ECG Findings In Patients Research Articles

Effect of Sacubitril / Valsartan Combination on Abnormal ECG Findings in Patients with Heart Failure with Reduced Ejection Fraction

Abstract Background The mortality rate of patients suffering from choronic heart failure is still high despite advantages in diagnosis and treatment. A new therapeutic class of agents acting on the renin angiotensin aldosterone system (RAAS) and neutral endopeptidase system has been developed, known as angiotensin receptor neprilysin inhibitors (ARNI). Recently, promising data from its administration have demonstrated a decrease in the mortality rate as compared to angiotensin receptor blocker alone. Aim of the Work The aim of this study is to asses effect of Sacubitril/Valsartan combination on abnormal ECG and ECHO parameters in patients with heart failure with reduced ejection fraction as a marker of reverse cardiac remodeling. Patients and Methods Our study was conducted at Ain Shams university hospitals and our target population was heart failure patients with reduced ejection fraction planned to initiate Sacubitril \ Valsartan combination therapy. 100 patients were collected from February 2022 to August 2022. It was an interventional study to follow up the effects of the drug on ECG parameters besides ECHO parameters 6 months after drug initiation. Results We found that in Sacubitril/Valsartan combination therapy there was significant decrease in HR, QRS width and QTc values which reflects the role of this combination to reduce ventricular arrhythmias and preventing SCD. There was significant increase in the EF which was correlated to the significant decrease in QRS width. There was significant improvement in diastolic dysfunction. There was significant decrease in the LA and LV dimensions giving an explanation of the role of the drug in reverse cardiac remodeling. There was significant improvement in NYHA class reflecting the role of the drug in improving quality of life. Conclusion HR, QRS width and QTc were significantly decreased with Sacubitril/Valsartan combination therapy through the follow up period reflecting the effect of the drug on ECG. EF, LA dimension and LVID were improving with Sacubitril/Valsartan combination therapy through the follow up period which give an explanation of the combination therapy for its role in reverse cardiac remodeling. NYHA class of our patients was improving through follow up period which means this drug improves quality of life and reduces hospitalization.

ODP112 Post-infusion ECG Changes in Patients Receiving Intravenous Bisphosphonates: a Systematic Review and Meta-Analysis

Abstract Bisphosphonates are the first-line treatment for several bone and mineral disorders. Randomized trials and cohort studies have reported increased rates of atrial fibrillation in patients receiving bisphosphonates, however, uncertainty remains as to whether other electrical disturbances are precipitated by bisphosphonates. We aimed to review the literature for studies reporting ECG findings in patients receiving intravenous bisphosphonates for any indication. We searched MEDLINE and EMBASE on 06/01/2022 for studies reporting ECG parameters following administration of intravenous bisphosphonates. We excluded studies that only reported atrial fibrillation, case reports and animal or cell-based studies. Study quality was assessed using the Newcastle-Ottawa Scale. Continuous data were meta-analysed if reported in at least two studies. Random-effects models were fitted and reported as standardized mean difference (SMD) with 95% confidence intervals (95%CI). Heterogeneity was determined by the I 2 statistic. All data were computed using R (4.1.1). We found 1,123 records of which six met our inclusion and exclusion criteria, of which five had data for meta-analysis. Studies were of low to moderate quality. Five studies used zoledronic acid while one study used pamidronate. Most studies [n=4] were conducted in postmenopausal women with osteoporosis, one study was conducted in patients with bone metastases and one study was conducted in children with cerebral palsy and osteoporosis. Most studies [n=4] reported outcomes in the sub-acute (>24 hours) phase. Study populations ranged from n=15 to n=116. There was a significant difference in QTc dispersion (SMD= -0.456 milliseconds [95%CI: -0.800 to -0.113]; I 2 = 0%; n= 67 patients; k= 2 studies) but no differences in heart rate, P wave (maximum), P wave (minimum), P wave dispersion, PR interval, QRS duration, QTc (maximum), QTc (minimum), or QTc. The correlation between pre- and post-infusion QTc dispersion was rho= 0.981 (p=0.866). Results were unchanged when analysing studies reporting acute or sub-acute phase ECG changes. Overall, there is insufficient and low quality evidence to support an association between intravenous bisphosphonate administration and acute phase dysrhythmias. These data underscore the importance of performing a pre-infusion ECG to evaluate potentially unreported conduction abnormalities. Presentation: No date and time listed

Anovel ECG finding in patients with epicardial infarct-associated ventricular tachycardia: acase series.

This study analyzes the incidence, characteristics, and ECG morphology of ventricular tachycardia (VT) in post-infarction patients undergoing epicardial VT ablation. Ablation of recurrent VTs in patients with ischemic cardiomyopathy is typically performed endocardially. In rare cases, epicardial access is required to achieve non-inducibility. The study evaluated the baseline characteristics, procedural data, and ECG morphology of clinical VT in patients undergoing epicardial VT ablation. From the initial 491patients with coronary heart disease (CHD) and recurrent VTs undergoing ablation at the Heart Center of Leipzig, Germany, between 2012 and 2020, only 39patients required an additional epicardial access. In 17 patients, the VTs were associated with infarction scar, while the remaining patients had concomitant CHD without infarction-associated scar and were excluded from the analysis. Apropensity match study was performed at a1:2 ratio for these 17 patients, with 34patients of the initial cohort as a control group to evaluate the differences in baseline characteristics, procedural data, and ECG morphology of the VTs. The specific VT morphology of negative concordance and superior axis in patients with inferior scar as well as the history of VT ablation were independent predictors of the need for epicardial access. In addition to previous endocardial ablation, VT ECG morphology with negative concordance and superior axis in post-infarction patients with inferior scar predicted the need for epicardial VT ablation.

