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Journal of Electrocardiology xx (2015) xxx xxx
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Electrocardiogram score for the selection of reperfusion strategy in early

latecomers with ST-segment elevation myocardial infarction
Yu-Jiao Zhang, MD, PhD, a Wen Zheng, MD, PhD, a, Jian Sun, MD, PhD, a
Guo-Li Li, MD, b Bao-Rong Chi, MD a,
a

Department of Cardiology, the First Hospital of Jilin University, Changchun, China

b
Department of Cardiology, the Peoples Hospital of Jilin City, Jilin, China

Abstract

Objective: The clinical benefit of percutaneous coronary intervention (PCI) is controversial in STsegment elevation myocardial infarction (STEMI) patients presenting 1272 hours after symptom
onset. Several studies suggested this conflicting result was associated with myocardial area at risk
(MaR) of enrolled patients. MaR could be estimated by the electrocardiogram (ECG) score. Our
objective was to evaluate the benefits of PCI in STEMI latecomers with different MaR.
Methods: We constructed a prospective cohort involving 436 patients presenting 1272 hours after
STEMI onset and who met an inclusion criteria. 218 underwent PCI and 218 received the optimal
medical therapy (OMT) alone. Individual MaR was quantified by the combined Aldrich ST and
Selvester QRS score. The primary endpoint was a composite of cardiovascular death, reinfarction or
revascularization within two years.
Results: The 2-year cumulative primary endpoint rate was respectively 9.2% in PCI group and 5.3%
in OMT group when MaR b 35% (adjusted hazard ratio for PCI vs. OMT, 1.855; 95% confidence
interval [CI], 0.6175.575; P = 0.271), and was 12.8% in PCI group and 23.1% in OMT group
when MaR 35% (adjusted hazard ratio for PCI vs. OMT, 0.448; 95% CI, 0.2280.884;
P = 0.021).
Conclusion: The benefit of PCI for the STEMI latecomers was associated with the MaR. PCI,
compared with OMT, could significantly reduce the 2-year primary outcomes in patients with
MaR 35%, but not in ones with MaR b 35%.
2014 Elsevier Inc. All rights reserved.

Keywords:

Electrocardiography/electrocardiogram(s); Myocardial infarction; Myocardial area at risk; Percutaneous coronary

intervention; Selvester QRS score; Aldrich ST score

Introduction
Primary percutaneous coronary intervention (PCI) is the
recommended treatment for patients with ST-segment elevation myocardial infarction (STEMI) within 12 hours after
ischemic symptom onset [1]. However, the clinical benefit of
PCI vs. optimal medical therapy (OMT) alone is controversial
in stable patients presenting over 12 hours timeframe [24]. A
comprehensive meta-analysis of 10 trials comparing the
efficacy of late PCI vs. medical therapy alone in 3560 patients
randomized over 12 hours after STEMI indicated this
conflicting result could be associated with enrolled patients
ischemia in the infarct-related artery territory [5].

Corresponding authors at: Department of Cardiology, the First

Hospital of Jilin University, Changchun, China, 130021.
E-mail addresses: zhengw.jlu@gmail.com, chibr@jlu.edu.cn
http://dx.doi.org/10.1016/j.jelectrocard.2015.01.004
0022-0736/ 2014 Elsevier Inc. All rights reserved.

This ischemic myocardial tissue within the vascular

territory that is distal to the culprit lesion of the infarctrelated artery is usually called myocardial area at risk (MaR)
[6]. MaR includes salvageable and infarcted myocardium.
For example, following acute coronary occlusion the MaR is
entirely ischemic, but over time the MaR gradually becomes
a mix of both ischemic and infarcted myocardium. The
extent of MaR is typically identified and qualified by singlephotoemission computed tomography (SPECT). Although
the SPECT analysis of MaR is a promising risk-stratification
tool for STEMI, it had very limited clinical applicability due
to high cost and uncommon availability [3,4]. In contrast, a
standard 12-lead electrocardiogram (ECG) is inexpensive
and easily applied before reperfusion treatment has commenced, and several algorithms have been developed to
estimate MaR by using the Aldrich ST score and Selvester
QRS score [710]. The Aldrich ST score estimates the size
of ischemic myocardium and Selvester QRS score estimates

