Abnormal QRS Research Articles

Significance of ST-segment deviation in patients with acute pulmonary embolism and negative T waves.

Common electrocardiogram (ECG) manifestations in acute pulmonary em-bolism (APE) include ST-segment deviation (STDV) along with negative T-waves (NTW). STDV could occur in 3 typical ischemic patterns: (i) the left ventricular (LV) subendocardial ischemic pattern; (ii) the right ventricular (RV) transmural ischemic pattern; and (iii) the LV subendocardial plus RV transmural ischemic pattern. The purpose of this study was to evalu-ate the relationship of STDV and adverse clinical outcomes and to identify the relationship of relatively normal ECG and favorable clinical outcomes. Retrospective analysis of electronic charts in APE patients was performed in a tertiary hospital. ECGs on admission were obtained and classified as with or without STDV. Adverse clinical outcomes were defined as need to intensify therapy and 30-day mortality. Relatively normal ECG was defined as without any STDV, abnormal QRS morphology in lead V1 and S1Q3T3. From a total of 210 patients with NTW, 131 had STDV ≥ 0.1 mV, while 79 did not. Patients with STDV had worse evolution: higher incidence of dyspnea, hypotension, cardiogen-ic shock, intensification of therapy, and death compared to patients without STDV (p = 0.001 for each variable). The majority (89%) of the patients with STDV presented with 1 of the 3 typical ischemic ECG patterns. LV subendocardial ischemic pattern (OR = 4.963, p = 0.004), RV transmural ischemic pattern (OR = 3.128, p = 0.021) and LV subendocardial plus RV transmural ischemic pattern (OR = 3.036, p = 0.017) independently predicted the need to intensify therapy. RV transmural ischemic pattern (OR = 4.227, p = 0.031) and LV subendocardial plus RV transmural ischemic pattern (OR = 4.022, p = 0.032) independently predicted 30-day mortality. Compared to the patients with abnormal ECG, the patients with relatively normal ECG had a significant lower incidence of death (0% vs. 16%; p = 0.001) and need to intensify therapy during hospitalization (6% vs. 30%; p = 0.002). Ischemic ECG patterns are common ECG manifestations of APE and predict worse evolution and 30-day mortality. Additionally, relatively normal ECGs may associate with favorable clinical outcomes.

QRS abnormalities of the fetal electrocardiogram, and their implications for ST-interval analysis during labor.

The objective of this study was to describe the QRS complex of the fetal electrocardiogram (fECG) in relation to fetal presentation, and explore the effect of abnormal QRS on automated ST-interval analysis (STAN). A case-control study was carried out at a University Hospital in Norway, between the years of 2004-2008. High-risk singleton deliveries with a gestational age >35(+6) weeks, were monitored with cardiotocography and STAN. Cases included breech presentations (n = 433) and controls included cephalic presentations (n = 433). The main outcome measures were QRS-complex abnormalities and fECG abnormalities. An abnormal QRS complex was found in 13.9% of the cases and 16.6% of the controls (p = 0.257). Split R (8.4%) and deep S (8.2%) were the most common abnormalities, and deep Q (4.4% vs. 0.7%, p ≤ 0.001) and split Q (1.8% vs. 0, p ≤ 0.005) were more common in breech than in cephalic presentations. QRS abnormalities impacted on the fECG in 114/866 (13.2%) of the total population. The most common finding was an ambiguous placement of R and S in cases of a split vector (n = 112, 12.9%). Deviance of the ECG baseline above null occurred less frequently (n = 33, 3.8%), and was more common in breech presentation (5.3 vs. 2.3%, p = 0.021). ST events due to an erroneous identification of the QRS vectors and/or a misplacement of the ECG baseline were found in 26 (3.0%) fetuses, with no significant difference in frequency between cases and controls. The appearance of the QRS complex of fECG is dependent upon the fetal presentation. QRS abnormalities impact automated fECG tracing and subsequent ST analysis. Clinicians should be aware of this finding in clinical practice.

Molecular and biochemical evidences on the protective effects of triiodothyronine against phosphine-induced cardiac and mitochondrial toxicity.