Arrhythmogenic right ventricular cardiomyopathy patients with a markedly enlarged RV compressing LV to left side have an atypical distribution of epsilon waves and elevated plasma BNP

Abstract Funding Acknowledgements Type of funding sources: None. Background Epsilon waves on V1-3 leads are specific ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) suggesting RV conduction delay. Four dimensional (4D) cardiac CT visualizes ARVC characteristics, such as fibro-fatty invasion into RV and left ventricular (LV) myocardium (RVM, LVM), an enlarged RV, reduced RV motion, and bulging. Purpose We hypothesize that Epsilon waves in V4-6 leads suggest LV invasion in ARVC. Alternatively, extreme RV enlargement may compress the LV and cause clockwise rotation; an enlarged RV may itself cause epsilon waves in V4-6 leads. Methods Retrospective analysis of 17 patients (11 males, 57 ± 17 yrs) with suspected ARVC undergoing cardiac CT and ECG, 9 of whom met 2010 ARVC task force criteria. Results All 9 patients had epsilon waves on ECG; 5 had fibro-fatty invasion into the LVM. We divided the 9 into 5 groups by CT: 1) markedly enlarged RV compressing the LV to the left side with fibro-fatty changes exclusively in RVM (N = 1); 2) similar findings in both RVM and LVM (N = 2); 3) moderately enlarged RV without compression of the LV to the left side and fibro-fatty changes exclusively in RVM (N = 3); 4) the same in both RVM and LVM (N = 2); 5) severe mitral valve regurgitation, a markedly enlarged LV, and a fibro-fatty change in both RVM and LVM (N = 1). The patient in group (gp) 1 showed epsilon waves in V1-6 leads, patients in gp 2 had epsilon waves in V1-6 (N = 1), and V3-5 (N = 1) leads; patients in gp 3 had epsilon waves in V1-4 (N = 2), and V1-3 (N = 1) leads, patients in gp 4 had epsilon waves in V1-3 (N = 1), and V1, 2 (N = 1) leads; finally, the patient in gp 5 had epsilon waves in V4-6 leads. Plasma brain natriuretic peptide (BNP) levels were significantly greater in patients in gp 1 & 2 than gp 3 & 4 (1255 ± 838 vs 80 ± 52 pg/ml, P = 0.016). Conclusions ARVC patients with a markedly enlarged RV compressing the LV to the left side (gp 1,2) had a broad (V1-6) or different range (V3-5) distribution of epsilon waves and significantly elevated plasma BNP independent of fibro-fatty invasion of the LV, different from typical ARVC (gp 3,4). Additionally, structural change due to complicated heart disease, such as valvular disease (gp5), may also influence the distribution of epsilon waves in ARVC. Abstract Figure. CT and ECG in ARVC group 1

Comparison of sites of wall thickening and abnormal late enhancement on cardiac CT and magnetic resonance imaging with electrocardiography findings in patients with confirmed cardiac amyloidosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Left ventricular (LV) wall thickening and diastolic dysfunction on a transthoracic echocardiogram (TTE) without a high voltage R wave on V5 leads on an ECG leads to a diagnosis of cardiac amyloidosis. A final diagnosis is made by endomyocardial biopsy. However, amyloid sometimes invades the right ventricle (RV), and left (LA) and right (RA) atria, causing ECG changes such as sick sinus syndrome (SSS), arrhythmia, and QRS wave axis deviation. Purpose To elucidate the relationship between sites of wall thickening and abnormal late enhancement (LE) on cardiac computed tomography (CT) and magnetic resonance imaging (MRI), suggesting amyloid invasion, with ECG findings in patients with cardiac amyloidosis confirmed by biopsy. Methods A total of 26 patients (11 females) with suspected cardiac amyloidosis, who had LV wall thickening by TTE without a high voltage R wave in V5 leads on ECG, underwent cardiac CT. LV wall thickening observed on CT in the early phase led to a late phase acquisition. Five patients (3 females, mean age 73 years) were diagnosed with cardiac amyloidosis: complicated multiple myeloma, 2; senile ATTR (transthyretin) amyloidosis, 1; immunoglobulin light chain (AL) amyloidosis, 1; and transthyretin mutation, 1. Four patients underwent cardiac MRI. Results Case 1 had wall thickening in the basal interventricular septum (IVS), LV inferior-posterior wall, LA on CT, abnormal LE in the endocardium in whole LV, RV, and RA on CT, and LE in the endocardium in whole LV, RV, LA, and IVS on MRI. ECG showed SSS (junctional rhythm), left axis QRS wave deviation, no low voltage R wave in limb leads, and a mild LA load. Case 2 had wall thickening in whole LV, RV, LA, and IVS on CT, and unclear (CT) or no (MRI) abnormal LE. ECG revealed SSS (junctional rhythm), a normal QRS axis, no low voltage R wave in limb leads, and no LA load. Case 3 had wall thickening in the LA and basal IVS on CT, abnormal LE in the LA and basal IVS on CT, and LE in the LA only on MRI. ECG revealed atrial tachycardia, a normal QRS axis with low voltage R wave in limb leads, and no LA load. Case 4 had wall thickening in the LA, an RV moderator band on CT, an unclear LE on CT, and LE in whole LV, endocardium in the RV, and whole IVS on MRI. ECG showed a normal sinus rhythm, left axis QRS wave deviation, with low voltage R wave in limb leads, and no LA load. Case 5 had wall thickening in the IVS, LV lateral wall, LV anterior wall, RA, RV outflow tract, and RA appendage, and no abnormal LE on CT (MRI not performed). ECG revealed a normal sinus rhythm, right axis QRS wave deviation, with low voltage R wave in limb leads, and a mild LA load. Conclusions In this pilot study of a small number of patients with cardiac amyloidosis, few relationships between sites of wall thickening and abnormal LE on ECG were found. However, a long-term follow-up study with more patients may reveal relationships between such parameters using this methodology. Abstract Figure. Classification by wall thickening on CT