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

the size of the infarcted myocardium. As time progresses

ischemia is replaced by infarction and the primary ECG STsegment deviation is replaced by QRS complex changes,
especially in STEMI latecomers. Thus the combined utilization of Aldrich and Selvester score would be more stable and
accurate to estimate the MaR of these patients [11].
This study aimed to evaluate whether the combined ECG
score could be applied (1) to quantify the MaR of STEMI
latecomers, and (2) to evaluate the clinical benefit of PCI vs.
OMT for these patients with different stratification of MaR. It
could provide an easy and quick clinical assessment for the
selection of reperfusion strategy.

Methods
All STEMI patients at the First Hospital of Jilin University
were recorded in a prospective cohort. Data elements included
demographic, clinical, angiographic/procedural, and follow-up
variables. Each patient had an outpatient visit at 1 month and
several follow-up phone calls using a standardized questionnaire at 6 months, 1 year, and then annually by trained
personnel to document long-term outcomes. In each contact,
details of any readmission during that time period and/or
mortality information were collected, including the date, the
place, and if the reason for readmission or death was
cardiovascular or non-cardiovascular.
Study population
Patients (1) who were over 18 years-old, (2) hospitalized
with a definitive diagnosis of new-onset STEMI through
January, 2010 to January, 2012 and (3) presented to our
department 1272 hours after symptom onset were included in
this study. This hospitalization was defined as the index
hospitalization. The exclusion criteria included patients with (1)
cardiogenic shock, electrical instability and severe congestive
heart failure (New York Heart Association III or IV) on
admission; (2) electrocardiogram presenting with complete left
or right bundle branch block, Wolff-Parkinson-White syndrome
and left ventricular hypertrophy; (3) receiving coronary artery
bypass grafting, and (4) in-hospital mortality during the index
hospitalization. In addition, (5) patients without angiographic or
complete clinical data were also excluded. Then, patients were
divided into two groups according to their treatments: receiving
PCI and OMT (PCI group) or OMT alone (OMT group). We
calculated a propensity score for each patient and matched each
PCI case to one OMT case (Fig. 1). The study was approved by
the Ethics Committee of the First Hospital of Jilin University.
Treatments
All patients received optimal medical therapy, including
aspirin, anticoagulation if indicated, angiotensin-convertingenzyme inhibition (ACEI)/angiotensin receptor blocker
(ARB), beta-blockade, and lipid-lowering therapy/plaque
stabilization, unless contraindicated. Patients were assigned
to perform coronary angiography/PCI within a few hours
after decision if the condition was permitted, and each
patients angiography record was collected.

Fig. 1. Flowchart of study population. STEMI indicates ST-segment elevation

myocardial infarction; SPECT, single-photon emission computed tomography.
Propensity score matching was used to ensure similarity of patients in two
groups, matching each PCI case to one medical therapy case.

ECG acquisition and evaluation

The standard 12-lead ECGs on admission from each patient
were collected within 10 minutes and transferred to a personal
computer for post-processing. Standard ECG amplitude and
duration measurements were performed automatically using
the algorithm provided with the ECG Research Workstation
Software (GE Healthcare, Milwaukee, WI, USA). The results
by computer measurements were then compared with those
by manual measurements which were used to increase
reproducibility and decrease the inter observer variability.
The Aldrich score in present study was based on the rule
set recommended by Bacharova et al. [12]. This scoring
system was calculated to estimate the magnitude of ST
segment elevation, which was measured at the J point in all
recordings. ST elevation was defined as an elevation of more

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

Fig. 2. Electrocardiogram scoring examples for estimating MaR. The 12-lead ECGs and algorithm for estimating myocardial area at risk (MaR) were shown in panel A and panel B. Panel A showed a 72 years old female with ECG
changes of acute anterior myocardial infarction caused by the occlusion of left anterior descending artery. Panel B showed a 59 years old male with ECG changes of acute inferior myocardial infarction caused by the occlusion of right
coronary artery.