Aluminum phosphide (AlP) is a widely used fumigant and rodenticide. While AlP ingestion leads to high mortality, its exact mechanism of action is unclear. There are ample evidences suggesting cardioprotective effects of triiodothyronine (T3). In this study, we aimed to examine the potential of T3 in the protection of a rat model of AlP induced cardiotoxicity. In order to induce AlP intoxication animals were intoxicated with AlP (12 mg/kg; LD50) by gavage. In treatment groups, T3 (1, 2 and 3 μg/kg) was administered intra-peritoneally 30 min after AlP administration. Animals were connected to the electronic cardiovascular monitoring device simultaneously after T3 administration. Then, electrocardiogram (ECG), blood pressure (BP), and heart rate (HR) were monitored for 180 min. Additionally, 24h after AlP intoxication, rats were deceased and the hearts were dissected out for evaluation of oxidative stress, cardiac mitochondrial function (complexes I, II and IV), ATP/ADP ratio, caspases 3 & 9, and apoptosis by flow cytometry. The results demonstrated that AlP intoxication causes cardiac toxicity presenting with changes in ECG patterns such as decrement of HR, BP and abnormal QRS complexes, QTc and ST height. T3 at a dose of 3 μg/kg significantly improved ECG and also oxidative stress parameters. Furthermore, T3 administration could increase mitochondrial function and ATP levels within the cardiac cells. In addition, administration of T3 showed a reduction in apoptosis through diminishing the caspase activities and improving cell viability. Overall, the present data demonstrate the beneficial effects of T3 in cardiotoxicity of AlP.

Managing mass events and competitions with difficult-to-access locations using mobile electrocardiac monitoring

ObjectiveUsing mobile wireless technology to monitor ECG in participants of mass events and sports taking place in difficult-to-access location could both prevent and easier detect arrhythmias as well as provide real-time monitoring for any type of injury. We assessed the effectiveness of mobile wireless monitoring technology and IT in detecting possible emergencies during a skyscraper race. MethodsWe attached specially designed wireless surveillance biopatches on 120 individuals participating to monitor their continuous ECG and location during a skyscraper run-up race at Taipei 101 building, Taiwan. The outcomes of interest were detection of abnormal heartbeats and QRS waves indicative of possible cardiac problems and the exact location of participants during the occurrence of emergencies. ResultsThe devices accurately sent over 50 warnings to our monitoring platform when both, danger limits were reached by competitors (<60 or >195 beats per minute) or competitors stopped moving, proving very effective in quickly detecting abnormities and alerting staff of possible emergencies at exact locations. ConclusionThis efficient and inexpensive monitoring method can also prevent arrhythmias in unscreened competitors, the danger of collision among staff and competitors, and preserves oxygen by eliminating additional on-foot monitoring staff. Additionally, it could have multipurpose usage, especially during disasters and accidents occurring in difficult-to-access locations, in military exercises and personal monitoring.

Defining the electrocardiogram in the neonate with hypoplastic left heart syndrome.

Hypoplastic left heart syndrome (HLHS) is a severe form of congenital heart disease characterized by underdevelopment of the left heart. There has been no previously defined "classic" ECG pattern in a large homogenous population of patients with HLHS. We performed a retrospective review of ECGs from neonates with HLHS from 2001 to 2011 with electrocardiograms available prior to surgical intervention. Eighty-nine neonates met the inclusion criteria and were compared to a control population. HLHS patients had a longer PR interval 108 ± 18 versus 98 ± 11 ms (p < 0.05), a wider QRS complex 84 ± 17 versus 54 ± 5 ms (p < 0.05), lower voltage S waves in V1 2.0 ± 3.3 versus 5.8 ± 4.6 mm (p < 0.001) or absent S waves in V1 52 versus 4 % (p < 0.001) and lower voltage R waves in V6 7.8 ± 4.8 versus 9.3 ± 4.2 mm (p < 0.05). Patients with HLHS were more likely to have absent Q waves in the lateral precordial leads 78 versus 0 % (p < 0.001) and inferior leads 20 versus 1 % (p < 0.001) and an abnormal frontal plane QRS axis 26 versus 11 % (p < 0.05). HLHS patients were more likely to have a preexcited appearance 11 versus 0 % (p = 0.001). Despite these findings, 20 % of patients with HLHS had a normal ECG. Compared to age-matched controls, patients with HLHS were more likely to exhibit a longer PR interval, a wider QRS complex, decreased left-sided forces, an absence of septal Q waves in the inferior and lateral leads, an abnormal frontal plane QRS axis and a preexcited appearance.

