Diagnostic value of biohumoral markers of necrosis and inflammation in patients with right ventricular myocardial infarction.

Introduction/aim: Patients with right ventricular myocardial infarction (RVMI) and patients with left ventricular myocardial infarction (LVMI) of the anterior wall with ST-elevation (STEMI), due to the profundity and volume of the necrosis, tend to have a more severe and more complicated clinical outcome as well as a higher mortality level compared to patients with myocardial infarction of inferoposterior localization in the left ventricle (IPILK), without the right ventricle being overtaken. C-Reactive protein (CRP) is a sensitive and reliable indicator of acute inflammation and is in good correlation with creatin kinasis (CK) or the enzymes which indicate necrosis markers in acute myocardial infarction (AIM). Because of this, a common biohumoral answer is of greater importance and more reliable both diagnostically and prognostically; it signifies a more severe and more complicated clinical outcome, especially on the rupture of the myocardium. The main goal of this study was to compare the maximum values of enzymes and CRP in patients with RVMI and LVMI who had first STEMI and who were in the acute phase treated with percutaneous transluminal coronary angioplasty (PTCA).

Methods: During a six-year period (2000-05), in the Clinic for Urgent Internal Medicine at the Military Medical Academy, a total of 74 patients included in a prospective study were divided into two groups. The first group consisted of patients with RMI 19 (25.67%), and the second group of patients with LMI 55 (74.33%). The patients in both groups received a percutaneous coronary intervention (PCI), if they had been admitted in the first 4 hrs from the beginning of the chest pain, and if there were no contraindications. All the others received thrombolitic therapy, and a "rescue" PCI if needed, in the next 24-48 hours. The risk factors, clinical outcome, necrosis and inflammation biomarkers (enzymes and CRP), coronary status, restenosis of stent, and intra-hospital mortality rate in the first month, as well as a long term prognosis over a period of one year, were analysed.

Results: The average age of the patients in the group with RVMI 19 (7 m + 12 f) was 66.1 +/- 11y, and in the group with LVMI 55 (45 m + 10 f) 59.6 +/-13y, with a statistical trend which indicated that the patients with RVMI were older (66.1 +/- 11y vs. 59.6 +/- 13y, p < 0.061) and that women dominated (63.1% vs. 18.8%, p < 0.001). No statistical differences were found between the two groups of patients concerning the length and the appearance of the chest pain before admission to the hospital and the beginning of the PCI treatment, as well as risk factors such as smoking, cholesterol or diabetes. Of the total of 74 patients with the first STEMI as a primary manifestation of a coronary disease, we performed a primary PCI on 58 (78.37%), and a "rescue" PCI on 16 (21.63%) after the thrombolitic therapy during the 24-48h after admission. We had no cases of death either during the primary or the delayed PCI, or in the next 24h following the intervention. During the hospital phase of treatment, in the group with RMI the causes of death were the rupture of the free wall of the right ventricle (1), acute pancreatitis (1), ARDS and hypostatic pneumonia (1), cerebrovascular insult (1). During the following year, one more patient died due to reinfarction of the anterior localization. In the group with LMI, during the hospital phase of treatment 5 (9.09%) patients died: reinfarction (2), rupture of the left ventricle (1), respiratory insufficiency and severe hypostatic pneumonia (1), cerebrovascular insult (1). During the following year, 4 more patients died, sudden death (2), ischemic dilatative cardiomyopathy (2). The total mortality rate over a one-year period of observation in the group with LMI was 9 (16.3%), and in the group with RMI 5 (26.3%). Radionuclide ventriculography (RNV) was performed in the acute phase of myocardial infarction from 7-14 days after PCI and after 6 months in both groups as an independent indicator of the ejection fraction (EF) of both ventricles. The given results show that a statistically proven significant difference exists in the recovery of the right ventricle in acute phase RMI (49.1 +/- 7.9 vs. 35.4 +/- 10, p< 0.001), as well as after 6 months (49.2 +/- 9.7 vs. 38.3 +/- 11.2, p < 0.010) in patients with RMI.

Conclusion: Primary PCI should be done whenever it is possible with all patients who have a great volume and depth of necrosis, especially if that is the first manifestation of a coronary disease and the first acute STEMI, as were all of our patients in both groups. Our results show that older patients with RMI, and dominantly women, have a more severe and more complicated clinical outcome in the acute phase of RMI compared to patients with LMI of the anterior wall. In the longer prognosis of this case, they have a quicker and a more complete recovery of the right ventricle due to which they have a better immediate and long term prognosis, but demand careful overseeing and energetic treatment in the acute phase of the myocardial infarction, especially considering that their treatment is often specific compared to patients with an infarction of the left ventricle.