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

than 0.10 mV. The size of the ischemic component of the

MaR (%LV) for anterior/inferior AMI was calculated by
using the following formulas:
Anteriorwall AM I %LV 31:5No: of leads with ST 0:4
Inferiorwall AM I %LV 30:6ST I I ; I I I ; aV F 2:0

The Selvester score estimated the size of the infarcted

myocardium based on modified 32 points QRS-scoring. Every
point was developed to represent infarction of 3% of the total left
ventricular mass (%LV) [79]. The electronic GE Healthcare
QRS waveform amplitude and duration measurements were
recorded by two separated investigators.
The combined Aldrich and Selvester score, that was total
MaR (%LV), was determined by adding the Aldrich ST and
the Selvester QRS score (Fig. 2) [9,10].
MaR measured by SPECT
A subgroup of 32 patients received baseline viability
scanning with a SPECT and 99mTc-Sestamibi to assess MaR
before the procedure.
Angiographic evaluation
Coronary angiography data were assessed off-line in the
Angiographic Core Laboratory by personnel unaware of study
allocation. Classification of anterograde coronary flow in the
infarct-related artery was performed according to Thrombolysis
in Myocardial Infarction (TIMI) classification. Angiographic
collateral vessels were scored using the grading system
proposed by Rentrop et al. [13]: 0 = none; 1 = visualization
of branches 0 ~ 1; 2 = branches plus a portion of the epicardial
vessel; 3 = visualization of the entire vessel.
Outcomes definition
The primary outcome was major adverse cardiovascular
events (MACE), which was a composite of cardiovascular
death, reinfarction and revascularization within two years.
Cardiovascular death was defined as in or out of hospital
mortality due to ischemic heart disease or sudden cardiac arrest.
The definition of reinfarction required two of the following
three criteria: the persistence of symptoms for 30 or more
minutes, electrocardiographic changes, and elevated cardiac
markers. The definition of revascularization referred to patients
receiving revascularization procedures (PCI/CABG, but not
including staged/assigned procedure) due to recurrent coronary
stenosis or persistent chest pain after discharge from the indexhospitalization. Secondary endpoints included the separate
components of the primary endpoints within two years.
Statistical analysis
Descriptive data were reported as mean standard deviation (SD) or frequencies expressed as percentages. Pearson 2
and Student t tests were used for comparison among categorical
and continuous variables, respectively. The Spearman's
correlation coefficient was used to measure the correlation
between MaR estimated by ECG score vs. by SPECT.
A propensity score model was built to eliminate covariate
differences; 2 cohorts of 1:1 nearest-neighbor-matched
patients were consequently obtained [14,15]. The propensity

Table 1
Baseline characteristics (N = 436).

Demographic Characteristic
Age (means SD, y)
Female (%)
Clinical characteristic
Congestive heart failure (%)
Hypertension (%)
Hyperlipidemia (%)
Diabetes mellitus (%)
COPD (%)
Renal failure (%)
Angiographic characteristic
Infarct-related artery (%)
LAD
LCX
RCA
TIMI flow grade in
infarct-related artery (%)
0
1
2
3
Collateral grade (means SD)
Multivessel disease (%)
LVEF (means SD)
Estimated MaR (%LV)

PCI group
(N = 218)

OMT group
(N = 218)

P value

61 14
59 (27.1)

61 13
58 (26.6)

0.818
0.914

118 (54.1)
117 (53.7)
13 (6.0)
52 (23.9)
6 (2.8)
7 (3.2)

100 (45.9)
113 (51.8)
19 (8.7)
58 (26.6)
9 (4.1)
12 (5.5)

0.085
0.701
0.271
0.222
0.601
0.174

113 (51.8)
36 (16.5)
69 (31.7)

114 (52.3)
38 (17.4)
66 (30.3)

0.939

0.412
206 (94.5)
6 (2.8)
4 (1.8)
2 (0.9)
0.31 0.66
25 (11.5)
50.0 13.0
35 10

211 (96.8)
3 (1.4)
3 (1.4)
1 (0.5)
0.29 0.63
39 (17.9)
48.6 11.2
34 8

0.711
0.058
0.243
0.305

SD, standard deviation; LAD, left anterior descending artery; LCX, left
circumflex coronary artery; RCA, right coronary artery; TIMI, Thrombolysis in
Myocardial Infarction; LVEF, left ventricle ejection fraction.
New York Heart Association functional class II heart failure.

