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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 97-104

Biventricular dysfunction and angiographic correlates of inferior wall myocardial infarction with high degree AV blocks


1 Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh, India
2 Department of General Medicine, ASRAM Medical College, Eluru, Andhra Pradesh, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Tammiraju Iragavarapu
Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_18_19

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  Abstract 


Objectives: Inferior wall myocardial infarction (IWMI) accounts for about 50% of acute myocardial infarction (MI) which are caused predominantly by occlusion of the right coronary artery which also mostly supplies both the SinoAtrial and atrioventricular (AV) nodes. The objective of this study is to analyze the incidence of high-degree AV blocks in IWMI with respect to right ventricular (RV) MI, RV dysfunction, left ventricular (LV) dysfunction, and their angiographic correlation.
Methods: This study was a hospital-based retrospective cross-sectional analytical study involving 150 patients presenting to our casualty with Acute IWMI during August 2016–February 2018. We have collected the demographic details of these patients and analyzed various complications pertaining to AV Blocks. The patients were categorized into two groups – Group 1-IWMI with high-degree AV blocks and Group 2-IWMI without AV blocks. In-depth history and other details such as electrocardiogram, ventricular dysfunction by echocardiogram and angiographic data were analyzed among these two groups.
Results: Among 150 patients with acute IWMI, high-degree AV blocks were seen in 35 patients (23%). The mean age of presentation was 56–65 years (31.4%) with male preponderance (60%). Severe LV dysfunction (ejection fraction <30%) in Group 1 (60%) was statistically significant with P < 0.00001 when compared to Group 2 (17.3%). RV dysfunction (tricuspid annular plane systolic excursion <16 mm) is seen in 57.2% versus 4.3% cases in Group 1 which is statistically significant with P < 0.00001. The triple vessel disease was significant in Group 1 (57.1% vs. 17.3%) whereas single-vessel disease (8.5% vs. 43.5%) was significant in Group 2 with P < 0.00001. Reversal of AV block is seen in 94.2% of cases after recanalization of RCA. Mortality was more in Group 1 (5.8% vs. 2.6%).
Conclusion: IWMI with high-degree AV block has a worse prognosis with increased incidence of RV and LV dysfunction and multivessel disease. Prompt intervention can reverse AV block in most of the cases.

Keywords: Complete heart block, inferior wall myocardial infarction, multivessel disease, right ventricular dysfunction


How to cite this article:
Iragavarapu T, Tadi S, Babu K J, Naresh K P, Sruthi M, Roopini A. Biventricular dysfunction and angiographic correlates of inferior wall myocardial infarction with high degree AV blocks. Heart India 2019;7:97-104

How to cite this URL:
Iragavarapu T, Tadi S, Babu K J, Naresh K P, Sruthi M, Roopini A. Biventricular dysfunction and angiographic correlates of inferior wall myocardial infarction with high degree AV blocks. Heart India [serial online] 2019 [cited 2019 Nov 15];7:97-104. Available from: http://www.heartindia.net/text.asp?2019/7/3/97/268167




  Introduction Top


Inferior wall myocardial infarction (IWMI) accounts for 40%–50% of cases of acute myocardial infarction (MI).[1],[2] Inferior infarctions are caused by occlusion of the right coronary artery (RCA) in >70% of cases which also supplies both the SinoAtrial (SA) and atrioventricular (AV) nodes in most of the cases.[3],[4],[5] Hence, there is a higher chance of conduction blocks in IWMI when compared to anterior wall myocardial infarction (AWMI). There is 19% incidence of high-degree AV block complicating acute IWMI. The right ventricular MI (RVMI) has shown to occur in 38% of cases of acute IWMI with AV block, as reported by Berger and Ryan.[5] This subset of patients is more prone to complications such as congestive heart failure and shock secondary to biventricular dysfunction with grave prognosis[6] AV blocks are mostly transient which improves with revascularization. Early complete recanalization is associated with lower mortality, improvement in ventricular function, improved exercise capacity, and better tolerance to future acute myocardial ischemic events.[7],[8] We have analyzed the cases of IWMI with and without a high degree/complete heart block (CHB) focusing on biventricular function and angiographic correlates.

Study design

The current study was an observational, single-center study conducted at ASRAM Medical College, Department of Cardiology, Eluru, Andhra Pradesh, India. The study was conducted in accordance with Declaration of Helsinki and under guidelines of good clinical practice. Patients were enrolled after providing them with complete information about the study and obtaining their written, informed consent.

Objectives

Evaluate the frequency of complete heart block in acute IWMI and its association with complications such as RV MI with RV dysfunction, left ventricular dysfunction (LV), and angiographic analysis of these patients.

Place and duration of the study

The Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh, India, from August 2016 to February 2018.


