1. Gottlieb SO, Weisfeldt ML, Ouyang P, Melhts ED, Gerstenblith G. Silent &hernia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986;314:1214-1219. 2. Nademanee K, Intarachot I, Josephson MA, Rieders D, Mody FV, Singh BN. Prognostic significance of silent myocardial ischemia in patients with unstable angina. JACC 1987:10:1-9. 3. Tzivoni D, Weisz G, Gavish A, Zin D, Keren A, Stern S. Comparison of mortality and myocardial infarction rates in stable angina pectoris with and without ischemic episodes during daily activities. Am J Cardiol 1989;63;273276. 4. Raby KE, Goldman L, Creager MA, Cook EF, Weisberg MC, Whittemore AD, Selwyn AP. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery. N Engl J Med 1989;321:1296-1300. 5. Feldman RL. Ambulatory electrocardiographic monitoring: the test for ischemia in 19887 Ann intern Med 1988;109:608-610. 6. Selwyn AP. The value of Halter monitoring in managing patients with coronary artery disease. Circulation 1987;75:31-32. 7. Knight AA, Hollenbery M, London MJ, Mangano DT. S.P.I. Research Group. Myocardial ischemia in patients awaiting coronary artery bypass grafting. Am Heart J 1989;117:1189-1195. 8. Freeman LJ, Nixon PGF, S&bank P, Reaveley D. Psychological stress and

Clinical Significance Myocardial Infarction

of Pericardial

silent myocardial ischemia. Am Heart J 1987;114:477-482. 9. Kennedy HL, Wiens RD. Ambulatory (Halter) electrocardiography and myocardial &hernia. Am Heart J 1989;117:164-176. 10. Aronow WS, Epstein S. Usefulness of silent myocardial ischemia detected by ambulatory electrocardiographic monitoring in predicting new coronary events in elderly patients. Am J Cardiol 3988,62;1295-1297. 11. Epstein SE, Quyyumi AA, Bonow RO. Sudden cardiac death without warning: possible mechanisms and implications for screening asymptomatic populations. N Engl J Med 1989;321’:320-324. 12. Hands ME, Sia STB, Shook TL. Anderson K, Stone PH, Levy D, Castelli WP, Rutherford JD, The Framingham Heart Study Group. Silent myocardial ischemia in asymptomatic survivors of unrecognized myocardial infarction and matched controls. Am Heart J 1988;116:1488-1492. 13. Egstrup K. Asymptomatic myocardial ischemia as a predictor of cardiac events after coronary artery bypass grafting for stable angina pectoris. Am J Cordial 1988;61:248-252. 14. Nabel EG, Barry J, Rocco MB, Campbell S, Mead K, Fenton T. Orav EJ, Selwyn AP. Variability of transient myocardial ischemia in ambulatory patients with coronary artery disease. Circulation 1988;78:60-67. 15. Epstein SE. Quyyumi AA, Bonow RO. Myocardial ischemia-silent or symptomatic. N Engl J Med 1988;318:1038-1043.

Rub in Inferior

Wall

-Wave Acute

Tetsuro Sugiura, MD, Toshiji Iwasaka, MD, Nobuyuki Takahashi, MD, Yo Nagahama, MD, Tadashi Hasegawa, MD, Masahide Matsutani, MD, Tsutomu Sumimoto, MD, and Mitsuo lnada, MD ericardial rub is common during the course of acute myocardial infarction (AMI).le3 Infarct-associated pericardial rub is usually transient and associated with transmural AMI,‘T~ but it has been reported with a greatly variable frequency and its incidence in respect to the infarct site is controversiaLm3 Some have observed that pericardial rub was a more frequent complication in anterior rather than inferior infarcts.2,3 Others’ report that pericardial rub was equally distributed among patients with anterior and inferior AMI. Because the proximity of the stethoscope to the inflamed pericardium permits better detection of rubs, we hypothesized that the association of right ventricular AMI could affect the incidence of pericardial rub in patients with inferior AMI. We elucidated the difference in the incidence of pericardial rub with and without right ventricular AM1 in patients after their first Q-wave inferior AMI. We studied 134 consecutivepatients after theirfirst Q-wave inferior AM who were admitted to the coronary care unit within 24 hours of the onset of chestpain and who survived the first 3 days after admission. It is a routine procedure in our hospital to insert a Swan-Ganz catheter in patients with AM who are admitted within 24 hours of onsetof chestpain. All patients were examined by a physician, and a written informed consentwas obtained before the Swan-Ganz catheter insertion. No patient had prior history of AM, intraventricular conduction abnormalities, chronic renal failure, collagen disease,cardiac surgery within the previous 6 months or cancer. From

the

Second

University, script

received

accepted

Department

1 Fumizono March

February

9, 1990.

of Internal

cho Moriguchi 5, 1990,

Medicine,

City, Osaka, revised

manuscript

Kansai

Medical

Japan 570. Manureceived

and

The diagnosisof AMI was made when the patients had ST elevation with a new Q wave (II, III and al/F) on serial electrocardiograms and at least twice normal elevation of serum creatine kinase with MB isoenzyme 15%. At least 1 mm of ST-segment elevation and QS or QR in right precordial lead (VgR) at the time of admission were considered diagnostic of right ventricular AA4I.4 All patients were monitored continuously in the coronary care unit, and all were examined by careful auscultation at least twice daily. Pericardial rub was consideredasa scratchy or grating noiseand the diagnosisof pericardial rub was made after contrmation by at least 2 cardiologists. Hemodynamic measurementsincluding cardiac output, pulmonary artery wedgepressureand right atria1pressurewere determinedon admission. A coronary arteriogram was performed before each patient was dischargedfrom the hospital. Coronary artery lesionswith 270% reduction in diameter were considered to be obstructive. Each patient was classified as having I-, 2- or 3-vesseldisease.Proximal right coronary artery lesionswere defined as located before the acute marginal branch. Results are reported as mean f standard deviation. A Student’s t test was usedfor quantitative data, and chi-square analysis was usedfor qualitative data. A p value