score was calculated using logistic regression covariates

including age, gender, comorbidities (congestive heart failure,
hypertension, hyperlipidemia and diabetes), angiographic data
(infarct-related vessels, TIMI flow grade, collateral grade,
multivessel disease) and estimated MaR. After propensity
score matching, all baseline variables were comparable.
Primary and secondary outcomes during follow-up were
analyzed using the KaplanMeier method, and treatments
were compared by log-rank test. The covariate-adjusted hazard
ratio was quantified by utilizing a Cox proportional-hazard
regression model that included eleven variables of interest:
demographic (age and sex), clinical (congestive heart failure,
hypertension, diabetes and hyperlipidemia), angiographic
(infarct-related artery, TIMI, collateral flow grade and multivessel disease) and treatment (PCI vs. OMT) variables.
Proportional-hazard assumptions, linearity of continuous
variables and lack of interactions were tested for each model.
In addition, the subgroup analysis of admission time was
performed by the same Cox proportional-hazards regression
model. The relationship between the estimated MaR and 2year incidence of MACE was assessed as a continuous
function and depicted with a quadratic regression model. The
incidence was calculated with adjustment for age and sex by
each three points of the MaR, fitting generalized estimating
equations with a Poisson link function.
All analyses were performed with SAS, version 9.3 64-bit
(SAS Institute, U.S.A.). A 2-tailed P value b 0.05 was regarded
as statistically significant in all calculations.

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

Comparison of MACE outcomes between PCI group and

OMT group

Results
Baseline patients characteristics
In all, 436 STEMI patients with average follow-up of
2.7 0.6 years were enrolled in this study. Of 218 (50%)
were matched into the PCI group and the other 218 (50%)
were matched into the OMT group. A detailed description
and distribution of baseline characteristics were given in
Table 1. The baseline characteristics were all comparable
between two groups.
Treatments in two groups
In the PCI group, average time from admission to procedure
was 45 hours. 58 patients underwent immediate PCI (the
average interval from arrival: 1 hour) and 160 patients
underwent elective PCI (the average interval from arrival: 65
hours). The duration from decision (non-randomization) to
PCI was less than 6 hours. PCI was performed successfully in
205 patients (94%), and 198 had a TIMI flow grade of three
after the procedure (successful PCI defined as an open artery
with residual stenosis of less than 50% and a TIMI flow
antegrade grade of 2 or 3); 200 patients (92%) were placed at
least one stent, and 191 received drug-eluting stents;
glycoprotein IIb/IIIa antagonists was administered to 94%
patients during or after procedure. 4 patients (2%) received
thrombolysis before admission.
In the OMT group, average interval from admission to
angiography performed was 3.5 days. Only 2 patients (1%)
received thrombolysis before admission.
During 2-year follow-up or until the events occurred, the
usage rate of aspirin (96% vs. 94%, P = 0.381), betablocker (75% vs. 77%, P = 0.653), ACEI or ARB (62% vs.
65%, P = 0.486) and statin (65% vs. 57%, P = 0.077) was
similar in two groups, except for higher usage rate of
clopidogrel (65% vs. 38%, P b 0.001) in the PCI group than
the OMT group.

In all 436 patients, the average MaR was 35%, which was
similar in two groups (35% vs. 34%, P = 0.305). When 35%
was selected as the cut-off, KaplanMeier analysis showed 2year cumulative MACE incidence was similar (P = 0.278)
between two groups in patients with MaR b 35%, while PCI
group had significant lower incidence (P = 0.043) in patients
with MaR 35% (Table 2 and Fig. 3). The covariatesadjusted hazard ratio (HR) for PCI vs. OMT was 1.855 (95%
confidence intervals: 0.6175.575, P = 0.271) in the patients
with MaR b 35%, and the adjusted HR for PCI vs. OMT in
patients with MaR 35% was 0.448 (95% confidence
intervals: 0.2280.884, P = 0.021). Furthermore, the relationship between the estimated MaR and the incidence of 2-year
MACE was depicted in the Fig. 4. Two curves representing for
the PCI group and the OMT group respectively crossed around
35%. These two curves accompanied with each other before the
intersection, and separated after the intersection with significantly ascending in OMT group.
On the basis of the study definition, one reinfarction and
four revascularization events occurred due to in-stent thrombus/restenosis in PCI group with MaR b 35%, and one
reinfarction and five revascularization events occurred due to
in-stent thrombus/restenosis in PCI group with MaR 35%.
In secondary outcomes, the cumulative events of PCI group,
compared with OMT group, showed more revascularization (9
(8.3%) vs. 5(5.4%), P = 0.246) when MaR b 35%, fewer
cardiovascular death (2(1.8%) vs. 7(6.7%), P = 0.078) and
lower reinfarction (4(3.7%) vs. 11(10.8%), P = 0.045) when
MaR 35% (Table 2). As the early latecomers were
defined as 1272 hours after onset of symptoms, it was a
long timespan. A subgroup analysis therefore was performed in
order to reduce the impact of admission time. The results
showed no significant difference of benefits in different
subgroup of admission time (Fig. 5).

