OBJECTIVE To assess whether the sum of ST segment elevation and depression (ST segment deviation score [SUMSTdev]) is a better predictor for 24 h, nonfatal complications in patients with acute myocardial infarction (MI) than the sum of ST segment elevation (SUMSTelev) alone in the admission electrocardiogram. METHODS Patients with acute MI receiving thrombolytic therapy were observed and ST scores were evaluated. Nonfatal, 24 h complications were defined as acute congestive heart failure or severe rhythm disturbances within 24 h after the start of thrombolysis. The outcome measures were the relationship between both the SUMSTdev and the SUMSTelev and the occurence of 24 h complications, and the identification of a cut-off value with the highest sensitivity and specificity for the prediction of complications. RESULTS Three hundred eighty-two patients (288 male patients, mean age 58 years) with acute MI (179 patients with anterior MI) were included in the study. The SUMSTdev was significantly higher in patients with 24 h complications than in patients without complications (anterior MI 23.9 mm versus 11.5 mm, respectively, P<0.001; inferior MI 21.6 mm versus 12.0 mm, respectively, P<0.001). Using the receiver operating characteristic analysis, the SUMSTdev significantly improved the ability to estimate the occurence of 24 h complications for anterior and inferior MI compared with the SUMSTelev (anterior MI 0.87+/-0.03 versus 0.84+/-0.03, P=0.04; inferior MI 0.79+/-0.03 versus 0.74+/-0.04, P=0.03). The optimal cut-off for the SUMSTdev was found at 16 mm for anterior MI and 13 mm for inferior MI. Multivariate regression analysis showed that the SUMSTdev was an independent predictor of the occurrence of early complications in patients with anterior MI (odds ratio 28.4, 95% CI 11.0 to 73.6, P<0.0001) and inferior MI (odds ratio 9.7, 95% CI 4.7 to 20.2, P<0.001). CONCLUSIONS The SUMSTdev is superior to the SUMSTelev in predicting 24 h, nonfatal complications after acute MI. The use of the SUMSTdev is therefore recommended for the stratification of patients with acute MI into low and high risk patients.

Thrombolysis in patients with suspected acute myocardial infarction (MI) without increase of cardiac enzymes (i.e. creatine kinase) above the normal level is a rare phenomenon which is not well described in the literature. We studied 1.077 consecutive patients admitted to the General Hospital of Vienna who were treated for suspected acute MI with thrombolytic agents between January 1992 and December 1998. In 39 patients (3.6%) MI was ruled out on the basis of persistently normal creatine kinase (CK) levels. By means of chart review and database inquiry 28 (72%) of these patients were finally diagnosed as having an acute coronary syndrome (coronary group); 11 patients (non-coronary group) had other diagnoses (pericarditis in 5 cases). Comparison of the coronary vs. the non-coronary group showed no differences in risk factors, in the history of cardiac events and vital signs at the time of admission. Statistically significant differences were found in age [61 (IQR 50-70) years in the coronary group vs. 47 (IQR 4755) years in the non-coronary group, p=0.009], in gender distribution (p=0.007), in the ST-depression score [4 (IQR 1-5) mm vs. 0 (IQR 0-0) mm, p<0.0001], in the difference between highest CK level and CK level at admission [21 (IQR 8-35) U/I vs. 0 (IQR 0-0) U/I, p<0.0001] and in the time difference from admission to highest CK level [6 (IQR 3-10) hours vs. 0 (IQR 0-0) hours, p<0.0001]. A trend towards more complications, i.e. pulmonary congestion, bradycardia, ventricular taycharrhythmia and in-hospital mortality (21% vs. 0%, p=0.09) was found in the coronary group. The relativley low number of patients with "unjustified" thrombolysis does not justify the need for a change in criteria for thrombolysis. Patients of the non-coronary group may be identified by a lack in ST-depression. Moreover, patients of the coronary group may have benefitted from thrombolysis by prevention of myocardial damage.

