEMI in contrast to a predominantly vagal modulation in anterior STEMI.
There are several important limitations of this study. This was a single-center, nonrandomized observational study and may have been subject to bias, although we included consecutive patients. Future larger studies on bigger samples are required to confirm these preliminary results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lombardi F, Sandrone G, Pernpruner S, Sala R, Garimoldi M, Cerutti S, et al.
Heart rate variability as an index of sympathovagal interaction after acute myocardial infarction. Am J Cardiol 1987;60:1239-45.
Thames MD, Klopfenstein HS, Abboud FM, Mark AL, Walker JL. Preferential distribution of inhibitory cardiac receptors with vagal afferents to the inferoposterior wall of the left ventricle activated during coronary occlusion in the dog. Circ Res 1978;43:512-9.
Lombardi F, Sandrone G, Spinnler MT, Torzillo D, Lavezzaro GC, Brusca A, et al.
Heart rate variability in the early hours of an acute myocardial infarction. Am J Cardiol 1996;77:1037-44.
Webb SW, Adgey AA, Pantridge JF. Autonomic disturbance at onset of acute myocardial infarction. Br Med J 1972;3:89-92.
Chakko S, Fernandez A, Sequeira R, Kessler KM, Myerburg RJ. Heart rate variability during the first 24 hours of successfully reperfused acute myocardial infarction: Paradoxic decrease after reperfusion. Am Heart J 1996;132:586-92.
Zabel M, Klingenheben T, Hohnloser SH. Changes in autonomic tone following thrombolytic therapy for acute myocardial infarction: Assessment by analysis of heart rate variability. J Cardiovasc Electrophysiol 1994;5:211-8.
Fröhlich GM, Meier P, White SK, Yellon DM, Hausenloy DJ. Myocardial reperfusion injury: Looking beyond primary PCI. Eur Heart J 2013;34:1714-22.
Montano N, Porta A, Cogliati C, Costantino G, Tobaldini E, Casali KR, et al.
Heart rate variability explored in the frequency domain: A tool to investigate the link between heart and behavior. Neurosci Biobehav Rev 2009;33:71-80.
Tobaldini E, Porta A, Wei SG, Zhang ZH, Francis J, Casali KR, et al.
Symbolic analysis detects alterations of cardiac autonomic modulation in congestive heart failure rats. Auton Neurosci 2009;150:21-6.
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al.
2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.
Coviello I, Pinnacchio G, Laurito M, Stazi A, Battipaglia I, Barone L, et al.
Prognostic role of heart rate variability in patients with ST-segment elevation acute myocardial infarction treated by primary angioplasty. Cardiology 2013;124:63-70.
Karp E, Shiyovich A, Zahger D, Gilutz H, Grosbard A, Katz A. Ultra-short-term heart rate variability for early risk stratification following acute ST-elevation myocardial infarction. Cardiology 2009;114:275-83.
Porta A, Tobaldini E, Guzzetti S, Furlan R, Montano N, Gnecchi-Ruscone T. Assessment of cardiac autonomic modulation during graded head-up tilt by symbolic analysis of heart rate variability. Am J Physiol Heart Circ Physiol 2007;293:H702-8.
Guzzetti S, Borroni E, Garbelli PE, Ceriani E, Della Bella P, Montano N, et al.
Symbolic dynamics of heart rate variability: A probe to investigate cardiac autonomic modulation. Circulation 2005;112:465-70.
Pitzalis MV, Mastropasqua F, Massari F, Passantino A, Luzzi G, Ligurgo L, et al.
Different trends of changes in heart rate variability in patients with anterior and inferior acute myocardial infarction. Pacing Clin Electrophysiol 1998;21:1230-8.
De Ferrari GM, Sanzo A, Castelli GM, Turco A, Ravera A, Badilini F, et al.
Rapid recovery of baroreceptor reflexes in acute myocardial infarction is a marker of effective tissue reperfusion. J Cardiovasc Transl Res 2014;7:553-9.
Airaksinen KE, Ikäheimo MJ, Huikuri HV, Linnaluoto MK, Takkunen JT. Responses of heart rate variability to coronary occlusion during coronary angioplasty. Am J Cardiol 1993;72:1026-30.
Bonnemeier H, Hartmann F, Wiegand UK, Irmer C, Kurz T, Tölg R, et al.
Heart rate variability in patients with acute myocardial infarction undergoing primary coronary angioplasty. Am J Cardiol 2000;85:815-20.
Lotze U, Ozbek C, Gerk U, Kaufmann H, Heisel A, Bay W, et al.
Early time course of heart rate variability after thrombolytic and delayed interventional therapy for acute myocardial infarction. Cardiology 1999;92:256-63.
[Table 1], [Table 2], [Table 3], [Table 4]