Evaluation the correlation between ECG score and SPECT

Discussion

In the subgroup of 32 patients (21 patients in the PCI

group) who received SPECT, the MaR estimated by the ECG
was significantly correlated with that measured by SPECT
(r =0.64, P b 0.001).

In this study, we evaluated the efficacy of PCI for stable

patients presenting 1272 hours after STEMI onset with
different MaR. Our results showed that STEMI latecomers with
severe ischemia (MaR 35%) could benefit from the patency

Table 2
Primary and secondary outcomes.
Endpoints (2-y
cumulative event rate)
MACE (%)
Cardiovascular death (%)
Reinfarction (%)
Nonfatal reinfarction (%)
Revascularization (%)

MaR b 35%

MaR 35%

PCI (N = 109)

OMT (N = 114)

P value

PCI (N = 109)

OMT (N = 104)

P value

10 (9.2)
1 (0.9)
1 (0.9)
1 (0.9)
9 (8.3)

6 (5.3)
1 (0.9)
3 (2.6)
3 (2.6)
5 (5.4)

0.278
0.972
0.337
0.337
0.246

14 (12.8)
2 (1.8)
4 (3.7)
4 (3.7)
13 (11.9)

24 (23.1)
7 (6.7)
11 (10.8)
10 (9.9)
13 (12.8)

0.043
0.078
0.045
0.072
0.771

P values were calculated with the use of the log-rank test for KaplanMeier curves through one year of follow-up.
MACE refers to major adverse cardiovascular event including cardiovascular death, reinfarction or revascularization.

Revascularization was defined as another procedure (PCI or CABG but not include staged-procedure) performed due to recurrent coronary stenosis or
persistent chest pain after discharge from the index hospitalization.

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

Fig. 3. KaplanMeier curves for the primary endpoint. The primary endpoint was the composite occurrence of cardiovascular death, reinfarction, or
revascularization. KaplanMeier estimates of the cumulative event rates in the PCI group and the optimal medical therapy (OMT) group, respectively, were
11.0% and 13.8% for all enrolled patients (panel A), 9.2% and 5.3% for patients with MaR b 35% (panel B), and 12.8% and 23.1% for patients with
MaR 35% (panel C). The P value was calculated with the use of the log-rank test.

of infarct-related artery compared with medical therapy only; in

constrast, patients with moderate ischemia (MaR b 35%) could
not get more benefit from the patency of infarct-related artery
than medical therapy only. This study supports the hypothesis
that the benefit of delayed PCI is related to MaR, providing an
easy and quick clinical assessment for the selection of
reperfusion strategy for early latecomers with STEMI.

Fig. 4. Relationship between estimated MaR and primary endpoint. The scatter
plots and fixed quadratic regression curves representing for the PCI group and
the OMT group respectively were depicted for fitting the relationship between
the MaR estimated by the combined Aldrich and Selvester score and the
adjusted incidence of primary endpoints (cardiovascular death, reinfarction, or
revascularization). The incidence was calculated with adjustment for age and
sex by each three points of the MaR, fitting generalized estimating equations
with a Poisson link function. Dotted lines represent 95% confidence intervals of
predicted incidence. Two curves representing for the PCI group and the OMT
group respectively crossed around 35%. These two curves accompanied with
each other before the intersection, and separated after the intersection with
significantly ascending in OMT group. R square in PCI group was 0.876 and R
square in OMT group was 0.834.