Electrocardiographic Features and Outcome: Correlations in 124 Hospitalized Patients With COVID-19 and Cardiovascular Events

ObjectivesElectrocardiographic (ECG) changes have been associated with coronavirus disease 2019 (COVID-19) severity. However, the progression of ECG findings in patients with COVID-19 has not been studied. The purpose of this study was to describe ECG features at different stages of COVID-19 cardiovascular (CV) events and to examine the effects of specific ECG parameters and cardiac-related biomarkers on clinical outcomes in COVID-19.DesignRetrospective, cohort study.SettingMajor tertiary-care medical centers and community hospitals in Louisville, KY.ParticipantsA total of 124 patients with COVID-19 and CV events during hospitalization.InterventionsNone.Measurements and Main ResultsTwelve-lead ECG parameters, biomarkers of cardiac injuries, and clinical outcomes were analyzed with Spearman correlation coefficients and Kruskal-Wallis 1-way analysis of variance. Atrial fibrillation/atrial flutter was more frequent on the ECG obtained at the time of the CV event when compared with admission ECG (9.5% v 26.9%; p = 0.007). Sinus tachycardia was higher in the last available hospital ECG than the CV event ECG (37.5% v 20.4%; p = 0.031). Admission ECG-corrected QT interval was significantly associated with admission troponin levels (R = 0.52; p < 0.001). The last available hospital ECG showed nonsurvivors had longer QRS duration than survivors (114.6 v 91.2 ms; p = 0.026), and higher heart rate was associated with longer intensive care unit length of stay (Spearman ρ = 0.339; p = 0.032).ConclusionsIn hospitalized patients with COVID-19 and CV events, ECGs at various stages of COVID-19 hospitalization showed significantly different features with dissimilar clinical outcome correlations.

Echocardiographic Evaluation of Systolic Left Ventricular function in Acute Myocardial Infarction in 1st Week of Hospitalization

Objectives: To assess systolic left ventricular function determined by left ventricular ejection fraction (LVEF) with the help of Echocardiography and correlate with ECG findings in patients of AMI. Methods: One hundred (100) cases of acute myocardial infarction were studied in the Department of Cardiology, DMCH from July 2015 to December 2015. It was an observational study. All selected patients were interviewed with a preformed questionnaire and were observed up to 7 days in hospital. Echocardiography was done to assess left ventricular ejection fraction (LVEF) by applying Teichholz (cube) formula. Results: 83% of them were males and 17% of them were females. Mean age (±SD) was 52.24±11.59 years (range 34-82 years). The important risk factors among the study subjects, was hypertension (45%) (Male 40.96%; Female 64.7%) followed by Diabetes mellitus (33%) (Male 31.32%; Female 41.17%). Most of the admitted patients could reach in hospital within 4-12 hours of onset of symptoms and most of the patients of acute myocardial infarction had anterior wall involvement (37%). Mild systolic LV dysfunction (52.87%) was revealed in echocardiography among the survivors. Conclusion: The incidence of AMI was seen common among farmers who were mostly hypertensive. Systolic LV dysfunction was common in most patients where anterior wall involvement was present. Bangladesh J Medicine July 2022; 33(1) : 12-18

Abstract 11877: Arrhythmogenic Right Ventricular Cardiomyopathy Patients with a Markedly Enlarged RV Compressing LV to Left Side Have an Atypical Distribution of Epsilon Waves and Elevated Plasma BNP