  Methods Top


In this study, we have analyzed 150 patients presenting to our casualty with acute IWMI. We have collected the demographic details of these patients and analyzed the ventricular function and angiographic data focusing on high degree/CHB. RV dysfunction is taken as a surrogate to significant RVMI along with electrocardiogram (ECG) changes.

Patients of either sex with age >18 years were included in this study. Patients presenting with recurrent infarctions or prior coronary revascularization (e.g., coronary artery bypass grafting or percutaneous coronary intervention [PCI]) were excluded from the study. Permission is taken from hospital ethical committee. Patients were included in the study after taking informed consent. The study cases were categorized into two groups: Group 1– IWMI with high degree/CHB and Group 2 – IWMI without AV blocks.

A detailed history was taken from each patient, including risk factors such as diabetes, hypertension, smoking, and family history. Clinical examination was carried out in detail. Standard 12 lead ECG is recorded immediately after admission along with right-sided leads. The diagnosis of acute IWMI is made in the presence of ST-elevation >0.1 mv (1 mm) in two or more of leads II, III and aVF[9] and RVMI by ST-segment elevation of 1 mm or more in the right precordial leads, i.e., V3R/V4R to V6R in particular lead v3R/V4R when there is associated ST-segment elevation in lead II, III, aVF along with elevation of cardiac markers (CK-MB, Trop T).[10] The presence of rhythm disturbance was recorded at the time of admission, post-procedure, and every day during the hospital stay. High-degree AV block is a 2nd degree heart block with a P: QRS ratio of 3:1 or higher, producing an extremely slow ventricular rate. CHB is 3rd degree AV block with a complete absence of AV conduction. 2D-ECHO was done to assess RV and LV dysfunction. Tricuspid annular plane systolic excursion (TAPSE) is a parameter of global RV function which describes apex-to-base shortening. In apical 4-chamber view, M-mode cursor was placed through tricuspid annulus at lateral RV free wall in such a way that the annulus moved along M-mode cursor. From M-mode tracing the amount of longitudinal motion of annulus at peak systole was measured. Total displacement was measured by leading edge of echoes and expressed in millimeter. TAPSE correlates closely with the RV ejection fraction (EF) and has been found to be both highly specific and easy to measure. TAPSE <16 indicates significant RV dysfunction. Both the groups underwent coronary angiography (CAG) based on the American College of Cardiology (ACC)/European Society of Cardiology (ESC) indications for CAG. CAG was done through the right radial (optitorque catheter) or right femoral route (Judkins) after taking the patient's consent. Critical coronary artery disease (CAD) was defined as 70% or more narrowing of a coronary artery that results in a significant reduction in maximum flow capacity in a distal vascular bed. The patients were grouped into single-vessel disease (SVD), double-vessel disease (DVD), and triple-vessel disease (TVD) according to the number of major epicardial coronary arteries (left anterior descending artery [LAD], left circumflex artery, and RCA) involved. All patients were managed with standard treatment strategies with temporary pacing, primary or rescue (PCI) in both the groups. Thrombolysis was not done in any case of IWMI with AV block.

The statistical significance of each risk factor between the groups was done using Statistical Package for Social Sciences program (Graphpad Software Inc., San Diego, CA, USA) in which we used a frequency percentage and Chi-square with Yates' correction at the level of significance α = 0.05 (P< 0.05).

Observations

Of 150 patients with acute IWMI, high-degree AV blocks were diagnosed in 35 patients (23%). The mean age of presentation was 56–65 years (31.4%) in both the groups, the youngest being 32 years in Group 1. Male preponderance was observed in both the groups with 60% in Group 1 and 56.5% in Group 2.

Various risk factors such as diabetes, hypertension, dyslipidemia, smoking, and obesity have been studied extensively in these two groups. Most of the patients in both the groups had multiple risk factors such as hypertension (91.4%), diabetes mellitus (77.1%), dyslipidemia (37.1%), and smoking (34.2%) without any statistical significance between the two groups.

The analysis of Biventricular function showed that severe LV dysfunction (EF < 30%) is more in Group 1 (60%) when compared to Group 2 (17.3%) with P < 0.00001. The pie diagram comparing severe LV dysfunction in the two groups was shown in [Figure 1]. RV dysfunction (TAPSE <16 mm) was seen in 57.2% of cases of Group 1 when compared to 4.3% of Group 2 which is very much significant statistically (P< 0.00001). The RV dysfunction profile was depicted in [Figure 2].
Figure 1: Comparision of severe left ventricular dysfunction in two groups. Group 1: Inferior wall myocardial infarction with atrioventricular blocks, Group 2: Inferior wall myocardial infarction without atrioventricular blocks

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Figure 2: Pie diagram showing right ventricular dysfunction profile in patients with atrioventricular blocks

