showed that STE (measured 80 ms after the J point) was more com- mon during early evaluation, and that 60% of the episodes were as- sociated with periods of increased heart rate (arbitrarily defined as an increase in 10 beats/min above the adjacent base line). They found that the mortality rate tended to be higher in patients with STE, but STE was too infrequent to be a valuable prognostic indicator. More recently, Mickley et aL4 in a long-term follow-up study of post-AM1 patients, reported an an association between episodes of STE and (1) cardiac deaths, and (2) cardiac death and nonfatal reinfarction. STE did, however, not correlate with different indi- cators of myocardial ischemia. Cinca et al5 showed, in an animal model, that acute ischemia adja- cent to a chronic infarction in- duces STE at the surface of the scar. The magnitude of STE is, however, lower than that induced by myocardial ischemia not adja- cent to a necrosis.

As we clearly stated ( “study limitations” paragraph), ’ we could not confirm the hypothesis that STE represented myocardial ischemia. The achievement of this issue dur- ing ambulatory monitoring is al- most impossible. What we clearly demonstrated, was a statistical as- sociation between the presence of STE (measured from the J point and using the “24-hour” median as ref- erence line) and mortality. STE oc- curred in 4 of 18 (22%) versus 3 of 56 (5%) patients dying/surviving, p = 0.03. This association was stronger when either ST-segment deptession or STE was present: 14 of 18 (78%) versus 16 of 56 (29%) pa- tients dying/surviving, p = 0.0002.

In our study, leads showing pathologic Q waves or rS com- plexes were excluded from the anal- ysis, indicating that the VI-like lead (usually characterized by an rS complex) was excluded for evalu- ation of STE. STE was therefore di- agnosed in a Vs-like lead. All pa- tients, but 2, presented with ST-segment depression in a Vs-like lead (in those patients, the QRS complex showed an R wave >25% of S wave). STE was, in addition, analyzed according to the com-

monly used criteria (shifts ~0.1 mV measured 80 ms after the J point from the reference baseline). No association was found between cardiac events and its presence (un- published data).

Langer also expresses concern with respect to the studied popula- tion. Ambulatory monitoring was performed 4 + 2 days after hospital arrival. All patients met intemation- ally accepted criteria for diagnosing AM1 (chest pain during >30 minutes accompanied by electro- cardiographic changes and/or en- zyme alterations). Additional de- tails of the studied group are published elsewhere.6

Langer has absolutely misin- terpreted the survival curves (Fig- ure 3) of our report.’ The mortal- ity rates reported at 1 month, 1 year, and at the end of follow-up period were as follows: 8% (6 of 74), 12% (9 of 74), and 24% (18 of 74), respectively. These fig- ures, although somewhat higher than those reported by the GISSI and GUSTO megatrials,‘p8 are in accordance with those shown by the TRACE trial.g In that study, the l-year mortality in the entire screened group was 23%. The l-year mortality reported in the GUSTO and GISSI trials’~* only represented the mortality of randomized patients. What Langer surely means is that the l-month and 1 -year mortality rates in the group of patients showing ST- segment depression/STE were ap- proximately 20% and 30%. This is correct and stresses the necessity to investigate more invasively patients showing these characteristics.

In the present study,’ the pa- tients’ attending physicians were unaware of the results of ambula- tory monitoring. A noninvasive risk stratification was done by means of known clinical risk pre- dictors and by means of a predis- charge exercise test. These results are under publication elsewhere.” The patient approach during risk stratification was conservative ow- ing to limited technical resources. This was evidenced by the low rate of referrals to coronary angiog- raphy (39%). This fact does not make the results of the study less generalizable. On the contrary, they emphasize the prognostic value of

the ST-segment changes detected with the new criteria and encourage the attending physicians to investi- gate more aggressively and treat these patients in order to avoid poor prognoses.