Introduction: Epsilon waves on V1-3 leads are specific ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC). 4D cardiac CT visualizes ARVC characteristics, such as fibro-fatty invasion into RV and left ventricular (LV) myocardium (RVM, LVM), an enlarged RV, reduced RV motion, and bulging. Hypothesis: We hypothesize that epsilon waves in V4-6 leads suggest LV invasion in ARVC. Alternatively, extreme RV enlargement may compress the LV and cause clockwise rotation; an enlarged RV may itself cause epsilon waves in V4-6 leads. Methods: Retrospective analysis of 17 patients (11 males, 57±17 yrs) with suspected ARVC undergoing cardiac CT and ECG, 9 of whom met 2010 ARVC task force criteria. Result: All 9 patients had epsilon waves ; 5 had fibro-fatty invasion into the LVM. We divided the 9 into 5 groups by CT: 1) markedly enlarged RV compressing the LV to the left side with fibro-fatty changes exclusively in RVM (N=1); 2) similar findings in both RVM and LVM (N=2); 3) moderately enlarged RV without compression of the LV to the left side and fibro-fatty changes exclusively in RVM (N=3); 4) the same in both RVM and LVM (N=2); 5) severe mitral valve regurgitation, a markedly enlarged LV, and a fibro-fatty change in both RVM and LVM (N=1). The patient in group (gp) 1 showed epsilon waves in V1-6 leads, patients in gp 2 had epsilon waves in V1-6 (N=1), and V3-5 (N=1) leads; patients in gp 3 had epsilon waves in V1-4 (N=2), and V1-3 (N=1) leads, patients in gp 4 had epsilon waves in V1-3 (N=1), and V1, 2 (N=1) leads; finally, the patient in gp 5 had epsilon waves in V4-6 leads. Plasma BNP levels were significantly greater in patients in gp 1 &amp; 2 than gp 3 &amp; 4 (1255±838 vs 80±52 pg/ml, P=0.016). Conclusions: ARVC patients with a markedly enlarged RV compressing the LV to the left side (gp 1,2) had a broad (V1-6) or different range (V3-5) distribution of epsilon waves and significantly elevated plasma BNP independent of fibro-fatty invasion of the LV, different from typical ARVC (gp 3,4).

Abstract 12060: Comparison of Sites of Wall Thickening and Abnormal Late Enhancement on Cardiac CT and Magnetic Resonance Imaging with Electrocardiography Findings in Patients with Confirmed Cardiac Amyloidosis

Introduction: Left ventricular (LV) wall thickening and diastolic dysfunction on a TTE without a high voltage R wave on V5 leads on an ECG to a diagnosis of cardiac amyloidosis (CA). However, amyloid sometimes invades right ventricle (RV), and left (LA) and right (RA) atria, causing ECG changes such as sick sinus syndrome (SSS), arrhythmia, and QRS wave axis deviation. Hypothesis: We hypothesize that there is the relationship between sites of wall thickening and abnormal late enhancement (LE) on cardiac CT and MRI, suggesting amyloid invasion, with ECG findings in patients with CA confirmed by biopsy. Methods: A total of 26 patients (11 females) with suspected CA, who had LV wall thickening by TTE without a high voltage R wave in V5 leads, underwent cardiac CT. 5 patients (3 females, mean age 73 years) were diagnosed with CA. 4 patients underwent MRI. Results: Case 1 had wall thickening in the basal interventricular septum (IVS), LV inferior-posterior wall, LA on CT, LE in endocardium in whole LV, RV, and RA on CT, and LE in endocardium in whole LV, RV, LA, and IVS on MRI. ECG showed SSS (junctional rhythm), left QRS axis deviation, no low voltage R wave in limb leads, and a mild LA load. Case 2 had wall thickening in whole LV, RV, LA, and IVS on CT, and unclear (CT) or no (MRI) LE. ECG revealed SSS (junctional rhythm), a normal QRS axis, no low voltage R wave in limb leads, and no LA load. Case 3 had wall thickening in LA and basal IVS on CT, abnormal LE in the LA and basal IVS on CT, and LE in the LA only on MRI. ECG revealed atrial tachycardia, a normal QRS axis with low voltage R wave in limb leads, and no LA load. Case 4 had wall thickening in the LA, an RV moderator band on CT, an unclear LE on CT, and LE in whole LV, endocardium in the RV, and whole IVS on MRI. ECG showed a normal sinus rhythm, left QRS axis deviation, with low voltage R wave in limb leads, and no LA load. Case 5 had wall thickening in the IVS, LV lateral wall, LV anterior wall, RA, RV outflow tract, and RA appendage, and no abnormal LE on CT (MRI not performed). ECG revealed a normal sinus rhythm, right QRS axis deviation, with low voltage R wave in limb leads, and a mild LA load. Conclusions: This pilot study revealed the presence of wall thickening and abnormal LE in RV, LA, and RA in addition to LV would be important which may influence ECG changes in patients with CA.

Abstract 12086: Relationship of Cardiac Rhythm and Other Electrocardiogram Findings with Sites of Wall Thickening and Abnormal Late Enhancement in Patients with Confirmed Cardiac Amyloidosis