Fragmented QRS and other depolarization abnormalities in Nigerians with heart failure: Prevalence and clinical correlates

Background: Fragmented QRS (fQRS), QT prolongation and wide QRS have been associated with increased risk for cardiac arrhythmias. Objectives : To describe the prevalence and correlates among Nigerians with heart failure. Methods: A total of 129 subjects were consecutively recruited for the present study. QT interval, QRS duration and fQRS were determined. SPSS version 16 was used for analysis. Results: The mean (± SD) age was 62.1±13.7 years (43.4% female). Mean QT, QTc and QRS durations were 390.4±56.2 ms, 451.3±62.7 ms and 99.5±23.9 ms, respectively. fQRS, QTc prolongation and wide QRS occurred in 41.1%, 44.2% and 41.9%, respectively, of study participants. fQRS appeared to be more likely associated with prolonged QTc, increased heart rate, presence of old myocardial infarction and wide QRS duration among study participants. Conclusion: fQRS, QTc prolongation and wide QRS are frequent among Nigerians with heart failure. Appropriate screening for heart failure is suggested for early intervention.

Abstract 14707: Effect of Cardiac Resynchronization Therapy (CRT) on Right Ventricular (RV) Function

Background: Right ventricular (RV) dysfunction has been associated with adverse clinical outcomes in patients with heart failure (HF). Cardiac resynchronization therapy (CRT) improves left ventricular size and function in patients with markedly abnormal ECG QRS duration. However, the effect of CRT on RV function has not been well described. Objective: To evaluate change in RV function after CRT. Methods: A systematic search of studies published between 1966 to May 2014 was conducted using Pub Med, CINAHL, Cochrane CENTRAL and the Web of Science databases. Studies reporting tricuspid annular plane systolic excursion (TAPSE) or RV basal strain or RV long axis diameter or RV short axis diameter or RV fractional area change (FAC) before and after CRT were identified. A meta-analysis was performed using random effects with inverse variance method to determine the change in various parameters of RV function after CRT therapy. Results: Twelve studies (N=1478) were selected for final analysis. CRT therapy led to statistically significant increase in TAPSE [1.32(95% CI 0.67 -1.96; p&lt;0.001)], RV FAC [2.88 (95% CI 0.94; 4.83; p=0.004)] and basal strain [2.03(95% CI 0.81-3.26; p=0.001)] and statistically significant decrease in mean RV long axis [-2.95 (95% CI -5.07; -0.83; p=0.01)] and short axis [- 1.39 (95% CI -2.11; -0.67; p&lt;0.001)] after a mean follow up period of 8.7 months. Conclusion: CRT resulted in improved RV size and function as measured by TAPSE, RV FAC, RV basal strain, RV long axis and short axis diameters. Future studies should assess the impact of these changes on symptoms, quality of life and major HF morbidity and mortality.

Abstract 13286: Non-Specific Intraventricular Conduction Delay and Risk of Sudden Death

Introduction: We and others have reported an independent association between prolonged QRS duration and risk of sudden cardiac death (SCD) in the general population. Left and right bundle branch block have been studied previously, but there is little information regarding non-specific intraventricular conduction delay and risk of SCD. Hypothesis: Completed conduction defects, including non-specific IVCD, are associated with increased SCD risk. Methods: Sudden cardiac death cases and controls from an ongoing large population based study in the Northwestern US (2002 to 2010) were included if age ≥ 35 years with a non-paced 12-lead ECG (recorded prior and unrelated to SCD in cases). QRS morphology was subcategorized as normal, intermediate [left anterior fascicular block (LAFB), left posterior fascicular block (LPFB), and incomplete right or left bundle branch block (IRBBB/ILBBB)] or completed conduction defects [left bundle branch block (LBBB), right bundle branch block (RBBB), or nonspecific intraventricular conduction delay (IVCD)]. Comparisons were conducted using chi-square tests for categorical variables and independent samples t-tests for continuous variables. Logistic regression was used to evaluate the association of QRS morphology with SCD. Results: We evaluated 761 SCD cases (64% male) and 539 controls (65% male). Cases were significantly older (69.7 vs 66.3 years, p&lt;0.0001) with greater QRS duration (102 vs. 98 ms, p=0.001). For conduction categories, intermediate or completed conduction defects were significantly more common in cases whereas normal QRS morphology was more common among controls (p=0.01). And for specific morphology overall, QRS morphology patterns differed between cases and controls (p=0.03); abnormal QRS morphologies were more frequent in cases than controls except for LAFB. After adjustment for age and gender, however, only a finding of LBBB or non-specific IVCD remained a significant predictor of SCD [OR 1.34 (95% CI 1.03-1.75)]. Conclusions: LBBB and non-specific IVCD, but not RBBB, are significant predictors of SCD in the general population. These findings contribute to the utility of the 12-lead EKG for SCD risk stratification.