Detecting microalbuminuria (MA) and proteinuria (PA) is an essential part of the diagnostic management of hypertensive patients. Evidence of MA is associated with a higher rate of cardiovascular events and an increased morbidity and mortality. The spot urine sampling is an easily available method for the diagnosis of MA, which may provide advantages compared to the “gold standard”. i.e. 24-hour urine sampling. We, therefore, evaluated whether spot urine sampling is a reliable parameter in hypertensive patients. Following collection of a spot midstream urine sample usually obtained in the morning, urine was then collected for 24 hours for measurement of MA and PA. Both samples were analysed in a blinded fashion. 24-hour urine sampling was used as a gold standard to determine the diagnostic value of spot urine sampling for detection of MA in 192 patients. A receiver operating characteristic curve (ROC) was constructed to determine the optimum spot urine sampling cut-off-value defined as maximum sensitivity and specificity. The area under the ROC-curve was 0.89. The value of MA with the highest sensitivity (56,4%) and specificity (97,7%) was 71 mg/L. Our data indicate that spot urine sampling does not reveal reliable data to detect hypertension associated renal damage as a high number of false positive results occur.

No data are available about frequency and influence of renal insufficiency on clinical presentation and treatment outcome in patients with hypertensive crisis. We, therefore, evaluate the association between renal impairment and clinical presentation as well as treatment modalities in patients with hypertensive crisis. Data of 979 patients presented with hypertensive crisis were prospectively collected. Factors examined were medical history (age, sex, duration of hypertension, cause and duration of renal disease, history of diabetes mellitus and/or smoking habits) blood pressure and clinical presentation on admission (urgency, acute left ventricular failure, angina pectoris, stroke, aortic dissection), serum parameters (creatinine, blood urea nitrogen, potassium, sodium), creatinine clearance (Ccr) calculated by Cockroft-Gault (renal impairment was defined as Ccr < 55 ml/min) and treatment (kind and number of drugs). Impaired renal function was observed in 268 (27%) patients with hypertensive crisis. In a forward stepwise regression analysis impaired renal function was positively associated with increasing age (odds ratio 1.6 per 20 years increase. 95% confidence interval 1.4 to 2.0), with acute congestive heart failure on admission (odds ratio 1.8, 95% confidence interval 1.3 to 2.6) and with an increasing number of antihypertensive drugs (odds ratio 1.4 per drug added, 95% confidence interval 1.1 to 1.7). The overall response rates of all drugs except enalaprilat and sodium nitroprusside were lower in patients with renal impairment than in those with normal renal function (x2 = 13.3; d.f. = 6; p = 0.038). Renal impairment is associated with an increased age, a higher risk for emergencies, in particular acute left ventricular failure, and a higher number of drugs required to lower blood pressure sufficiently.

Hypertensive patients with an acute coronary syndrome are frequently observed in an Emergency Department (ED). No data are available about the frequency of patients developing myocardial infarction (MI) and factors (patients characteristics, blood pressure (BP), antihypertensive treatment) which may be associated with MI. We prospectively collected the following data of all hypertensive patients (defined as systolic BP > 200 mmHg and/or diastolic BP > 100 mmHg) with an acute coronary syndrome (chest pain lasting for more than 10 minutes and/or pain relief after nitroglycerine application): age, gender, highest and lowest systolic and diastolic BP, history of myocardial infarction, evidence of diabetes mellitus, hyperlipidemia, current cigarette smoking, time until BP reduction reached 75% of highest BP and lowest BP, antihypertensive treatment, and anticoagulation treatment. MI was defined as an elevation of CK-MB above 10%. One hundred and twenty eight (22,4%) out of 571 patients with hypertensive emergencies presented with acute coronary syndrome. MI occured in 29 patients (22,7%). No significant differences between MI- and non-MI patients were observed concerning highest (sys: 206 ± 22 vs 202 ± 23 mmHg; dia: 106 ± 18 vs 106 ± 15 mmHg) and lowest BP reached in the ED (sys: 129 ± 19 vs 124 ± 15 mmHg; dia: 67 ± 13 vs 68 ± 10 mmHg), baseline characteristics, time until BP reached 75% of highest BP (79 ± 74 vs 80 ± 64 min) and lowest BP (194 ± 149 vs 230 ± 123 min), and anticoagulation treatment. The lowest rate of MI was noted in patients treated with nitroglycerine (19.1%). In patients treated with an alpha- or betablocker the percentage of MI was markedly higher (32.1% or 33.3%). The only possible factor for the development of MI is the antihypertensive drug used in these patients. Nitroglycerine exhibit a coronary vasodilation independent from BP reduction, which may be beneficial in this group.