Background Acute inferior myocardial infarction frequently involvesthe right ventricle. We hypothesized that right ventricularinvolvement, as diagnosed by ST-segment elevation in the rightprecordial lead V4R, may affect the prognosis of patients withinferior myocardial infarctions.
Methods In 200 consecutive patients admitted to the hospitalwith acute inferior myocardial infarctions, we assessed theprevalence and diagnostic accuracy of ST-segment elevation inlead V4R (as compared with four other diagnostic procedures)to identify right ventricular involvement and its prognosticimplications for in-hospital and long-term outcomes.
Results The in-hospital mortality after inferior myocardialinfarction was 19 percent, and major complications occurredin 47 percent of the patients. The presence of ST-segment elevationin lead V4R in 107 patients (54 percent) was highly predictiveof right ventricular infarction (sensitivity, 88 percent; specificity,78 percent; diagnostic accuracy, 83 percent), as compared withthe other diagnostic procedures. The patients with ST-segmentelevation in lead V4R had a higher in-hospital mortality rate(31 percent vs. 6 percent, P<0.001) and a higher incidenceof major in-hospital complications (64 percent vs. 28 percent,P<0.001) than did those without ST elevation in V4R. Multiplelogistic-regression analysis showed ST elevation in V4R to beindependent of and superior to all other clinical variablesavailable on admission for the prediction of in-hospital mortality(relative risk, 7.7; 95 percent confidence interval, 2.6 to23) and major complications (relative risk, 4.7; 95 percentconfidence interval, 2.4 to 9). The post-hospital course (follow-up,at least 1 year; mean follow-up, 37 months) was similar in patientswith and in those without electrocardiographic evidence of rightventricular infarction.
Conclusions Right ventricular involvement during acute inferiormyocardial infarction can be accurately diagnosed by the presenceof ST-segment elevation in lead V4R, a finding that is a strong,independent predictor of major complications and in-hospitalmortality. Electrocardiographic assessment of right ventricularinfarction should be routinely performed in all patients withacute inferior myocardial infarctions.
Despite the initial observation of serious hemodynamic consequencesof right ventricular infarction nearly two decades ago,1 thiscondition has received little clinical attention until recentyears2,3,4. Postmortem studies revealed that there is rightventricular involvement in 19 to 51 percent of patients withacute inferior myocardial infarctions5,6,7,8. Right ventricularinfarction contributes markedly to hemodynamic instability,atrioventricular conduction block, and in-hospital mortalityin patients with inferior myocardial infarctions3,4,9,10,11,12.However, simple diagnostic criteria that can be routinely appliedand shown to be of prognostic value remain to be identified2,3,4,13,14.
The diagnosis of right ventricular infarction can be made fromthe physical examination,3,15 echocardiography,3,15 first-pass16,17or equilibrium radionuclide9,18 ventriculography, technetiumpyrophosphate myocardial scanning,18,19 and hemodynamic measurements,3,15,20but right precordial electrocardiography21,22,23,24,25 is themost readily available, simplest, and most objective of thesetechniques26. The presence of acute ST-segment elevation,13,21,22,23,24,25,26,27,28,29,30,31Q waves, or both in the right precordial leads (V3R to V6R)13,24,29,32was found to be highly reliable in the diagnosis of right ventricularinfarction, as compared with the gold standard of hemodynamicassessment or autopsy3,26. A study by Andersen et al.27 suggestedthat ST-segment elevation in leads V3R through V6R is a usefulmarker of poor outcome after an inferior myocardial infarction.However, the prognostic effect of these criteria as comparedwith other clinical variables is uncertain.
In a prospective study of 200 consecutive patients with acuteinferior myocardial infarctions, we evaluated in-hospital andlong-term outcomes with regard to the presence or absence ofright ventricular infarction, as indicated by ST-segment elevationin the right precordial lead V4R.
Methods
Patients
From August 1985 through January 1990, we prospectively studied200 consecutive and consenting patients who were admitted toour institution with acute inferior myocardial infarctions diagnosedby typical chest pain lasting for more than 30 minutes, ST-segmentelevation of 0.1 mV in two or more of leads II, III, and aVF,and an increase in the serum creatine kinase level to more thantwice the normal value (>140 U per liter) less than 24 hoursafter admission. Patients were included in the study if chestpain had begun less than 24 hours before admission (mean [±SD]duration of pain, 6.1 ±4.6 hours; range, 0.5 to 23).The clinical data on the patients are presented in Table 1.