English

OBJECTIVES: To determine the ECG changes in a group of out-patients on antipsychotics medication, and the association, if any, with factors such as gender, age, co-morbid illness and the use of concomitant medication. METHODS: Study subjects included patients 18 years and older attending the outpatient departments of Basaveshwar Teaching and General Hospitals. The subject's demographic and clinical characteristics were obtained and a resting ECG was recorded. RESULTS: Eighty patients were included in the study. The mean age of the subjects was 45.4 (standard deviation (SD) =18.2) years, with a minimum age of 18 and a maximum of 85 years. Fifty-four subjects (67.5%) had evidence of some ECG abnormalities. There was no significant difference between the occurrence of ECG abnormalities and the different age groups (p > 0.05), gender (p > 0.05), and different race groups (p > 0.05). Sixty-one subjects (76.3%) had no co-morbid medical illness and were on psychotropic medication only; of these patients 43 (70.5%) had abnormal ECG tracings (p >0.05). The ECG abnormalities recorded included abnormal rate (28.8%), abnormal ST segment (20.5%), abnormal QRS complex (17.8%), abnormal T wave (15.4%), prolonged or borderline corrected QT interval (8.2%), irregular rhythm (5.5%) and prolonged PR interval (2.7%). There was a significant positive correlation between the corrected QT interval and age (r = 0.43, p 0.05). CONCLUSION: The use of psychotropic drugs is associated with ECG changes in ordinary doses. However, this study serves to strengthen previous evidence that, although common, most of these changes are of a benign nature.

Paced QRS axis as a predictor of pacing-induced left ventricular dysfunction.

The selection of the optimal right ventricular (RV) pacing site remains unclear. We hypothesized that a normal paced QRS axis would provide a physiological ventricular activation and lead to a better long-term outcome. We evaluated 187 patients who underwent a permanent pacemaker implantation and were dependent on RV pacing. The pacing sites were classified as the apex and non-apex according to the chest radiography. A paced QRS axis was defined as that between -30° and 90°. Preservation of the left ventricular (LV) systolic function was defined as that with a <10 % decrease in the ejection fraction after the pacemaker implantation. The median follow-up period was 5.8 years (interquartile 3.9-9.0). Radiographically, the RV leads were located in the apex (n = 148, 79 %) or non-apex (n = 39, 21 %). In the electrocardiogram, normal paced and abnormal paced QRS axes were observed in 28 patients (15 %) and 159 patients (85 %), respectively. The LV ejection fraction was decreased in the patients with an abnormal paced QRS axis (-10 ± 10 %, P < 0.001), but not in those with a normal axis (0 ± 6 %, P = 0.80). The electrocardiographic determinant differentiated a preserved LV function (95 % vs. 35 %, log-rank P = 0.04). Among the patients with radiographically non-apical pacing, a normal paced QRS axis was an additional meaningful predictor of a preserved LV function after the pacemaker implantation (95 % vs. 24 %, log-rank P = 0.002). Compared with the radiographic method, a normal paced QRS axis was associated with a preserved LV function.

Monitoring respiration rate in sleep-disordered breathing patients using chest belts or ECG