The ST deviations were highly correlated with MaR

measured by SPECT only when ischemia was present during
the initial time following coronary occlusion [16]. And the QRS
abnormities have been well-developed to estimate infarct size
during the infarction process [13,1618]. Bacharova L et al.
[19] indicated that these changes of electrogenesis manifesting
as ST segment deviations and QRS complex changes after
persisted occlusion of a coronary artery and consequent
ischemia/infarction were related to slowing of ventricular
activation and changes in morphology and duration of action
potentials in the affected area. Irene E.G. van Hellemond et al.
[9,10] showed the combined Aldrich and Selvester score,
estimating the MaR, was moderately correlated with that
measured by SPECT in either acute anterior or inferior-wall MI.
Our studies similarly observed a significant correlation (r =
0.64, P b 0.001) between the combined score and SPECT for
measuring MaR in STEMI latecomers.
The accepted definition of early latecomers refers to
patients with STEMI presenting 1272 hours after symptoms
onset [20]. In China, there are only 3% STEMI patients who
underwent primary PCI within recommended 12 hours [21],
and the overall rates of timely reperfusion therapies did not
improved during the past 10 years [22]. Therefore, there was a
considerable proportion of early latecomers facing the
decision of whether should be performed delayed PCI. Our
study showed patients with moderate MaR could not get more
clinical benefit from PCI than OMT alone, and there was an
increased risk of repeat revascularization within the 2-year
follow-up. Excess revascularization might derive on PCIrelated restenosis because 4 of 9 events were related. The
mechanism of PCI-related restenosis could be a consequence
of distal atherothrombotic embolization or microvascular
plugging in the early stage or in-stent thrombosis in the late
stage [3,23]. Although clopidogrel was prescribed at discharge
in almost all patients with PCI, the agents were being taken in
only 65% patients when the events occurred. This could be
another reason for in-stent thrombosis. On the other hand,

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

Fig. 5. Subgroup analysis. Hazard ratios (black spots), 95% CIs (horizontal lines), cumulative 2-year primary outcomes (cardiovascular death, reinfarction, or
revascularization) for different subgroups of admission time (1248 hours and 48 hours72 hours) were shown.

there was a high-risk of cardiac function deterioration,

cardiogenic shock or even death for patients with severe
MaR. PCI could significantly reduce the short-term cardiovascular events by reducing infarction area and improvement
on cardiac function [24,25]. Our result showed lower
cumulative incidence of cardiovascular death (PCI vs. OMT:
1.8% vs. 6.7%) and reinfarction (3.7% vs. 10.8%) occurred in
PCI group when MaR 35%. Therefore, the estimated MaR
is effective to stratify the risk for reperfusion strategy selection.
As the present study was based on a prospective
observational cohort, the grouping and the selection of
operation timing were not randomly assigned compared with
randomized controlled trials. Therefore, there could exist some
potential impact factors leading to selective bias, but we
conducted this cohort through propensity score matching and
adjusted possible risk factors to reduce these biases. Of note,
propensity score matching could result in the loss of cases, and
thus we conducted a similar model in the subset of 681
patients, and the trend of benefit did not change (adjusted HR:
0.42, 95% CI: 0.200.94, P = 0.035). So we think it is
reasonable to only conserve the patients with comparable
baseline characteristics (propensity score matching) for
reducing selective bias given non-randomized sample selection in this study. In addition, only patients alive at discharge
from the index-hospitalization were enrolled. Although it could
underestimate the event rates of two groups, this recruitment
would reduce the unbalanced in-hospital mortality between two
groups due to time-to-treatment bias, especially in stable patients.

with MaR 35%, but not in ones with MaR b 35%. The MaR
estimated by the combined Aldrich and Selvester score can
provide an easy and quick clinical assessment for the selection
of reperfusion strategy for early latecomers with STEMI.
Contributors
Study concept and design: Dr. Bao-Rong Chi, Dr. YuJiao Zhang, Dr. Wen Zheng, Dr. Jian Sun and Dr. Guo-Li Li.
Manuscript writing: Dr. Yu-Jiao Zhang and Dr. Wen Zheng.
Critical revision of the manuscript for important intellectual
content: Dr. Jian Sun, Dr. Bao-Rong Chi and Dr. Guo-Li Li.
Dr. Bao-Rong Chi and Dr. Wen Zheng have full access to
all of the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis and
are the guarantors.
Conflict of interest
No conflict of interest.
Patient consent
Obtained.
Ethics approval
The Ethics Committee of the First Hospital of Jilin
University.