Table 1. Clinical Characteristics and In-Hospital Outcomes in 200 Consecutive Patients with Acute Inferior Myocardial Infarctions.
We considered thrombolytic therapy for every patient who presentedwith chest pain that had begun no more than six hours earlier,who was 75 years old or less, and who did not have contraindicationsto thrombolysis (Table 1). Coronary balloon angioplasty wasnot routinely performed after thrombolytic therapy.
Diagnostic Evaluation
Standard 12-lead electrocardiograms (with leads I through III,aVR, aVL, aVF, and V1 through V6) and right precordial electrocardiograms(V3R through V6R) were recorded immediately after admissionto the hospital. In the patients receiving thrombolytic therapy,electrocardiograms were obtained before the administration ofthe thrombolytic agent. The electrocardiograms were classifiedaccording to the Manhattan Code Criteria33. ST-segment deviationswere assessed 0.04 second after the J point in all 16 leads.Three consecutive QRS complexes were measured with the PQ levelused as the isoelectric line. ST-segment elevation of 0.1 mVin more than two leads of II, III, and aVF was considered tobe an indicator of infarction. The presence or absence of abnormalQ waves ( 0.04 second) was separately noted in leads II, III,and aVF and in the right precordial leads. All analyses wereperformed by a cardiologist unaware of the clinical status ofthe patient. ST elevation of 0.1 mV in lead V4R was chosenfor the prognostic analysis24,26,27,28,29,30,31. Other thanST-segment elevation in leads II, III, and aVF, no patient hadST-segment elevation in leads V1 through V3, 7 of 200 patients(4 percent) had ST-segment elevation in leads I, aVL, or both(none of 107 patients with ST-segment elevation in lead V4R,as compared with 7 of 93 patients without such elevation; P= 0.004), 44 of 200 patients (22 percent) had additional ST-segmentelevation in leads V4 through V6 (25 of 107 patients vs. 19of 93 patients, P = 0.73), and 46 of 200 patients (23 percent)had a tall R wave in leads V1 and V2 (26 of 107 patients vs.20 of 93 patients, P = 0.74).
The diagnostic accuracy of ST-segment elevation in lead V4Ras an indication of right ventricular infarction was determinedby (1) autopsy findings,3,13 (2) left and right ventriculographyand coronary angiography (with wall-motion abnormalities, occlusionor severe stenosis of the right coronary artery proximal tothe right ventricular branch, or both used as criteria),34 (3)technetium-99m pyrophosphate imaging (15 mCi of technetium-99mcoupled with 5 mg of stannous pyrophosphate; with focal uptakein projection to the right ventricle used as the criterion),9,19(4) invasive hemodynamic measurements (right atrial pressureequal or nearly equal to the pulmonary-capillary pressure ora severely noncompliant pattern [M- or W-shaped wave form forright atrial pressure, with a Y descent deeper than the X descent]was used as the criterion)3,20.
Hemodynamic measurements and technetium-99m pyrophosphate imagingwere considered only when they could be performed during theacute phase of myocardial infarction (within less than 24 hours),whereas coronary angiography and ventriculography were consideredwhen they could be performed during hospitalization. The sensitivity(the percentage of patients with right ventricular infarctionswho were identified correctly by ST-segment elevation in V4R),the specificity (the percentage of patients without right ventricularinfarction who did not have ST-segment elevation in V4R), andthe diagnostic accuracy of ST-segment elevation in V4R (thepercentages of patients with and without right ventricular infarctionwho were correctly identified by the presence or absence ofST-segment elevation in V4R) were calculated for each of thefour diagnostic tests. Overall diagnostic accuracy was calculatedby using the results of the first test administered in eachpatient according to the above sequence. These tests includedautopsy findings in 18 patients, angiographic and ventriculographicfindings in 112, technetium-99m pyrophosphate imaging in 37,and hemodynamic findings in 20. Thirteen patients in whom noneof the four tests could be performed adequately for variousreasons (such as early death or technical reasons) were excludedfrom this analysis.
Prognostic Assessment
In-hospital and long-term outcomes were studied for all patients.The prognostic effect of ST-segment elevation in lead V4R wasevaluated in relation to the clinical variables available atthe time of admission, including age, sex, maximal increasein creatine kinase, initial blood pressure, history of myocardialinfarction, use of thrombolytic therapy, ventricular fibrillationbefore hospitalization, and cardiogenic shock at the time ofadmission (systolic blood pressure below 90 mm Hg for more than30 minutes, with signs of impaired peripheral circulation and,in the case of right ventricular infarction, a lack of responseto volume loading, as well as a requirement for intravenouscatecholamines for hemodynamic support).