Introduction: Left ventricular (LV) wall thickening and diastolic dysfunction on TTE without high voltage R wave on ECG to a diagnosis of cardiac amyloidosis (CA). However, amyloid sometimes invade right ventricle (RV), and left (LA) and right (RA) atria to cause ECG changes such as sick sinus syndrome (SSS), arrhythmia, and QRS axis deviation. Hypothesis: We hypothesized that sites of wall thickening and abnormal late enhancement (LE) on cardiac CT and MRI, suggesting amyloid invasion, correlated with cardiac rhythm and other ECG findings in patients with CA confirmed by biopsy. Methods: 26 patients (11 females) with suspected CA, showing LV wall thickening by TTE without a high voltage R wave, underwent cardiac CT. 5 patients (3 females, mean 73 years) were diagnosed with CA: complicated multiple myeloma, 2; senile ATTR (transthyretin) amyloidosis, 1; immunoglobulin light chain amyloidosis 1; and transthyretin mutation, 1. 4 patients underwent cardiac MRI. Results: 2 patients (cases 1 and 2) had SSS (junctional rhythm), 1 had atrial tachycardia, and the remaining 2 (cases 4 and 5) had a normal sinus rhythm. In case 1, ECG showed a left QRS axis deviation, no low voltage R wave and a mild LA load. Wall thickening in basal interventricular septum (IVS), LV inferior-posterior wall, LA on CT, LE in endocardium in whole LV, RV, and RA on CT, and LE in endocardium in whole LV, RV, LA, and IVS on MRI were observed. In case 2, ECG showed a normal QRS axis, no low voltage R wave, no LA load, wall thickening in whole LV, RV, LA, and IVS on CT, and unclear (CT) or no (MRI) LE. In case 3, ECG showed a normal QRS axis, with low voltage R wave, no LA load, wall thickening in LA and basal IVS on CT, LE in LA and basal IVS on CT, and LE in LA only on MRI. In case 4, ECG showed left QRS axis deviation, a low voltage R wave, and no LA load, wall thickening in LA and RV on CT, unclear LE on CT, and LE in whole LV, endocardium in RV, and whole IVS on MRI. In case 5, ECG showed a right QRS axis deviation, low voltage R wave, and a mild LA load, wall thickening in IVS, LV lateral wall, LV anterior wall, RA, RV outflow tract, and RA appendage, and no LE on CT (MRI not performed). Conclusions: The presence of wall thickening and abnormal LE in RV, LA, and RA in addition to LV on CT or MRI would be important which may influence ECG changes in patients with CA.

Prediction of sites of wall thickening and abnormal late enhancement on cardiac CT and magnetic resonance imaging using electrocardiography findings in patients with confirmed cardiac amyloidosis

Abstract Background Left ventricular (LV) wall thickening and diastolic dysfunction on a transthoracic echocardiogram (TTE) without high voltage R wave in V5 leads on ECG leads to a diagnosis of cardiac amyloidosis. A final diagnosis is made by endomyocardial biopsy. However, amyloid sometimes invade the right ventricle (RV), and left (LA) and right (RA) atria to cause ECG changes such as sick sinus syndrome (SSS), arrhythmia, and QRS wave axis deviation. Purpose To predict sites of wall thickening and abnormal late enhancement (LE) on cardiac computed tomography (CT) and magnetic resonance imaging (MRI), suggesting amyloid invasion, using cardiac rhythm and other ECG findings in patients with cardiac amyloidosis confirmed by biopsy. Methods A total of 26 patients (11 females) with suspected cardiac amyloidosis, showing LV wall thickening by TTE without a high voltage R wave in V5 leads on ECG, underwent cardiac enhanced CT. LV wall thickening on CT in the early phase led to late phase acquisition to detect LE. Five patients (3 females, mean age 73 years) were diagnosed with cardiac amyloidosis: complicated multiple myeloma, 2; senile ATTR (transthyretin) amyloidosis, 1; immunoglobulin light chain (AL) amyloidosis 1; and transthyretin mutation, 1. Four patients underwent cardiac MRI. Results Two patients (cases 1 and 2) had SSS (junctional rhythm), one had atrial tachycardia, and the remaining two (cases 4 and 5) had a normal sinus rhythm. In case 1, ECG showed a left axis QRS wave deviation, no low voltage R wave in limb leads and a mild LA load. Wall thickening in the basal interventricular septum (IVS), LV inferior-posterior wall, LA on CT, LE in the endocardium in whole LV, RV, and RA on CT, and LE in the endocardium in whole LV, RV, LA, and IVS on MRI were observed. In case 2, ECG showed a normal QRS wave axis, no low voltage R wave in limb leads, no LA load, wall thickening in whole LV, RV, LA, and IVS on CT, and unclear (CT) or no (MRI) LE. In case 3, ECG showed a normal QRS wave axis, with low voltage R wave in limb leads, no LA load, wall thickening in LA and basal IVS on CT, LE in LA and basal IVS on CT, and LE in LA only on MRI. In case 4, ECG showed left axis QRS wave deviation, a low voltage R wave in limb leads, and no LA load, wall thickening in the LA and RV moderator band on CT, unclear LE on CT, and LE in whole LV, endocardium in the RV, and whole IVS on MRI. In case 5, ECG showed a right axis QRS wave deviation, low voltage R wave in limb leads, and a mild LA load, wall thickening in the IVS, LV lateral wall, LV anterior wall, RA, RV outflow tract, and RA appendage, and no LE on CT (MRI not performed). Conclusions This pilot study of a few patients with cardiac amyloidosis revealed few links between cardiac rhythm and other ECG findings with sites of wall thickening and abnormal LE. However, a longer-term study of more patients may lead to detecting an association between these variables with this methodology. Funding Acknowledgement Type of funding sources: None.