Background: For patients with suspected sleep-disordered breathing respiration rate (RR) is typically measured using a nasal airflow sensor. Additionally, two belts measure the movement of the chest ribcage and upper abdominal walls. At least one channel of ECG is also monitored. Instead of airflow, which could be considered the gold standard, RR may be computed using belts or ECG-derived respiration (EDR) techniques. In this study we compare the performance of such techniques to using airflow. Methods: Evaluation was done on 24 adult polysomnograms from the publicly available PhysioNet/ucddb database. Subjects were randomly selected from patients referred to a sleep lab for possible diagnosis of sleep apnea. Subjects had no known cardiac disease, autonomic dysfunction, and were not on medication known to interfere with heart rate. ECG was automatically analyzed using the Philips ST/AR algorithm to detect normal and exclude abnormal QRS complexes. The EDR waveform was then constructed by measuring the peak to trough amplitude in each normal QRS complex, and interpolating the measurements using cubic splines. A frequency-domain method was developed to calculate RR in a 30-second sliding window with a 5-second step by finding the fundamental frequency of oscillations. This method was applied to all four waveforms: airflow, EDR, ribcage, and abdominal belts. The RR values computed from airflow, used as reference, were compared with RRs from the other waveforms. Results: A total of 119,698 respiration cycles were analyzed. The average difference in RR from airflow was 0.7 ± 1.8 breaths-per-minute (bpm) for abdominal belt, 1.0 ± 2.4 for ribcage belt, and 1.8 ± 2.7 for EDR. Percentage distributions of RR differences are listed below.

Reduction of corrected QT interval during the first week after cardioversion of atrial fibrillation to sinus rhythm during sotalol treatment

Background: For patients with suspected sleep-disordered breathing respiration rate (RR) is typically measured using a nasal airflow sensor. Additionally, two belts measure the movement of the chest ribcage and upper abdominal walls. At least one channel of ECG is also monitored. Instead of airflow, which could be considered the gold standard, RR may be computed using belts or ECG-derived respiration (EDR) techniques. In this study we compare the performance of such techniques to using airflow. Methods: Evaluation was done on 24 adult polysomnograms from the publicly available PhysioNet/ucddb database. Subjects were randomly selected from patients referred to a sleep lab for possible diagnosis of sleep apnea. Subjects had no known cardiac disease, autonomic dysfunction, and were not on medication known to interfere with heart rate. ECG was automatically analyzed using the Philips ST/AR algorithm to detect normal and exclude abnormal QRS complexes. The EDR waveform was then constructed by measuring the peak to trough amplitude in each normal QRS complex, and interpolating the measurements using cubic splines. A frequency-domain method was developed to calculate RR in a 30-second sliding window with a 5-second step by finding the fundamental frequency of oscillations. This method was applied to all four waveforms: airflow, EDR, ribcage, and abdominal belts. The RR values computed from airflow, used as reference, were compared with RRs from the other waveforms. Results: A total of 119,698 respiration cycles were analyzed. The average difference in RR from airflow was 0.7 ± 1.8 breaths-per-minute (bpm) for abdominal belt, 1.0 ± 2.4 for ribcage belt, and 1.8 ± 2.7 for EDR. Percentage distributions of RR differences are listed below.

The spectrum of electrocardiographic manifestations of acute myocarditis: An expanded understanding

Background and PurposeDescriptions of the significance of ST segment or QRS abnormalities in myocarditis are limited because documentation of the diagnosis has previously required myocardial biopsy. Late gadolinium enhancement (LGE) and T2 weighted imaging in the midventricular wall on cardiac magnetic resonance imaging (CMRI) has a very good positive predictive value for the diagnosis of myocarditis. We hypothesized to reexplore the diagnostic value of these electrocardiographic (ECG) changes in myocarditis by utilizing CMRI as the reference standard. MethodsData on demographics, clinical presentation, laboratory tests, echocardiograms, coronary angiograms, and computed tomography angiography of 41 consecutive patients with definite midventricular or subepicardial LGE and T2 weighted imaging on CMRI were extracted from the available clinical records. ECGs were blindly examined by two independent readers and divided based on (a) STT changes into: 1. No STT changes, 2. STT changes but no ST elevation, 3. ST elevation (STE); and (b) the presence or absence of QRS abnormalities. Associations of these ECG changes with differences in left ventricular ejection fraction, as measured from CMRI was the main aim of this study. In addition, a complete clinical profile of these patients with myocarditis as identified by CMRI was also created. Results80% of our study population were male with a mean age of 38.6±15.5 and a paucity of traditional cardiovascular risk factors (<30%). 90% presented with chest pain with more than half having dyspnea and a viral prodrome, but fever was infrequent (15%). Peak troponin-I and creatine kinase-MB levels exceeded the upper limit of normal in latest 85%, often by more than 5 times the limit. 18% had a coronary luminal narrowing of ≥50%, while 56% had echocardiographic wall motion abnormalities. The left ventricular ejection fraction averaged 54.3±10.8%. In 24.4% of patients, the ECG was entirely normal; while 39% had STE. STT changes did not detect any differences in the ejection fraction. An abnormal QRS, which was present in 29%, was associated with a lower left ventricular ejection fraction (p=0.005). ConclusionsPatients with clinical features suggestive of myocarditis and confirmatory CMRI findings, can present with a variety of ECG findings, some of which have the potential to identify those with a worse cardiac function, and potentially with a worse prognosis.