There was no attempt to standardize therapy. In patients withevidence of right ventricular infarction, volume loading wasthe therapy of choice, and nitrates were given only in the presenceof a pulmonary-capillary wedge pressure of 15 mm Hg or higher.Major in-hospital complications included ventricular fibrillation,sustained ventricular tachycardia (lasting more than 30 secondsor causing hemodynamic intolerance), cardiogenic shock, myocardialrupture, second-degree (Mobitz II) and third-degree atrioventricularblock requiring temporary or permanent cardiac pacing, and reinfarction.All complications were analyzed according to whether they occurredless than 24 hours after admission or at any time during thehospitalization.
All the patients were followed for at least one year. At theend of follow-up, 141 patients were still alive. The observationperiod ranged from 12 to 76 months (mean [±SD], 37 ±12).Information on vital status, including causes of death and follow-upevents (e.g., reinfarction, cardiac pacing, aortocoronary bypasssurgery, and percutaneous transluminal angioplasty) was obtainedfrom the patient, the general practitioner, or both by meansof a standardized questionnaire.
Statistical Analysis
Means ±SD were calculated for continuous variables, andabsolute and relative frequencies were measured for discretevariables35. Differences between groups were examined for statisticalsignificance by a two-sample t-test in the case of continuousvariables and by Fisher's exact test in the case of discretevariables. The independent effect of selected clinical variableson short-term mortality (during the first 24 hours and the entirehospitalization) as well as on short-term complications wasassessed with multiple logistic-regression analysis and estimatedas relative risks with corresponding 95 percent confidence intervals.The independent prognostic value of the clinical variables withrespect to long-term survival was assessed with use of a Coxproportional-hazards model applied to the patients' survivaltimes. From this model, survival rates were estimated afteradjustment for prognostic variables. The following variableswere included in the multivariate analyses: sex, age, historyof myocardial infarction, increase in creatine kinase levelto a value above 1000 U per liter, cardiogenic shock on admission,use of thrombolytic therapy, and the presence of ST-segmentelevation of 0.1 mV in lead V4R on admission. The statisticalsignificance of these variables in the multivariate models wasevaluated by Wald's test36. All tests of significance were two-tailed,and a P value of 0.05 was considered to indicate statisticalsignificance.
Results
In-Hospital Course of Acute Inferior Myocardial Infarction
At the time of admission, 22 of the 200 patients with acuteinferior myocardial infarctions (11 percent) had cardiogenicshock. A total of 38 patients died (19 percent), and 94 patients(47 percent) had major complications during hospitalization(Table 1). Most complications occurred less than 24 hours afteradmission; during this period, 13 patients (7 percent) diedof cardiac causes and 58 patients (29 percent) had major complications(Table 1).
Diagnostic Accuracy of ST-Segment Elevation in V4R for the Detection of Right Ventricular Infarction
ST-segment elevation in lead V4R on the first electrocardiogramobtained at the time of admission was observed in 107 patients(54 percent). As compared with autopsy, coronary angiographyand ventriculography, technetium-99m pyrophosphate imaging,and hemodynamic measurements, ST-segment elevation in V4R predictedright ventricular infarction with a sensitivity of 76 to 92percent, a specificity of 50 to 81 percent, and a diagnosticaccuracy of 78 to 87 percent (Table 2). When one of these testswas considered in each patient according to the sequence shownin Table 2, the overall diagnostic utility of ST-segment elevationin V4R was 88 percent (for sensitivity), 78 percent (for specificity),and 83 percent (for diagnostic accuracy).
Table 2. Diagnostic Accuracy of ST-Segment Elevation in Lead V4R as an Indicator of Right Ventricular Involvement in the Study Patients with Acute Inferior Myocardial Infarctions Who Underwent Any of Four Other Diagnostic Tests.