MigUd QUinbnO, MD Stockholm, Sweden

20 October 1995

I. Quintana M, Lindvall K, Brolund F. Assessment and significance of ST-segment changes detected by ambulatory electrocardiography after acute myocar- dial infarction. Am J Cardiol 1995;76:6- 13. 2. Fisch C. Electrocardiography and vectorcardiog- raphy. In Braunwald E. ed. Heart Disease. A text- book of Cardiovascular Medicine. Philadelphia: WB Saunders, 1992:116- 160. 3. Currie P, Salt&i S. Significance of ST-segment elevation during ambulatory monitoring after acute myocardial infarction. Am Heart J 1993;125:41- 47. 4. Mickley H, Nielsen JR, Beming J, Junker A, Moller M. Characteristics and prognostic impor- tance of ST-segment elevation on Halter monitoring early after acute myocardial infarction. Am J Car- diol 1995;76:537-542. 5. Cinca J, Bardaji A, Carrerio A, Mont Ll, Bosch R, Soldevilla A, Tapias A, Soler-Soler J. ST seg- ment elevation at the surface of a healed transmural myocardial infarction in pigs. Conditions for pas- sive transmission from the ischemic p&infarction zone. Circu2arion 1995;91:1552- 1559. 6. Quintana M, Lindvall K, Carlens P, Bevegtid S, Brolund F. ST-segment depression on ambulatory electrocardiography in the early in-hospital period after acute myocardial infarction predicts early and late mortality: a short-term and a 3-year follow-up study. Clin Cardiol 1995;18:392-340. 7. Gruppo Italiano per lo Studio della Streptochinasi nell’Infsrt0 miocardico (GISSI). Long-tetm effects of intravenous thrombolysis in acute myocardial in- farction: final report of the GISSI study. Lancer 1987;2:872-874. 8. Califf RM, Top01 EJ, Van de Werf F, Lee KL, Woodlief L. One year follow-up from the GUSTO- I trial (abstr). Circulation 1994;90 (suppl I):I- 325. 9. Keber L, Torp-Pedersen C. On behalf of the TRACE study. Clinical characteristics and mortality in patients screened for entry into the trandalopril cardiac evaluation (TRACE) study. Am J Cardiol 1995:76:1-5. IO. Quintana M, Lindvall K, Brolund F, Eriksson SV, Ryddn L. Prognostic value of exercise stress test versus ambulatory electrocardiography after acute myocardial infarction: a three-year follow-up study. Coronary Artery Disease; in press.

Short-Coupled Variant of Torsades De Pointes With Normal QT Interval and Risk of Sudden Death

I read with interest the report by Eisenberg and associates’ of 15 patients with polymorphic ven- tricular tachycardia, normal QT interval, and sudden death. How- ever, this electrocardiographic en- tity is not new and has been de- scribed before by the French in- vestigators under a different name.’ Leenhardt and associates,’ in 1994, reported 14 patients with

1028 THE AMERICAN JOURNAL OF CARDIOLOGY” VOL. 77 MAY 1, 1996

this electrocardiographic entity in the spectrum of idiopathic ventric- ular tachyarrhythmias without prolonged QT interval or struc- tural heart disease and called it the short-coupled variant of torsades de pointes.

All of the French patients had a strong family history of sudden death; 1 of the 14 patients died suddenly after a follow-up of 24 months. It is important to identify this variant of torsades de pointes, irrespective of what it is called, because of the characteristic elec- trocardiographic pattern and the risk of sudden death in young adults with normal QT interval and no structural heart disease.

Tsung 0. Cheng, MD Washington, D.C.

7 April 1995

1. Eisenberg SJ, Scheimnan MM, Dullet NK, Fink- beiner WE, Griffin JC, El& M, Franz MR, Gonzalez R, Kadish AH, Lesh MD. Sudden cardiac death and wlvmomhous ventricular tachveardia in oatients with normal QT intervals and normal systolic cardiac func tion. Am .I Cardiol 1995;75:687-692. 2. Leenhardt A, Glaser E, Bqwa M, Numberg M, Maison-Blanche P, Coumel P. Short-coupled variant of torsades de pointes. A new elec@ocardiographic en- tity in the spectrum of idiopathic ventricular tachyx- rhythmias. Circulation 1994;89:206-215.

