Akut ST Yükselmeli Miyokart İnfarktüsü Hastalarında Magnezyum Tedavisi ve P Dalga Dispersiyonu

Yıl 2015, Cilt: 12 Sayı: 2, 220 - 229, 30.08.2015

Mehmet Baran Karataş , Barış Güngör , Ender Özgün Çakmak Göktürk İpek Tolga Onuk , İbrahim Halil Altıparmak Kazım Serhan Özcan , Yiğit Çanga , Gündüz Durmuş Osman Bolca

Öz

Amaç: Miyokard infarktüsünün (MI) akut fazında gelişen atriyal fibrilasyon (AF) hastane içi ve sonrasında
uzun dönemdeki mortalitenin önemli göstergelerinden biridir. Bu çalışmanın amacı, primer perkütan
koroner girişim uygulanmış akut anterior ST yükselmeli miyokard infarktüsü hastalarında MgSO4
infüzyonunun en uzun p dalga süresi( Pmax ), en kısa p dalga süresi( Pmin ) , p dalga dispersiyonu (Pdd) ve
bunun AF ile ilişkisi üzerine etkisini araştırmak olarak belirlenmiştir.
Metod: Çalışmaya akut anterior ST yükselmeli miyokard infarktüsü tanısıyla hastaneye yatırılan ve primer
perkütan koroner girişim uygulanmış 55 hasta ( yaş ortalaması 55.1 ± 6.7 ) ile kontrol grubu olarak 47
normal birey ( yaş ortalaması 54.1 ± 7.2 ) prospektif olarak alındı. Bütün hastaların demografik ve klinik
özellikleri kaydedildi. Hasta grubunda Mg tedavisi uygulanan 25 hasta ile Mg tedavisi uygulanmayan 30
hastanın, başvuru sırasında ve PKG sonrası 5.saatte elektrokardiyografileri çekilerek Pmax, Pmin ve Pdd
süreleri ölçüldü.
Bulgular: Akut MI hastalarında Pmax. ve Pdd, kontrol grubuna göre daha yüksek bulundu ( sırasıyla 118.7 ±
6.3 msn vs. 107.1 ± 3.4 msn, p = 0.01 ve 40.5 ± 4.8 msn vs. 30.2 ± 3.3 msn; p = 0.01). Magnezyum tedavisi
alan hastaların PKG sonrası 5.saat EKG'sindeki Pmax. ve Pdd değerleri, başvuru EKG'sine göre
karşılaştırıldığında anlamlı olarak daha düşük saptandı ( sırasıyla 121.4 ± 7.1 vs. 109.6 ± 4.1 msn, p= 0.01 ve
41.3 ± 4.7 vs 30.7 ± 2.9 msn, p = 0.01). Magnezyum tedavisi almayan hastaların ise PKG sonrası 5.saat EKG'
sindeki sadece Pmax değeri başvuru EKG' sine göre anlamlı olarak düşük bulundu (116.6 ± 4.7 vs 114.7 ± 4.2
msn, p = 0.04). Tedavi sonrası Pdd azalışı, Mg (+) grupta Mg (-) gruba göre anlamlı olarak daha yüksek
saptandı ( 10.6 ± 5.1 vs 2.1 ± 1.4 msn, p = 0.01). Sonuç: Akut anterior MI nedeniyle primer PKG uygulanan hastalarda Mg tedavisi Pdd' da belirgin azalma
sağlamaktadır. Bu sonuç, özellikle AF gelişme riski yüksek olan hasta grubunda Mg tedavisinin yararlı
olabileceğine işaret etmektedir.

Anahtar Kelimeler

Akut anterior STyükselmeli miyokard infarktüsü, Magnezyum, Pdalga dispersiyonu

Magnesium Treatment and P wave Dispersion in Patients with Acute ST Elevation Myocardial Infarction