Prognostic Effect of the Right Precordial Leads
There was no difference with respect to sex, age, history ofmyocardial infarction, use of thrombolytic therapy, and incidenceof cardiogenic shock at the time of admission between the patientswith and those without ST-segment elevations of 0.1 mV in V4Ron the first in-hospital electrocardiogram (Table 3). However,the presence of ST-segment elevation of 0.1 mV in lead V4Ridentified a subgroup of patients with unfavorable clinicalcourses (Table 3). In the univariate analysis, ST-segment elevationin lead V4R was highly predictive of both early and overallin-hospital mortality (P<0.001) and any major complications(P<0.001), as well as of cardiogenic shock, ventricular fibrillation,third-degree atrioventricular block, and need for temporarypacing (Figure 1). Altogether, ST-segment elevation in leadV4R was associated with an in-hospital mortality of 31 percent,as compared with 6 percent in patients without such ST-segmentelevation (P<0.001), and it was associated with risks of64 and 28 percent, respectively, for major complications (P<0.001).By contrast, the presence or absence of ST-segment depressionin the left precordial leads (depression of 0.1 mV in two ormore of leads V1 through V5) was not associated with significantdifferences in mortality (22 percent vs. 14 percent, respectively)or with a higher complication rate (47 percent vs. 46 percent).When both criteria were considered together, the prognosticvalue was similar to that of ST-segment elevation in lead V4Ralone.
Table 3. Clinical Characteristics, Mortality, and Complications during Hospitalization after an Acute Inferior Myocardial Infarction, According to the Presence or Absence of ST-Segment Elevation in Lead V4R.
Figure 1. Mortality Rate and Prevalence of Major Complications during the First 24 Hours after Admission (Panel A) and the Entire Hospitalization (Panel B) among 200 Consecutive Patients with Acute Inferior Myocardial Infarctions, According to the Presence (Solid Bars) or Absence (Shaded Bars) of ST-Segment Elevation of 0.1 mV in Lead V4R.
The numbers above the bars are percentages of patients in each group. P values were determined by univariate analysis. NS denotes not significant.
Multivariate Analysis to Predict In-Hospital Course
A multivariate analysis of the clinical data that were availablewithin 24 hours after admission identified ST-segment elevationin V4R at the time of admission, cardiogenic shock, age greaterthan 70 years, and use of thrombolytic therapy as independentprognostic features for early in-hospital mortality, overallin-hospital mortality, or both (Table 4). Only ST-segment elevationin lead V4R and cardiogenic shock were independent predictorsof major complications. ST-segment elevation of 0.1 mV in leadV4R was most strongly associated with both mortality (relativerisk, 7.7; 95 percent confidence interval, 2.6 to 23) and majorcomplications (relative risk, 4.7; 95 percent confidence interval,2.4 to 9) (Table 4).
Table 4. Multivariate Analysis of the Prognostic Value of Clinical and Electrocardiographic Criteria for the Incidence of Death and Major Complications during Hospitalization.
Follow-up after Discharge from the Hospital
A total of 162 patients were discharged from the hospital. Medicationsprescribed at discharge did not differ significantly accordingto whether the patients had right ventricular infarctions oraccording to whether they had had in-hospital complications.During 37 ±12 months of follow-up, 21 patients died (13percent). The mean annual mortality rate was 4.2 percent, andthis rate was highest (6.8 percent) in the first year afterinfarction. Seventeen patients died of cardiac causes, and fourpatients of noncardiac causes. Twenty-one patients (13 percent)had nonfatal reinfarctions. Forty-six patients (28 percent)required aortocoronary bypass surgery, percutaneous transluminalangioplasty, or both. Seven patients required permanent cardiacpacing 3.2 ±3 months after discharge from the hospital.
Cox regression analysis showed that only age and a history ofmyocardial reinfarction were associated with increased mortalityafter discharge from the hospital. In addition, ST-segment elevationin lead V4R during the acute phase of inferior myocardial infarctionwas predictive of a later requirement for permanent pacing (P= 0.048). Cox regression analysis was also used to estimatethe overall survival distribution of patients with and withoutright ventricular infarction after adjustment for the otherimportant prognostic variables (Figure 2).
Figure 2. Estimated Probabilities of Survival for All 200 Patients with Acute Inferior Myocardial Infarctions over a Six-Year Follow-up Period.
The mean follow-up was 3.1 ±1 years. Survival rates are stratified according to the presence or absence of right ventricular infarction as predicted by ST-segment elevation of 0.1 mV in lead V4R at the time of admission, after adjustment for all other important prognostic variables. The numbers at the bottom of the graph are the numbers of patients in each group who were at risk at each time point.