Abstract 13144: Epsilon Waves on Electrocardiograms in Pulmonary Hypertensive Patients With and Without Right Ventricular Hypertrophy or Fibrosis: Comparison With Arrhythmogenic Right Ventricular Cardiomyopathy

Introduction: Epsilon waves on V1-3 leads are one of the specific ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) that suggest the presence of RV conduction delay. Hypothesis: In patients with pulmonary hypertension (PH) due to RV pressure load, RV hypertrophy and fibrosis are frequently observed that may lead to RV conduction delay and epsilon waves. Methods: We retrospectively analyzed 43 PH patients (33 females, 55 ± 15 years, 31 chronic thromboembolic PH, seven idiopathic pulmonary arterial hypertension), with proven PH by right heart catheterization. On CT, RV fibrosis was defined as a contrast defect in the early phase and a conversely abnormal enhancement in the late phase. We also retrospectively analyzed 17 patients (11 males, 57 ± 17 years) with suspected ARVC who underwent cardiac CT. Of these, nine met 2010 ARVC task force criteria on cardiac CT. Results: All 9 ARVC patients (100%) had epsilon waves on ECG. In PH patients, 32 and 9 patients had RV hypertrophy and fibrosis, respectively. Of these, 4 patients had both. Among 32 PH patients with RV hypertrophy, 2 had complete right bundle branch block (RBBB) and 8 had incomplete RBBB. Of 22 PH patients with RV hypertrophy but without any RBBB, two (9%, P &lt; 0.01, compared with ARVC) had waves with abnormal small upward spikes after the QRS wave. These were more marked in lead II and aVF leads than in V1 and 2 leads, and were not typical epsilon waves, suggesting RV conduction delay shown in ARVC. Fourteen patients had a negative T wave in V1-3 leads (5 had only a V1 lead, one had only V1 and 2 leads, four had only V1-3 leads, and four only had V1-4 leads, respectively). Of nine PH patients with RV hypertrophy, one had complete RBBB and one had incomplete RBBB. Of seven PH patients with RV fibrosis but without any RBBB, none (0%, P &lt; 0.01, compared with ARVC) had epsilon waves in V1-3 leads; all seven had a negative T wave in V1-3 leads (three only had a V1 lead, one had only V1 and 2 leads, two had only V1-3 leads, and one had V1-4 leads). Conclusions: In PH patients with an organized RV myocardial change, such as RV hypertrophy and/or fibrosis, the frequency of epsilon waves was significantly less than those in ARVC. Epsilon waves seem not only to be caused by an organized RV myocardium but also by other factors.

Abstract 13084: Epsilon Waves on Electrocardiograms in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy: Relationship to Left Ventricular Invasion or Heart Compression Due to an Enlarged Right Ventricle

Introduction: Epsilon waves on V1-3 leads are known as one of the specific lead ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) that suggests the presence of RV conduction delay. Four dimensional (4D) cardiac CT visualizes ARVC characteristics, such as fat and fibrotic invasion in RV (RVM) and left ventricular (LV) myocardium (LVM), an enlarged RV, reduced RV motion, and bulging. Hypothesis: If epsilon waves are observed in V4-6 leads, this finding suggests the occurrence of LV invasion in ARVC. Another hypothesis exists in which extreme RV enlargement may compress the LV and cause clockwise rotation; an enlarged RV itself may cause epsilon waves in V4-6 leads. Methods: This is a retrospective analysis of 17 patients (11 males, 57 ± 17 years) with suspected ARVC who underwent cardiac CT. On 4D CT, nine met 2010 ARVC task force criteria. Results: All nine patients had epsilon waves on ECG. Five had fat and fibrotic invasion in the LVM but four did not. We divided nine into the following five groups by CT findings. On CT, a markedly enlarged RV compressed the LV to the left side and a fibro fatty change were observed exclusively in RVM (gp 1, N=1) or were observed in both RVM and LVM (gp 2, N=2). A moderately enlarged RV without compression of the LV to the left side and a fibro fatty change were observed exclusively in RVM (gp 3, N=3), or observed in both RVM and LVM (gp 4, N=2). The complications of severe mitral valve regurgitation, a markedly enlarged LV, and a fibro fatty change were observed in both RVM and LVM (gp 5, N=1). A patient in gp 1 showed epsilon waves in V1-6 leads. Patients in gp 2 showed epsilon waves in V1-6 (N=1), and V3-5 (N=1) leads, respectively. Patients in gp 3 showed epsilon waves in V1-4 (N=2), and V1-3 (N=1) leads, respectively. Patients in gp 4 showed epsilon waves in V1-3 (N=1), and V1, 2 (N=1) leads, respectively. A patient in gp 5 showed epsilon waves in V4-6 leads. Conclusions: The distribution of epsilon waves on ECG in patients with confirmed ARVC by cardiac CT was highly influenced by the degree of LV compression due to a markedly enlarged RV on CT rather than the presence of LV invasion. Also, structural change due to complicated heart diseases, such as valvular diseases, may also influence the distribution of epsilon waves in ARVC.