Conclusions
In summary, the benefit of PCI for the STEMI latecomers
was associated with the MaR. PCI, compared with OMT, could
significantly reduce the 2-year primary outcomes in patients

Acknowledgement
Research was supported by Research Funds of Jilin Provincial
Science &Technology Department (20130206021SF).

Y.-J. Zhang et al. / Journal of Electrocardiology xx (2015) xxxxxx

References
[1] American College of Emergency P, Society for Cardiovascular A,
Interventions, et al. 2013 ACCF/AHA guideline for the management of
ST-elevation myocardial infarction: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. J Am Coll Cardiol 2013;61(4):e78e140, http://dx.
doi.org/10.1016/j.jacc.2012.11.019 [published Online First: Epub Date].
[2] Erne P, Schoenenberger AW, Burckhardt D, et al. Effects of percutaneous
coronary interventions in silent ischemia after myocardial infarction: the
SWISSI II randomized controlled trial. JAMA 2007;297(18):198591,
http://dx.doi.org/10.1001/jama.297.18.1985 [published Online First:
Epub Date].
[3] Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for
persistent occlusion after myocardial infarction. N Engl J Med
2006;355(23):2395407, http://dx.doi.org/10.1056/NEJMoa066139
[published Online First: Epub Date].
[4] Schomig A, Mehilli J, Antoniucci D, et al. Mechanical reperfusion in
patients with acute myocardial infarction presenting more than 12
hours from symptom onset: a randomized controlled trial. JAMA
2005;293(23):286572, http://dx.doi.org/10.1001/jama.293.23.2865
[published Online First: Epub Date].
[5] Abbate A, Biondi-Zoccai GG, Appleton DL, et al. Survival and cardiac
remodeling benefits in patients undergoing late percutaneous coronary
intervention of the infarct-related artery: evidence from a meta-analysis
of randomized controlled trials. J Am Coll Cardiol 2008;51(9):95664,
http://dx.doi.org/10.1016/j.jacc.2007.11.062 [published Online First:
Epub Date].
[6] Rochitte CE, Azevedo CF. The myocardial area at risk. Heart 2011,
http://dx.doi.org/10.1136/heartjnl-2011-301332 [published Online
First: Epub Date].
[7] Ideker RE, Wagner GS, Ruth WK, et al. Evaluation of a QRS scoring
system for estimating myocardial infarct size. II. Correlation with
quantitative anatomic findings for anterior infarcts. Am J Cardiol
1982;49(7):160414.
[8] Roark SF, Ideker RE, Wagner GS, et al. Evaluation of a QRS scoring
system for estimating myocardial infarct size. III. Correlation with
quantitative anatomic findings for inferior infarcts. Am J Cardiol
1983;51(3):3829.
[9] van Hellemond IE, Bouwmeester S, Olson CW, et al. Consideration of
QRS complex in addition to ST-segment abnormalities in the estimated
"risk region" during acute anterior myocardial infarction. J Electrocardiol
2011;44(3):3706, http://dx.doi.org/10.1016/j.jelectrocard.2011.01.004
[published Online First: Epub Date].
[10] van Hellemond IE, Bouwmeester S, Olson CW, et al. Consideration of
QRS complex in addition to ST segment abnormalities in the estimation
of the 'risk region' during acute inferior myocardial infarction. J
Electrocardiol 2013;46(3):21520, http://dx.doi.org/10.1016/j.jelectrocard.2013.02.004 [published Online First: Epub Date].
[11] Carlsen EA, Hassell ME, van Hellemond IE, et al. The stability of
myocardial area at risk estimated electrocardiographically in patients with
ST elevation myocardial infarction. J Electrocardiol 2014;47(4):5405,
http://dx.doi.org/10.1016/j.jelectrocard.2014.04.016 [published Online
First: Epub Date].
[12] Bacharova L, Mateasik A, Carnicky J, et al. The Dipolar
ElectroCARdioTOpographic (DECARTO)-like method for graphic presentation of location and extent of area at risk estimated from
ST-segment deviations in patients with acute myocardial infarc-