Discussion
Our consecutive series of patients with acute inferior myocardialinfarctions had an in-hospital mortality of 19 percent and a47 percent incidence of major complications (e.g., cardiogenicshock, ventricular fibrillation, and high-degree atrioventricularconduction block). ST-segment elevation of 0.1 mV in V4R, shownto be a reliable diagnostic criterion for right ventricularinfarction, was present in half the patients with inferior myocardialinfarctions and was the most accurate independent prognosticindicator of the in-hospital course. The presence of right ventricularinfarction increased in-hospital mortality from 5 to 31 percent(P<0.001), and the rate of major complications rose from28 to 64 percent (P<0.001).
Prognosis of Acute Inferior Myocardial Infarction
Inferior myocardial infarction is usually considered to havea better prognosis in both the short and the long term thananterior myocardial infarction10,11. Recent studies of inferiormyocardial infarction, however, evaluated a selected populationof patients suitable for thrombolytic therapy, including 9 to38 percent of the patients screened37,38. Pooled data on thecontrols in nine of these studies indicate an in-hospital mortalityof 8.6 percent and a 50 percent risk of in-hospital complications37.Both mortality rates and in-hospital complication rates increasedmarkedly in the 60 to 80 percent of patients not suitable forthrombolytic therapy37,38,39,40. In our series of consecutivepatients, two thirds of those with inferior myocardial infarctionshad contraindications to thrombolytic therapy, and these patientsaccounted for a substantial proportion of the high overall in-hospitalmortality. Among the 36 percent who were suitable for thrombolytictherapy, in-hospital mortality was 7 percent, but this figureincreased by more than three times among the patients who werenot candidates for thrombolytic therapy.
Risk stratification of patients with acute inferior myocardialinfarctions has been assessed by others4,37,41. Because therapeuticinterventions are most effective when applied early, readilyassessable clinical features of prognostic importance are neededat the time of admission to the hospital. In this study, multivariateanalysis revealed the absence of right ventricular infarctionas diagnosed by ST-segment elevation in lead V4R, age of lessthan 70 years, the absence of cardiogenic shock on admission,and the use of thrombolytic therapy to be predictive of lowerin-hospital mortality. Only the absence of right ventricularinfarction and the absence of cardiogenic shock on admissionpredicted, in addition, a lower rate of major in-hospital complications.
The electrocardiogram, which is readily available, simple, andobjective, has been used to relate infarct size to prognosis.Bates et al.42 found that precordial ST-segment depression predicteda poor prognosis in inferior myocardial infarction, even whenreperfusion therapy was used. Other studies have also confirmedan unfavorable clinical course when electrocardiographic criteriasuggested a larger infarction and, as a consequence, more extensiveleft ventricular dysfunction9,41,43,44,45. The role of rightventricular infarction, however, has been studied less extensively.
Diagnostic Accuracy of ST Elevation in V4R for Right Ventricular Infarction
Right ventricular infarction complicates about 50 percent ofacute inferior myocardial infarctions2,3,4,15,26. ST-segmentelevations and Q waves in the right precordial leads (V3R throughV6R) have previously been shown to have a diagnostic accuracyfor right ventricular infarction greater than 80 percent26 orgreater than 90 percent22,30. In the present study, four diagnosticprocedures,3 including autopsy,13 coronary angiography and ventriculography,34technetium-99m pyrophosphate imaging,18,19 and hemodynamic measurements,20were considered to assess the accuracy of ST-segment elevationin lead V4R in the diagnosis of right ventricular infarction.Diagnostic accuracy was found to be well above 85 percent forST-segment elevation in lead V4R as assessed by the first threetests, whereas previously recommended criteria for hemodynamicmeasurements resulted in a diagnostic accuracy of only 78 percent.The overall diagnostic accuracy was calculated by using theresult of one test per patient in the sequence given above.Thus, ST-segment elevation in lead V4R had an overall sensitivityof 88 percent, a specificity of 78 percent, and a diagnosticaccuracy of 83 percent for the diagnosis of right ventricularinvolvement during acute inferior myocardial infarction.
Prognostic Effect of Right Ventricular Involvement during Acute Inferior Myocardial Infarction
The prognostic effect of electrocardiographic criteria for rightventricular infarction is uncertain. The studies by Andersenet al.27 and Rodrigues et al.14 described fewer than 50 patientswith right ventricular infarctions, but they strongly suggestedthat right precordial ST-segment elevation is a marker for theprognosis.