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Coronary angiogram results in Group 1, predominantly showed TVD in 57.1% of cases, followed by DVD in 34.2% and SVD in 8.6% of cases, whereas in Group 2, SVD was the most common lesion in 43.5% followed by DVD in 39.1%, TVD in 17.3%. The TVD was significant in IWMI with AV blocks with P < 0.00001 whereas SVD was significant in Group 2 with P < 0.0001. This was shown as bar diagram in [Figure 3]. Demographic, biventricular function, and angiographic features of patients in the two groups are tabulated in [Table 1].
Figure 3: Bar diagram showing angiogram analysis of inferior wall myocardial infarction patients with atrioventricular blocks. Group 1: Inferior wall myocardial infarction with high-degree atrioventricular blocks, Group 2: Inferior wall myocardial infarction without atrioventricular blocks

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Table 1: Demographic, biventricular function, and angiographic features of patients in the two groups

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Outcomes

Thirty-three cases out of 35 underwent PCI at the earliest possible time with thrombolytic predictive instrument (TPI) support. In 13 cases, who presented early within 12 h, reversal of heart block occurred in 4–6 h while in the remaining 20 cases with delayed presentation (after 1–2 days), reversal occurred in 3–4 days. Reversal of AV block is seen in 94.2% of cases (33 out of 35) after recanalization of RCA with PCI irrespective of diseases in other vessels. Death is the outcome in 2 patients (5.8%), who presented late to the hospital (after 2–3 days) with renal dysfunction before intervention in Group 1, whereas the mortality in Group 2 was 2.6% (3 cases).


  Discussion Top


Acute MI is one of the major public health problems worldwide as well as in India. The actual prevalence of CAD is shooting up in a linear fashion; from 4% in 1960 to 11% in 2001. In simple terms, from every 25th individual in 1960 to every 9th in 2001 can be suspected of having CAD.[11],[12] AWMI (55%) is the most common variant followed by IWMI. The inferior wall anatomically constitutes the lateral two-third of the left ventricle and the medial one-third of the right ventricle. Infarction involving this region of the heart causes ST elevation in Lead II, III and avF (IWMI), v3R/v4R (RVMI) on a 12 lead ECG and is clinically associated with increased incidence of conduction blocks.[13],[14] ECG changes are transient and disappear in 48% of cases within 10 h making it a less dependable tool in late presentations.[15]

There is a 19% incidence of high-degree (2nd or 3rd degree) heart block complicating acute inferior infarction.[16],[17],[18],[19],[20] Approximately one-half of the patients who develop heart block do so through a gradual progression of their conduction delay. AV block in the setting of IWMI is believed to be associated with a higher incidence of congestive heart failure, larger infarct size, and LV failure leading to increase in-hospital mortality. Various mechanisms of SA and AV block in inferior MI are mentioned in [Table 2].
Table 2: Factors leading to atrioventricular blocks in inferior wall myocardial infarction

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The most common age group is 55–65 years in both the study groups, which is concordant with Kumar et al.[20] who showed the mean age as 58.8 years. In our study, male outnumbered females which is in accordance with Keshava et al. study which reported that 77% were male and 23% were female.[11] The most common risk factor in Group I was hypertension (57.14%) followed by diabetes (40%), but there is no statistical significance between the two groups unlike the Kumar et al., who had shown that diabetes is more prevalent in patients with AV blocks than in patients without AV blocks.

RVMI is usually associated with IWMI in 24%–50% of cases and in practice, does not exist in isolation.[21],[22] In <10% of patients, RVMI is hemodynamically significant.[23]

Acute RCA occlusion proximal to the RV branch results in RV free wall dysfunction, exerting mechanically disadvantageous effects on biventricular performance. The relatively small percentage of RVMIs may be explained by several factors such as lower oxygen requirements of the RV due to its smaller muscle mass and workload; increased blood flow during diastole and systole; more extensive collateralization of the RV, primarily from the left coronary system; and diffusion of oxygen from intrachamber blood through the thin wall of the RV and into the Thebesian veins.[24],[25] The term RV “infarction” appears to be somewhat of a misnomer, for in most patients, acute RV dysfunction represents ischemic but predominantly viable myocardium. RV dysfunction as assessed by echocardiography[26],[27] indicates significant infarction of RV in IWMI. Earlier studies had shown good correlation of TAPSE with ECG evidence of RV infarction, but the number of patients was less, and there was no angiographic correlation.[28] TAPSE was also an independent predictor of mortality in IWMI. TAPSE <16 indicates RV systolic dysfunction according to the ASE guidelines.[29]