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]
[25]

tion. J Electrocardiol 2009;42(2):17280, http://dx.doi.org/

10.1016/j.jelectrocard.2008.12.005 [published Online First: Epub
Date].
Rentrop KP, Cohen M, Blanke H, et al. Changes in collateral channel
filling immediately after controlled coronary artery occlusion by an
angioplasty balloon in human subjects. J Am Coll Cardiol 1985;5
(3):58792.
D'Agostino Jr RB. Propensity score methods for bias reduction in the
comparison of a treatment to a non-randomized control group. Stat
Med 1998;17(19):226581.
Austin PC. An introduction to propensity score methods for reducing the
effects of confounding in observational studies. Multivar Behav Res
2011;46(3):399424, http://dx.doi.org/10.1080/00273171.2011.568786
[published Online First: Epub Date].
Persson E, Pettersson J, Ringborn M, et al. Comparison of ST-segment
deviation to scintigraphically quantified myocardial ischemia during
acute coronary occlusion induced by percutaneous transluminal coronary
angioplasty. Am J Cardiol 2006;97(3):295300, http://dx.doi.org/
10.1016/j.amjcard.2005.08.044 [published Online First: Epub Date].
Geerse DA, Wu KC, Gorgels AP, et al. Comparison between contrastenhanced magnetic resonance imaging and Selvester QRS scoring system
in estimating changes in infarct size between the acute and chronic phases
of myocardial infarction. Ann Noninvasive Electrocardiol 2009;14(4):3605,
http://dx.doi.org/10.1111/j.1542-474X.2009.00327.x [published Online First:
Epub Date].
Loring Z, Chelliah S, Selvester RH, et al. A detailed guide for
quantification of myocardial scar with the Selvester QRS score in the
presence of electrocardiogram confounders. J Electrocardiol 2011;44
(5):54454, http://dx.doi.org/10.1016/j.jelectrocard.2011.06.008 [published Online First: Epub Date].
Bacharova L, Szathmary V, Mateasik A. QRS complex and ST segment
manifestations of ventricular ischemia: the effect of regional slowing of
ventricular activation. J Electrocardiol 2013;46(6):497504, http://dx.
doi.org/10.1016/j.jelectrocard.2013.08.016 [published Online First:
Epub Date].
Fontanelli A, Bonanno C. Primary percutaneous coronary intervention
in 'early' latecomers with ST-segment elevation acute myocardial
infarction: the role of the infarct-related artery status. J Cardiovasc Med
2011;12(1):138, http://dx.doi.org/10.2459/JCM.0b013e32834038d8
[published Online First: Epub Date].
Huo Y. Current status and development of percutaneous coronary
intervention in China. J Zhejiang Univ Sci B 2010;11(8):6313, http://
dx.doi.org/10.1631/jzus.B1001012 [published Online First: Epub Date].
Li J, Li X, Wang Q, et al. ST-segment elevation myocardial infarction
in China from 2001 to 2011 (the China PEACE-Retrospective Acute
Myocardial Infarction Study): a retrospective analysis of hospital data.
Lancet 2014, http://dx.doi.org/10.1016/s0140-6736(14)60921-1 [published Online First: Epub Date].
Galiuto L, Paraggio L, Liuzzo G, et al. Predicting the no-reflow
phenomenon following successful percutaneous coronary intervention.
Biomark Med 2010;4(3):40320, http://dx.doi.org/10.2217/
bmm.10.55 [published Online First: Epub Date].
Hochman JS, Sleeper LA, White HD, et al. One-year survival following
early revascularization for cardiogenic shock. JAMA 2001;285(2):1902.
Wu AH, Parsons L, Every NR, et al. Hospital outcomes in patients
presenting with congestive heart failure complicating acute myocardial
infarction: a report from the Second National Registry of Myocardial
Infarction (NRMI-2). J Am Coll Cardiol 2002;40(8):138994.