개인별 이상신호 검출과 QRS 패턴 변화에 따른 조기심실수축 분류

ABSTRACT Premature ventricular contraction(PVC) is the most common disease among arrhythmia and it may cause serious situations such as ventricular fibrillation and ventricular tachycardia. Nevertheless personalized difference of ECG signal exist, performance degradation occurs because of carrying out diagnosis by general classification rule. In other words, the design of algorithm that exactly detects abnormal signal and classifies PVC by analyzing the persons’s physical condition and/or environment and variable QRS pattern is needed. Thus, PVC classification by personalized abnormal signal detection and QRS pattern variability is presented in this paper. For this purpose, we detected R wave through the preprocessing method and subtractive operation method and selected abnormal signal sets. Also, we classified PVC in realtime through QS interval and R wave amplitude. The performance of abnormal beat detection and PVC classification is evaluated by using MIT-BIH arrhythmia database. The achieved scores indicate the average of 98.33% in abnormal beat classification error and 94.46% in PVC classification..

English

BACKGROUND: Dilated cardiomyopathy (IDCM) is a severe illness with high mortality in the young adult population in resource limited settings. In north-east part of India, clinicians still continue to face the challenges of identifying and treating the dilated cardiomyopathy to improve quality of life due to various reasons. In India, there have been few investigations focusing on the dilated cardiomyopathy patients. But from this part of the country, there is paucity of data. Therefore, the present study was undertaken to examine the clinical characteristics of dilated cardiomyopathy patients who presented to our hospital. MATERIALS AND METHODS: This prospective observational study was carried out in the Department of General Medicine, Jorhat Medical College and Hospital, Jorhat, Assam, from January 2013 to December 2013. Total 31 consecutive patients fulfilling the criteria of dilated cardiomyopathy were studied. Dilated Cardiomyopathy was diagnosed if enlarged left ventricle with decreased systolic function as measured by left ventricular ejection fraction characterized dilated cardiomyopathy. Patients were excluded from the study if they have one or more of the following; systemic hypertension (> 160/100 mm Hg), evidence of coronary artery diseases, pericardial diseases, congenital heart disease, valvular heart diseases, cor pulmonale and rapid, sustained supraventricular tachycardia. Detailed inform consent from the patients and ethical permission from the concerned authorities were taken. RESULTS: Thirty one patients were diagnosed with dilated cardiomyopathy during the study period who fulfilled the inclusion and exclusion criteria of the study. Twenty-nine (92%) of 31 patients presented with clinical features of congestive heart failure as their initial presentation and majority presented with dyspnea (70.97%), followed by palpitation (64.52%). The mean cardio thoracic ratio was (0.61). Majority of the patients (70.97%) were in sinus rhythm and commonest abnormality detected in ECG was QRS abnormality (54.84%), followed by left axis deviation (48.39%). CONCLUSION: In majority of cases the cause of dilated cardiomyopathy is idiopathic, followed by alcohol consumption. Secondary causes occur with less frequency. Patients present with features of heart failure during the initial presentation associated with QRS abnormalities on ECG.

Abnormal electrocardiographic QRS transition zone and risk of mortality in individuals free of cardiovascular disease.