Abstract 13068: Epsilon and Inverted T Waves in Right Side Precordial Leads in Pulmonary Hypertensive Patients With or Without Right Ventricular Hypertrophy or Fibrosis on Cardiac Computed Tomography

Introduction: Epsilon and inverted T waves on V1-3 leads are known as specific ECG findings in patients with arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC), which suggests the presence of RV conduction delay. Right bundle branch block (RBBB) is often observed in ARVC. In patients with pulmonary hypertension (PH) due to RV pressure load, the occurrence of RV hypertrophy and fibrosis are frequently observed, which may also lead to the occurrence of RV conduction delay and epsilon waves. Hypothesis: We hypothesized that there were epsilon and inverted T waves in right side precordial leads on ECG in PH patients with RV hypertrophy and/or RV fibrosis, both confirmed on cardiac CT. Methods: We retrospectively analyzed 43 patients (33 females, 55 ± 15 years, 31 chronic thromboembolic PH, 7 idiopathic pulmonary arterial hypertension) with proven PH by right heart catheterization. On CT, RV fibrosis was defined as a contrast defect in the early phase and a conversely abnormal enhancement in the late phase. Results: 32 and 9 patients had RV hypertrophy and RV fibrosis, respectively; of these, 4 had both. Of 32 PH patients with RV hypertrophy, 2 had complete RBBB and 8 had incomplete RBBB. Of 22 PH patients with RV hypertrophy but without any RBBB, only one (5%) had typical epsilon waves and 2 (9%) had waves with abnormal small upward spikes after the QRS wave that were more marked in II and aVF leads than V1 and 2 leads; these were not typical epsilon waves. 14 had a negative T wave in V1-3 leads (5 had only a V1 lead, one had only V1 and 2 leads, 4 had only V1-3 leads, and 4 had V1-4 leads, respectively). Of 9 PH patients with RV hypertrophy, one had complete RBBB and one had incomplete RBBB. Of 7 PH patients with RV fibrosis but without any RBBB, none (0%) had epsilon waves in V1-3 leads. All 7 had a negative T wave in V1-3 leads (3 had only a V1 lead, one had only V1 and 2 leads, 2 had only V1-3 leads, and one had V1-4 leads). Conclusions: In a total of 37 PH participants with an organized RV myocardial change, such as RV hypertrophy and fibrosis confirmed on cardiac CT, only one (3%) had typical epsilon waves that are frequently found in patients with ARVC. The mechanism of epsilon waves occurring predominantly in V1-3 leads seems not only to be caused by an organised RV myocardium, but also by other factors.

3 Non-specific ECG Findings in Patients with Low High-Sensitivity Troponin Values Are Not Associated With Significant 30-day Adverse Outcomes

3 Non-specific ECG Findings in Patients with Low High-Sensitivity Troponin Values Are Not Associated With Significant 30-day Adverse Outcomes

Fragmented QRS on electrocardiography as a predictor of myocardial scar in patients with hypertrophic cardiomyopathy

Background: Fragmented QRS (fQRS) and Q waves are ECG findings in patients with myocardial scar. fQRS is more sensitive than pathological Q waves in detecting myocardial fibrosis in patients with coronary artery disease (CAD). Cardiac magnetic resonance (CMR) imaging is used for the diagnosis and for quantifying scar tissue in patients with HCM. Our aim was to correlate ECG parameters like fQRS and Q waves with the presence of late gadolinium enhancement (LGE) assessed by contrast CMR imaging to elucidate ECG markers which might predict scar tissue in HCM.Methods: This study is a retrospective analysis which included 39 patients who were diagnosed/suspected to have HCM on echocardiography and referred for contrast CMR imaging at our centre between 2010 and 2016. Presence of fQRS was correlated with scar demonstrated by LGE on CMR.Results: Twenty four (66.67%) patients had asymmetrical septal hypertrophy, 7 (19.44%) patients had apical involvement while 5 (13.89%) had concentric pattern. Only 4 (11.11%) patients had pathological Q waves in contiguous leads on surface ECG while fQRS in two contiguous leads was present in 23 (63.89%) patients. Presence of fQRS was more in patients with LGE on CMR than those without (84.61 versus 10%, p<.001). When presence of LGE in specific segments (anterior, lateral and inferior) was correlated with corresponding ECG leads, all the three segments showed significant correlation. The overall sensitivity, specificity, PPV and NPV of fQRS for predicting scar tissue were 84.6, 90.0, 95.6 and 69.2%, respectively.Conclusion: fQRS on surface ECG can be used as an indirect marker to predict the presence of fibrosis in HCM.

Clinical presentation and treatment in patients with acute coronary syndrome in a tertiary care general hospital in Bangladesh