The present study confirms these observations in a larger numberof patients. ST-segment elevation in V4R was shown to be a strongindependent prognostic marker and superior to the other clinicalvariables that were assessed at the time of admission to thehospital. Patients with ST-segment elevation in V4R had a 12percent risk of death and a 43 percent risk of major complicationsduring the first 24 hours in the hospital. In the absence ofST-segment elevation, no patients died during this period, andthe complication rate was more than two times lower. As comparedwith all clinical variables available at the time of admission,right ventricular infarction was associated with a relativerisk of in-hospital mortality of 7.7 (95 percent confidenceinterval, 2.6 to 23) and a risk of major in-hospital complicationsof 4.7 (95 percent confidence interval, 2.4 to 9). Ultimately,95 percent of patients without evidence of right ventricularinfarction at the time of admission were discharged from thehospital, as compared with only 69 percent of those in whomright ventricular infarction complicated the acute inferiormyocardial infarction.
The prognostic effect of right ventricular infarction was independentof and superior to the precordial ST-segment depression frequentlyused to indicate a larger area of left ventricular infarction42.When patients with and those without right ventricular infarctionswere compared, the left ventricular ejection fractions did notdiffer between the two groups. Therefore, during an acute inferiorinfarction, not only the size but also the location of the infarctzone (left vs. right ventricle) is of major prognostic interestand should be considered a guide to aggressive treatment strategies.
Prognostic Importance of Right Ventricular Involvement for Long-Term Survival
The long-term prognosis of patients with right ventricular involvementduring inferior myocardial infarctions is unknown4. In patientswith inferior myocardial infarctions, whether complicated byright ventricular involvement or not, annual mortality was foundto be 4.2 percent overall and 6.8 percent during the first year.In the only study providing similar data on a small group ofpatients with right ventricular infarctions, annual mortalitywas 4 percent during a 1.8-year follow-up27. Except for advancedage and a history of myocardial reinfarction, none of the clinicalor electrocardiographic criteria evaluated by Cox regressionanalysis were of prognostic importance for the clinical courseafter the patient survived the in-hospital phase. Right ventricularinfarction, however, was predictive of a later requirement forpermanent pacing.
Limitations of the Electrocardiogram in the Diagnosis of Right Ventricular Infarction
The use of ST-segment elevation in lead V4R for the diagnosisof right ventricular infarction is known to lose specificityin the presence of any heart disease that may induce ST-segmentelevation in lead V1, such as pericardial disease, acute pulmonaryembolism, left anterior fascicular block, and acute anteriormyocardial infarction (present in 10 percent of patients withright ventricular involvement8). The diagnostic accuracy ofright precordial ST-segment elevation is considered to be greatestduring the first 10 hours after an acute infarction, which underscoresthe need for an electrocardiographic assessment as soon as possibleafter admission to the hospital26,46.
Clinical Implications
Involvement of the right ventricle in acute inferior myocardialinfarction is common, and the early recognition of this involvementhas important prognostic implications. Right ventricular infarctioncan be diagnosed accurately on the basis of an ST-segment elevationof 0.1 mV in the right precordial leads (e.g., lead V4R) soonafter the onset of infarction, and this elevation indicatesa significantly increased risk of major complications and in-hospitaldeath.
We are indebted to Drs. Frank Marcus, L. Frye, and William Stevensonfor their critical comments on the study protocol and data interpretationbefore the submission of the manuscript for review.
Source Information
From the Abteilung fur Kardiologie, Innere Medizin III (M.Z., W.K., E.K., M.S., A.G., H.J.), and the Abteilung fur Medizinische Biometrie und Informatik (M.O.), Universitatsklinik Freiburg, Freiburg, Germany.
Address reprint requests to Dr. Zehender at Innere Medizin III, Universitatsklinik Freiburg, Hugstetterstr. 55, 78 Freiburg, Germany.
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Single-Drug Therapy for Hypertension in Men
Johnston G. D., Pettinger W. A., Lee H.-C., Paulshock B. Z., Materson B. J., Reda D. J., Cushman W. C., Rouse C. F.
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0.1 mV in two or more of leads II, III, and aVF, and an increase in the serum creatine kinase level to more than twice the normal value (>140 U per liter) less than 24 hours after admission. Patients were included in the study if chest pain had begun less than 24 hours before admission (mean [±SD] duration of pain, 6.1 ±4.6 hours; range, 0.5 to 23). The clinical data on the patients are presented in Table 1. 
0.05 was considered to indicate statistical significance. 
