RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, …
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
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|1. |NAME OF THE CANDIDATE AND ADDRESS |DR. VINAYAKUMAR S MASTAMMANAVAR, |
| | |PG IN GENERAL MEDICINE, |
| | |KARNATAKA INSTITUTE OF MEDICAL SCIENCES, |
| | |HUBLI – 580 022. |
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|2. |Name of the institution |KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI-22. |
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|3. |Course of the study and subject |m.d. in general medicine |
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|4. |Date of admission to the course |31-05-2008 |
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|5. |Title of the topic |THE STUDY OF CORRELATION OF TOMBSTONING ELECTROCARDIOGRAPHIC PATTERN IN ACUTE |
| | |ANTERIOR WALL MYOCARDIAL INFARCTION WITH EJECTION FRACTION. |
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|6. |Brief resume of intended work: |
| |6.1 NEED FOR THE STUDY: |
| |Acute coronary syndromes are by far the most common diagnosis for cardiovascular patients admitted to the hospital. |
| |Electrocardiography (ECG) remains a key test for diagnosis of myocardial infarction. An elevation of ST-segment is one of the earliest|
| |electrocardiographic sign of acute myocardial infarction and magnitude of ST-segment elevation has been used as an indicator of the |
| |degree of myocardial injury. However little is understood of the causes and the relation of these changes. The causes and the |
| |correlation between complications of acute myocardial infarction and the tombstoning electrocardiographic pattern have not yet |
| |clarified. |
| |Wimalaratana6 used the term ‘tombstoning’ to a characteristic shape of ST segment in patients with myocardial infarction. He also |
| |described the tombstoning may be a bad sign for prognosis in acute myocardial infarction. Only few studies have been done to compare |
| |this characteristic electrocardiographic pattern with prognosis like shock, arrhythmias, decreased ejection fraction and higher |
| |mortality rate. So the present study will be done to evaluate these conclusions, particularly the relation between the tombstoning |
| |electrocardiographic pattern and ejection fraction. |
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| |6.2 Review of Literature: |
| |Kukla et al1 studied 207 consecutive patients with STEMI from 2000-2002,Tombstoning pattern in ECG(TOMB-ST) was found in 55 |
| |(26.6%)patients, more often in anterior wall myocardial infarction-44( 40%) cases than in inferior wall myocardial |
| |infarction-11(11.6%) cases. The mortality was higher in the TOMB-ST patients compared to non TOMB-ST ones. This was observed both in |
| |patients with anterior wall myocardial infarction (TOMB-ST -38.8% versus non TOMB-ST-13.4%) and in subjects with inferior wall |
| |myocardial infarction (TOMB-ST -36.4% compared to non-TOMB-ST-7%). The TOMB-ST group had reduced ejection fraction (mean 41% compared |
| |to 49%). In- hospital complications such as ventricular fibrillation, heart failure and cardiogenic shock were more in TOMB-ST |
| |group. |
| |Tomcsanyi et al2 studied 87 consecutive patients with anterior wall STEMI between January 2004 to September 2004, to compare the form |
| |of STEMI, coronary anatomy, and the initial N Terminal Pro-Brain Natriuretic peptide level. The results showed that in -hospital |
| |complications like decreased ejection fraction, ventricular tachycardia, heart failure, cardiogenic shock, were higher in patients |
| |with tombstoning ECG pattern. The mean ejection fraction is 42% in patients with tombstoning ECG pattern compared to 45% in patients |
| |without having this pattern. The initial N Terminal Pro-Brain Natriuretic peptide levels were higher in patients with tombstoning ECG |
| |pattern compared to others. They concluded that in addition to changing the shape of repolarization, decreased microcirculation plays |
| |a role in the development of increased wall tension. Increased wall tension is the probable cause of higher NT-PRO-BNP levels and |
| |increased mortality. |
| |Balci et al3 studied 106 consecutive patients of first anterior wall myocardial infarction between 2001 and 2002 where 23 patients |
| |exhibited the typical Tombstoning ECG pattern , mean ejection fraction was about 42% in patients with Tombstoning of ST segment |
| |compared to 51%in others. CK-MB, the biochemical predictor of infarct size, was higher in patients with Tombstoning ECG pattern. Both |
| |systolic and diastolic blood pressures were lower in patients with Tombstoning of ST segment and also incidence of pre-infarct angina |
| |was significantly lower in these patients. Thus study revealed that Tombstoning ECG pattern was related to large infarct size, |
| |decreased ejection fraction and more in-hospital complications, thus providing a rationale for aggressive management of such patients.|
| |Guo X H et al4 studied 124 patients with acute myocardial infarction whose ECGs were taken within 24 hours of onset of symptoms and |
| |who subsequently underwent coronary angiography. Their results showed that 24 patients had definite Tombstoning pattern on their |
| |admission ECG. They concluded that all patients including those of inferior wall myocardial infarction had either total or partial |
| |occlusion of Left anterior descending artery. Patients with Tombstoning ECG had significantly greater incidence of occlusion of all 3 |
| |coronary arteries(54%in patients with Tombstone ECG pattern versus 22%in patients with non Tombstone ECG pattern).Tombstoning ECG |
| |pattern were strongly associated with anterior than inferior wall myocardial infarction. |
| |Huang J et al5 in 1994 conducted a retrospective study involving 605 patients with acute myocardial infarction. They concluded that |
| |patients with tombstoning ECG pattern tend to have reduced left ventricular dysfunction and higher in- hospital mortality. Thus they |
| |inferred that Tombstoning of the ST segment must be a grave prognostic sign in acute myocardial infarction. |
| |Wimalaratna6 in 1993, in a published letter has described about the tombstoning electrocardiographic pattern. He studied 100 |
| |consecutive patients with acute anterior wall myocardial infarction. 6 patients had tombstoning ECG pattern, all patients with this |
| |ECG pattern had 3 or more complications like hypotension, ventricular and supraventricular tachycardia ventricular ectopics of more |
| |than 15 per min, complete heart block or new development of bundle branch blocks and cardiogenic shock. Four patients died within 7 |
| |days. Only 16% patients with non Tombstoning ECG pattern had 2 or more complications and 2 patients died. He concluded that |
| |Tombstoning may be a sign of bad prognosis in patients with acute myocardial infarction. |
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| |aims of the Study: |
| |To study the correlation between Tombstoning ECG pattern in patients with first anterior wall acute myocardial infarction with left |
| |ventricular ejection fraction. |
|7. |materials and methods : |
| |7.1 Source of data: |
| |Patients admitted to intensive coronary care unit, KIMS Hospital, Hubli, during period of 1st of January 2009 to 31st of December |
| |2009, with first anterior wall myocardial infarction considering inclusion and exclusion criteria. |
| |7.2 methods of collection of data: |
| |Patients will be informed regarding the aim of study and consent will be taken. |
| |Information will be collected through prepared proforma from each patient. |
| |Complete clinical examination will be done. |
| |Admission ECG will be done for further evaluation. Tombstoning ECG is described by (as per Wimalaratna and Guo et al recommendations).|
| |R wave is either absent or if present duration of which is ................
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