Conservative Versus Invasive Strategy for Non-Q-Wave Acute Myocardial Infarction

Lotan et al ’ performed a retro- spective study of 110 patients with non-Q-wave anterior myocardial infraction comparing the long-term prognosis of a group treated by an “early invasive” versus a “con- servative’ ’ strategy. The invasive group underwent in-hospital cath- eterization followed by revascular- ization, if needed. The conserva- tive group consisted mostly of pa- tients admitted to 1 of 2 hospitals without angioplasty capabilities. The authors report that an “early invasive approach resulted in a sig- nificant decrease in major events” (defined as recurrent myocardial infarction, angina pectoris, mortal- ity, and congestive heart failure). The authors conclude that early catheterization, as opposed to a “true conservative” approach, should be recommended in pa- tients with non-Q-wave anterior myocardial infarction.

I find it difficult to accept that these patients were offered “true conservative therapy.” Conser- vative postmyocardial infarction therapy is generally accepted to mean cardiac catheterization in the setting of spontaneous or in- duced postmyocardial infarction ischemia. This was the definition of conservative treatment in the Thrombolysis in Myocardial In- farction IIIb (TIM1 IIIb) study (which the authors cite for com- parison). However, Lotan et al report that 20% of the patients in their conservative group had evidence of recurrent in-hospital chest pain, and 11% had electro- cardiographic changes. Why were these patients not offered early an- giography? The authors do not state the percentage of “conser- vatively’ ’ treated patients who had evidence of ischemia on their predischarge exercise tests, or whether such studies were routinely performed. Thus, a substantial number of these pa- tients should have received pre- discharge cardiac catheterization using a conventional ‘ ‘conserva- tive” strategy. It is not surprising that if angiography and subse- quent revascularization are with- held in postmyocardial infarction patients with evidence of sponta- neous or induced ischemia, poorer outcomes will result.

Mark J. Soda, MD Long Beach, California

17 October 1995

1. Lotan CS. Jonas M, Rozenman Y. Mosseri M, Benhorin J, Rudnik L, Hasin Y, Go&man MS. Com- parison of early invasive and conservative treat- ments in patients with anterior wall non-Q-wave acute myocardial infarctions. Am J Cardiol 1995;76:330-336. 2. The TIMI IIIB Investigators. Effects of tissue plas- minogen activator and a comparison of early invasive and conservative strategies in unstable angina and non- Q-wave myocardial infarction. Results of the TIMI- 1 llb trial. Circulation 1994;89:1545-1556.

REPLY: Dr. Sada raises the intriguing question of what a true “conservative approach” in the treatment of pa- tients with non-Q-wave myocardial infarction means. The patients in our study were recruited from 3 different hospitals (community as well as ter- tiary centers), which, in our mind, represent the ‘ ‘average’ ’ common practice in patients with non-Q-

wave infarction.’ The retrospective categorization of “invasive’ ’ versus “conservative” was done solely on the basis of whether the patient un- derwent in-hospital catheterization- a decision made at the discretion of the treating physicians. As already noted by Dr. Sada, 20% of patients in the conservative group experience recurrent chest pain. Nevertheless, as their condition improved, the treating physician did not feel that in-hospital catheterization was mandatory. Sub- sequently, 36% of patients in the con- servative group underwent coronary arteriography, most of them, during the first month after discharge.

It is difficult to compare our re- sults or any “common practice” re- sults with the TIM1 Illb study, in which all patients were treated un- der strict protocols2 However, it was surprising that in a very heter- ogenous group of patients with un- stable angina and non-Q-wave myocardial infarction in various locations, 64% of patients in the “conservative group” required catheterization. Unfortunately, the TIM1 investigators didn’t provide subgroup analyses. It seems reason- able to assume that in the high-risk group of patients with non-Q-wave anterior myocardial infarction (ap- proximately 10% of patients hos- pitalized for myocardial infarc- tion), the number of patients who may require catheterization accord- ing to the TIM1 Illb criteria would be significantly larger, thus raising the question of whether we can still call it a “true conservative ap- proach.” Furthermore, it raises the question of whether predischarge noninvasive tests are necessary and cost-effective in this subgroup of patients, since a most patients in this group will subsequently require with coronary arteriography.

Based on our results and the findings in the TIM1 Illb study,. we believe that early coronary angiog- raphy is justified in all patients with anterior non-Q-wave myocardial infarction, provided comorbid con- ditions adding to the risk of the pro- cedure do not exist.

Chaim ban, MD Jerusalem, Israel

27 November 1995

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