Öz

Backgrounds: Atrial fibrillation (AF) occuring in the acute phase of Myocardial Infarction (MI) is an
important predictor of in- hospital and long-term mortality. The aim of this study is to investigate the effect of
MgSO4 therapy on the maximum P wave duration(P max), minimum P wave duration (Pmin), P wave
dispersion (PWD) and its relationship with AF in acute anterior ST-segment elevation myocardial infarction
(STEMI) patients treated with primary percutaneous coronary interventions (PCI).
Methods: Fifty-five patients (mean age 55.1 ± 6.7) who were hospitalized with diagnosis of STEMI and 47
normal individuals (mean age 54.1 ± 7.2 years) were prospectively enrolled. Percutaneous coronary
intervention was performed to all MI patients with conventional methods. All patients' demografic and
clinical features were recorded. In STEMI patients group, admission and fifth-hour electrocardiographic
parameters (Pmax, Pmin, PWD) were measured in patients with Mg therapy(n=25) and patients without Mg
therapy(n=30).
Results: Pmax and PWD values were higher in acute MI patients than the control group. (118.7 ± 6.3 msn vs.
107.1 ± 3.4 msn, 40.5 ± 4.8 msn vs. 30.2 ± 3.3 msn; p = 0.01 and p = 0.01, respectively ). In Mg(+) group,
Pmax and PWD values were significantly lower on fifth-hour ECGs compared to admission ECGs( 121.4 ±
7.1 vs 109.6 ± 4.1 msn, 41.3 ± 4.7 vs 30.7 ± 2.9 msn, p = 0.01 and p = 0.01). In Mg(-) group , only Pmax
values were significantly lower on fifth-hour ECGs compared to admission ECGs(116.6 ± 4.7 vs 114.7 ± 4.2
msn, p = 0.04). PWD decrease after treatment was significantly higher in Mg (+) group than Mg (-) group (
10.6 ± 5.1 vs 2.1 ± 1.4 msn, p = 0.01).
Conclusions: Mg treatment causes significant reduction in PWD values in patients with acute anterior STelevation
MI after primary PCI. This result suggests that Mg treatment may be useful especially in high-risk
patients in terms of developing AF.