RVMIs are more often complicated by all types of arrhythmias, RV free wall rupture, cardiac tamponade, pulmonary embolism, and atrial fibrillation, resulting in poor clinical outcomes in patients with IWMI.[6],[30],[31],[32],[33] Our study had shown that the IWMI patients with RVMI had more incidence of CHB (57.2%.) when compared with IWMI without RVMI with significant P value (P< 0.00001). This is seen in many previous studies.[34],[35] In a study by Braat et al., the incidence of CHB was found to be 33% to 66% in IWMI patients with RV infarction.[15] The various studies comparing AV blocks in IWMI with and without RVMI were tabulated in [Table 3].
Table 3: Comparison of various studies showing atrioventricular blocks in patients with and without right ventricular myocardial infarction (right ventricular dysfunction)

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Although the incidence of heart failure after MI has fallen over the last few decades, it remains common, complicating up to 45% of infarcts[36] increasing the mortality and morbidity. LV dysfunction (particularly EF <30%) is an important predictor of mortality following acute IWMI[37] with complications like Sudden cardiac death, usually from various atrial and ventricular arrhythmias. Our study revealed that severe LV dysfunction was more predominant in Group 1 which is statistically proven significant. Bounhoure et al.[38] had shown that the LV function was under 30% in 53% of patients with AV block. The severity of these infarcts was not related to the AV block which regressed in 95% of cases but to the severity of the coronary disease, the LV dysfunction, and the advanced age of the patients. This severe LV dysfunction in our study can be attributed to the increased incidence of TVD in this subset of patients.

Angiographic analysis of our study groups revealed interesting features. It showed that the incidence of Multivessel disease (57%) is predominant in patients with CHB. This might be the reason for low collateral flow to AV node leading to more of AV dissociation. A study done by Bassan et al. had shown that AV block in Acute IWMI is a harbinger of associated LAD lesion.[39] Chaitman et al. concluded that functional angina class, age, and the presence of resting anterior ST and T abnormalities are highly predictive of associated left system disease in survivors of inferior infarction.[40] In a similar study by Bounhoure et al., the TVD was statistically significant, and the prevalence of >70% stenosis in both the RCA and LAD in patients with AV block was significantly high when compared to patients without AV blocks. The incidence of multivessel disease is high in patients with heart block and is associated with poor prognosis.

Complete AV block is known to be reversible in most cases of acute IWMI. Review of the literature reveals two possible mechanisms for the restoration of normal AV conduction following coronary revascularization. These mechanisms are vagally mediated heart block and ischemia-driven conduction delay. According to a case report by Bolorunduro, one of the mechanisms for AV block in Inferior wall ischemia is Bezold–Jarisch reflex as he had proven that revascularization of the acute marginal artery had resolved the AV block in a case of IWMI.[41] AV conduction defects which occur as a direct result of ischemia will be resolved with revascularization of the culprit artery. In patients with IWMI with RVMI, in whom PCI was successful, persistent hypotension and mortality were less compared to patients in whom PCI was unsuccessful.[42]

In our study, primary or rescue PCI was performed with the support of TPI (if HR <40/min) in 33 cases, all of which showed reversal of AV blocks with complete recanalization of coronaries. Most of these cases are transient and resolve either spontaneously or with revascularization, whereas approximately 9% will ultimately require a permanent pacemaker, implicating permanent damage to AV conduction tissue prior to or due to lack of revascularization.[43],[44]

Permanent pacemaker implantation (PPI) was not done in any case. The decision to implant a permanent pacemaker should not be taken easily as permanent pacemaker is a life-long commitment for a patient with the need for a generator change and surgical revisions for malfunctions, which become important considerations in younger patients. The indications for PPI should be according to ACC/AHA/ESC guidelines in case of persistent 2nd degree or 3rd degree AV blocks. However, conduction defects after an AWMI usually warrant a permanent pacemaker, cardiac resynchronization therapy defibrillator, or an implantable cardioverter-defibrillator.[45],[46]

The mortality is significantly high in patients with AV block which is shown in many of the previous studies as well.[47] In studies conducted by Hochman et al. and Jacobs et al., mortality of RV infarction with complications was comparable to that due to LV infarction.[48],[49] The mortality of the two patients with IWMI and AV blocks also had RVMI, which indicates that RVMI increases mortality along with AV blocks in IWMI patients, as shown by some earlier studies.

Study limitations

This was single-center observational study with a limited number of patients (n = 150). Results might vary in multicenter randomized study with larger population. The sample size was small to make any generalized comments. TAPSE has some limitations in that measurement is restricted to the longitudinal function of RV free wall, and the functional status of LV may have an influence on it.[50]


  Conclusion Top


IWMI with high degree/CHB had worse prognosis with increased incidence of RV and LV dysfunction and multivessel disease in comparison with IWMI without AV blocks. Prompt intervention can reverse the AV block in most of the cases.[53]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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