We examined the prognostic significance of abnormal electrocardiographic QRS transition zone (clockwise and counterclockwise horizontal rotations) in individuals free of cardiovascular disease (CVD). A total of 5541 adults (age 53 ± 10.4 years, 54% women, 24% non-Hispanic black, 25% Hispanic) without CVD or any major electrocardiogram (ECG) abnormalities from the US Third National Health and Nutrition Examination Survey were included in this analysis. Clockwise and counterclockwise horizontal rotations were defined from standard 12-lead ECG using Minnesota ECG Classification. Mortality and cause of death were assessed through 2006. At baseline, 282 participants had clockwise rotation and 3500 had counterclockwise rotation. During a median follow of 14.6 years, 1229 deaths occurred of which 415 were due to CVD. In multivariable-adjusted Cox proportional hazard analysis and compared with normal rotation, clockwise rotation was significantly associated with increased risk of all-cause mortality {hazard ratio (HR) [95% confidence interval (CI)]: 1.43 (1.15-1.78); P = 0.002} and CVD mortality [HR (95% CI): 1.61 (1.09, 2.37) P = 0.016]. In contrast, counterclockwise rotation was associated with significantly lower risk of all-cause mortality [HR (95% CI): 0.86 (0.76, 0.97); P = 0.017] and non-significant association with CVD mortality [HR (95% CI): 1.07 (0.86, 1.33); P = 0.549]. These results were consistent in subgroup analysis stratified by age, sex, and race. In a diverse community-based population free of CVD and compared with normal rotation, clockwise rotation was associated with increased risk of all-cause and CVD mortality while counterclockwise rotation was associated with lower risk of all-cause mortality and non-significant association with CVD mortality. These findings call for attention to these often neglected ECG markers, and probably call for revising the current definition of normal rotation.

Does cardiac resynchronization therapy benefit patients with right bundle branch block: cardiac resynchronization therapy has a role in patients with right bundle branch block.

Does cardiac resynchronization therapy benefit patients with right bundle branch block: cardiac resynchronization therapy has a role in patients with right bundle branch block.

Electrocardiogram patterns during hemodynamic instability in patients with acute pulmonary embolism.

We have previously described new electrocardiogram (ECG) findings for massive pulmonary embolism, namely ST-segment elevation in lead aVR with ST-segment depression in leads I and V4 -V6 . However, the ECG patterns of patients with acute pulmonary embolism during hemodynamic instability are not fully described. We compared the differences between the ECG at baseline and after deterioration during hemodynamic instability in twenty patients with acute pulmonary embolism. Compared with the ECG at baseline, three ischemic ECG patterns were found during clinical deterioration with hemodynamic instability: ST-segment elevation in lead aVR with concomitant ST-segment depression in leads I and V4 -V6 , ST-segment elevation in leads V1 -V3 /V4 , and ST-segment elevation in leads III and/or V1 /V2 with concomitant ST-segment depression in leads V4 /V5 -V6 . Ischemic ECG patterns with concomitant S1Q3 and/or abnormal QRS morphology in lead V1 were more common (90%) during hemodynamic instability than at baseline (5%) (P = 0.001). Hemodynamic instability in acute pulmonary embolism is reflected by signs of myocardial ischemia combined with the right ventricular strain pattern in the 12-lead ECG.

Prevalence of pre-transplant electrocardiographic abnormalities and post-transplant cardiac events in patients with liver cirrhosis

BackgroundAlthough cardiovascular disease is thouht to be common in cirrhosis, there are no systematic investigations on the prevalence of electrocardiographic (ECG) abnormalities in these patients and data on the occurrence of post-transplant cardiac events in comparison with the general population are lacking. We aimed to study the prevalence and predictors of ECG abnormalities in patients with cirrhosis undergoing liver transplantation and to define the risk of cardiac events post-transplant compared to the general population.MethodsCirrhotic patients undergoing first-time liver transplantation between 1999–2007 were retrospectively enrolled. ECGs at pre-transplant evaluation were reviewed using the Minnesota classification and compared to healthy controls. Standardized incidence ratios for post-transplant cardiac events were calculated.Results234 patients with cirrhosis were included, 186 with an available ECG (36% with alcoholic and 24% with viral cirrhosis; mean follow-up 4 years). Cirrhotics had a prolonged QTc interval, a Q wave, abnormal QRS axis deviation, ST segment depression and a pathologic T wave more frequently compared to controls (p < 0.05 for all). Arterial hypertension, older age, cirrhosis severity and etiology were related to ECG abnormalities. Compared to the general Swedish population, patients were 14 times more likely to suffer a cardiac event post-transplant (p < 0.001). A prolonged QTc interval and Q wave were related to post-transplant cardiac events (p < 0.05 for all).ConclusionsPre-transplant ECG abnormalities are common in cirrhosis and are associated with cardiovascular risk factors and cirrhosis severity and etiology. Post-transplant cardiac events are more common than in the general population.

Intraoperative interfascicular ventricular tachycardia: A rare occurrence

Intraoperative interfascicular ventricular tachycardia: A rare occurrence