Anahtar Kelimeler

Acute anterior ST-elevation myocardial infarction, Magnesium, Pwave dispersion

Kaynakça

• 1- Kannel WB, Abbot RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med. 1982; 306: 1018- 1022 2- Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ. Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation 2000; 101: 969- 074. 3- Crenshaw BS, Ward SR, Granger CB, Stebbins AL, Topol EJ, Califf RM. Atrial fibrillation in the setting of acute myocardial infarction: the GUSTO-I experience. Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries. J Am Coll Cardiol. 1997; 30: 406-413. 4- Goldberg RJ, Seeley D, Becker RC, Brady P, Chen ZY, Osganian V. Impact of atrial fibrillation on the inhospital and long-term survival of patients with acute myocardial infarction: a community-wide perspective. Am Heart J. 1990; 119: 996-1001 5-Dilaveris PE, Andrikopolus GK, Metaxas G, Richter DJ, Avgeropoulou CK, Androulakis AM et al. Effects of ischemia on P wave dispersion and maximum P wave duration during spontaneous anginal episodes. Pacing Clin Electrophysiol. 1999; 22: 1640-1647. 6- Levy D, Peter W, Wilson F. Atherosclerotic Cardiovascular Disease. Textbook of Cardiovascular Medicine. In Topol EJ (ed). Philadelphia, LippincottRaven Publishers, 1998; pp.14. 7-Dawber TR, Moore FE, Mann GV. Coronary heart disease in the Framingham study. Am J Public Health Nations Health. 1957; 47: 4-24. 8-Sugiura T, Iwasaka T, Koito H, Kimura Y, Inada M, Spodick DH. Supraventricular arrhythmias in the late hospital phase of acute Q-wave myocardial infarction. Supraventricular arrhythmia in myocardial infarction. Chest 1987; 92: 282-286. 9-Dilaveris PE, Gialafos EJ, Sideris SK, Theopistou AM, Andrikopoulos GK, Kyriakidis M et al. Simple electrocardiographic markers for prediction of idiopathic paroxysmal atrial fibrillation. Am Heart J. 1998; 135: 733-738. 10-Tukek T, Yildiz P, Akkaya V, Karan MA, Atilgan D, Yilmaz V et al. Factors associated with the development of atrial fibrillation in COPD patients; the role of P - wave dispersion. Ann Noninvasive Electrocardiol. 2002; 7: 222- 227. 11-Ozer N, Aytemir K, Atalar E, Sade E, Aksöyek S, Ovünç K et al. P wave dispersion in hypertensive patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2000; 23: 1859-1862. 12-Aytemir K, Ozer N, Atalar E, Sade E, Aksöyek S, Ovünç K et al. Pwave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation.. Pacing Clin Electrophysiol. 2000; 23: 1109-1112. 13-Ozmen F, Atalar E, Aytemir K, Ozer N, Açil T, OvünçK et al. Effect of balloon-induced acute ischaemia on P wave dispersion during percutaneous transluminal coronary angioplasty. Europace 2001; 3: 299-303. 14-Kidwell GA, Chung MK. Atherosclerosis and Coronary Artery Disease. Philadelphia, Lippincott-Raven. 1996; 995- 1012. 15-Wesley RC Jr, Haines DE, Lerman BB, DiMarco JP, Crampton RS. Effects of intravenous magnesium sulfate on supraventricular tachycardia. Am J Cardiol. 1989; 63: 1129- 1131. Cybulski J, Budaj A, Danielewicz H, Maciejewicz J, Ceremuzynski L. 16- A new-onset atrial fibrillation: the incidence of potassium and magnesium deficiency. The efficacy of intravenous potassium/magnesium supplementation in cardioversion to sinus rhythm. Kardiol Pol. 2004; Jun;60(6):578-81 17-Wan-Jie Gu, Zhen-Jie Wu, Peng-Fei Wang, Lynn Htet Htet Aung, Rui-Xing Yin. Intravenous magnesium prevents atrial fibrillation after coronary artery bypass grafting: a metaanalysis of 7 double-blind, placebocontrolled, randomized clinical trials. Gu et al. Trials 2012, 13:41 18-Toraman F, Karabulut EH, Alhan HC, Dagdelen S, Tarcan S. Magnesium infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg. 2001;72:1256-1262. 19-Rosiak M, Bolinska H, Ruta J. P wave dispersion and P wave duration on SAECG in predicting atrial fibrillation in patients with acute myocardial infarction. Ann Noninvasive Electrocardiol. 2002; 7: 363-368. 20-Celik T, Iyisoy A, Kursaklıoglu H, Kilic S, Kose S, Amasyali B et al. Effects of primary percutaneous coronary intervention on P wave dispersion. Ann Noninvasive Electrocardiol. 2005;Jul 10(3):342-7 21-Fazekas T, Scherlag BJ, Vos M, Wellens HJ, Lazzara R. Magnesium and the heart: antiarrhythmic therapy with magnesium. Clin Cardiol. 1993;16:768-774. 22-Schotten U, Verheule S, Kirschhof P, Goette A. Pathophysiological mechanism of atrial fibrillation-a translational appraisal. Physio Rev 2010 . 23-Kulick DL, Hong R, Ryzen E, Rude RK, Rubin JN, Elkayam U et al. Electrophysiologic effects of intravenous magnesium in patients with normal conduction systems and no clinical evidence of significant cardiac disease. Am Heart J. 1988;115:367-73. 24-Frick M, Darpo B, Ostergren J, Rosenqvist M. The effect of oral magnesium, alone or as an adjuvant to sotalol, after cardioversion in patients with persistent atriyal fibrillation. Eur Heart J. 2000;21:1177-1185. 25-Abraham AS, Eylath U, Weinstein M, Czaczkes E. Serum magnesium levels in patients with acute myocardial infarction. N Engl J Med. 1997; 296: 862- 863. 26-Flink EB, Brick JE, Shane SR. Alterations of long chain free fatty acid and magnesium in acute myocardial infarction. Arch Intern Med. 1981;141:441-443. 27-Roffe C, Fletcher S, Woods KL. Investigation of the effects of intravenous magnesium sulphate on cardiac rhythm in acute myocardial infarction. Br Heart J. 1994;71:141-145. 28-Rasmussen HS, Gronbaek M, Cintin C, Balsløv S, Nørregård P, McNair P. One-year death rate in 270 patients with suspected acute myocardial infarction, initially treated with magnesium and placebo. Clin Cardiol. 1998;11:377-381. 29-Ravn HB, Vissinger H, Kristensen SD. Magnesium inhibits platelet activity - an in vitro study. Thromb Haemost. 1996;76:88-93. 30-Tzivoni D, Keren A, Cohen AM, Loebel H, Zahavi I, Chenzbraun A et al. Magnesium therapy for torsades de pointes. Am J Cardiol. 1984;53:528-530. Khalil MA 31-Al-Agaty AE, Ali WG, Abdel Azeem MS. A comparative study between amiodarone and magnesium sulfate as antiarrhythmic agents for prophylaxis against atrial fibrillation following lobectomy. J Anesth. 2013 Feb;27(1):56-61. 32-Rasmussen HS, Suenson M, McNair P, Norregard P, Balsey S. Magnesium infusion reduces the incidence of arrhythmias in acute myocardial infarction. A double-blind placebo-controlled study. Clin Cardiol. 1987;10:351-356. 33-Abigail May Khan, Steven A. Lubitz, Lisa M. Sullivan, Jenny X. Sun, Daniel Levy, Ramachandran S. et al. Low Serum Magnesium and the Development of Atrial Fibrillation in the Community: The Framingham Heart Study Circulation. 2013 January 1; 127(1): 33–38.