Acute coronary syndrome (ACS) is a leading cause of death among people in Bangladesh. The aim of the study was to analyze the clinical course and treatment strategies in patients with ACS and to determine to what extent management of ACS in a tertiary care general hospital in Bangladesh adhered to current guidelines. This study was carried out in the coronary care unit (CCU) of a tertiary care general hospital, Rajshahi, for a period of 3-months. A total number of 240 patients presenting with ACS were included in our study and the most common symptoms were acute chest pain (90%) and dyspnea (49%). The study group comprised of 27% female and 73% male patients with varying risk factors including hypertension (45%), hyperlipidemia (43%), family records of coronary artery disease (CAD) (20%), diabetes (17%) and smoking (15%). The most frequent ECG finding in patients was T wave change (71%), pathological Q wave (67%), ST segment elevation (33%), ST depression (9%), whereas, 12% patients with ACS reported to have normal ECG. Patients with ACS had elevated levels of SGOT and CK-MB. Troponin I level was positive in 100% of the patients with a mean peak troponin level of 1.5± 0.15ng/ml. In clinical setting, the patients were immediately managed with isosorbidedinitrate (58%), streptokinase (40%) and intravenous heparin (LMWH) followed by (46%) and (54%) of aspirin and aspirin-clopidogrel combinations respectively. In addition, long-term management with antihypertensive included β-blocker (58%), calcium channel blocker (29%), ACE-I (25%) and diuretics (12%). Anti-diabetic (18%) drugs were also prescribed in patients with co-existing diabetes and CAD. Adherence to guidelines is limited by lack of funds and resources in the hospital; however, attention must be paid to improve patient outcome. The average hospital stay ranges 2-3 days and hospital mortality was 10%.Asian J. Med. Biol. Res. March 2018, 4(1): 117-122

Electrocardiographic changes in organophosphate poisoning - A prospective study of 50 cases at a tertiary care center in Gujarat

Introduction: Organophosphates (OP) are irreversible cholinesterase inhibitors, producing nicotinic and muscarinic effects. Cardiac complications with these compounds are often fatal. Early recognition of abnormal rhythm protects the patients against acquiring life-threatening arrhythmias. Hence, this study was done to determine the ECG findings in patients with OP poisoning. Aims & Objectives: To determine the various electrocardiographic changes & its importance in acute Organophosphate poisoning. Materials and methods: This prospective observational study of 50 cases was conducted for 2 years in a tertiary care institute. All adults with history of OP poisoning, admitted within 12 hours were enrolled. Patients with cardiac disease or treated from outside were excluded. Diagnosis was made by history, clinical features and confirmed by serum cholinesterase level. ECG analysis of each case was done for rate, rhythm, ST-T changes, PR and QTc intervals, and conduction defects etc. Results: Mean age in the study group was 30.66 ± 11.70(SD). Male:Female ratio was 1.94:1. 78% were suicidal, 22% were accidental and 6(12%) cases expired. Most common mode of poisoning was ingestion 45 cases (90%). Most common ECG abnormality was Sinus Tachycardia in 12(24%) followed by ST-T changes 8(16%), QTc prolongation in 6(12%), Sinus Bradycardia 4(8%), Extrasystole 2(4%), PR Prolongation 1(2%), AF 1(2%) and VT 1(2%). Conclusion: Poisoning with OP compounds can produce significant ECG abnormalities especially sinus tachycardia, non specific ST-T changes and QTc interval prolongation. Since these abnormalities can cause lethal arrhythmia and cardiac damage, careful observation of the electrocardiogram of the patients exposed to OP compound is necessary, parallel to the appropriate medical management.

Abstract 308: Aortic Valve Stenosis Causes Both Delayed Ventricular Depolarization and Repolarization

Background: Increased QRS duration (QRSD), a common ECG finding in patients (pts) with aortic valve stenosis (AVS), can result in false QT prolongation. This study aimed to test a hypothesis that in AVS delayed ventricular repolarization is independent from the delayed depolarization. Methods: In a retrospective AVS study, ECGs prior to valve repair/replacements were evaluated. QRSD and QTc (Bazett's) were compared between pts with severe and non severe AVS. ECGs showing QRSD &gt; 120 ms or non-sinus rhythm were excluded for analysis. In pts with both wider QRS and longer QT interval (QTc &gt; 440 ms), JT (QT-QRSD) was used to determine the repolarization time. Results: Pts with severe AVS (n=219) had longer QRSD [100 (16) ms vs. 88 (12) ms, p&lt;0.001], with QTc ≥ 450 ms seen in 53%. JT is much longer in the ALQTS group (Table 1). More pts had QTc ≥ 470 ms (33% vs 23%, p&lt;0.05) in the severe AVS than the non-severe AVS. Conclusion: A wider QRS and higher prevalence of moderate to markedly prolonged QT interval in pts with severe AVS indicates AVS itself can result in a delay of both ventricular depolarization and repolarization.

T-wave inversion in patients with acute pulmonary embolism: Prognostic value

IntroductionT-wave inversion (TWI) is a common ECG finding in patients with acute pulmonary embolism (APE). ObjectivesTo determine the prevalence of TWI in patients with APE and to describe their relationship to outcomes. MethodsRetrospective study of 437 patients with APE. TWI patterns were described in two distributions: inferior (II, III, aVF) and precordial (V1-V6). ResultsTWI was observed in 258 (59%) patients. The mortality rate was significantly higher in the group with TWI in the inferior AND precordial leads compared to the group without TWI (OR: 2.74; p = 0.024) and the group with TWI in the inferior OR precordial leads (OR: 2.43; p = 0.035). As compared those with TWI in <5 leads, patients with TWI in ≥5 leads experienced significantly higher rates of death (17.1% vs. 6.6%, OR: 2.92; p = 0.002) and complications. ConclusionsTWI and the quantitative assessment thereof can be useful to risk stratify patients with APE.