EKG Changes Research Articles

Heart rate and EKG changes in 102 seizures: analysis of influencing factors

Purpose: Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in patients with epilepsy. Since cardiac arrhythmia may be a responsible factor, we sought to determine the prevalence of significant EKG abnormalities during and immediately after epileptic seizures, and to identify risk factors for these changes. Methods: We retrospectively assessed changes in heart rate (HR) and the occurrence of EKG abnormalities in 102 seizures (71 non-generalized, 31 generalized) from 41 patients using video-EKG-EEG recordings. Results: The majority of seizures (101/102; 99%) led to an increase in HR. EKG abnormalities (other than sinus tachycardia) were noted in 22/102 (21.5%) seizures overall. Most EKG changes were benign, but potentially serious changes occurred in 6/102 (6%) seizures and 4/41 (10%) patients. These included ST-depression (5 seizures in 3 patients) and T-wave inversion (1 seizure). Ictal HR was higher ( P<0.03) and EKG-abnormalities were more common ( P<0.05) in generalized compared to non-generalized seizures. Ictal EKG abnormalities were seen in 35% of generalized seizures, including potentially serious changes in 13%. There was a trend towards higher risk of ictal EKG abnormalities when seizures arose from sleep or from the left hemisphere, when MRI showed evidence of hippocampal sclerosis, and when ictal HR was higher. Age and seizure duration had no effect on the occurrence of EKG abnormalities. Conclusion: We conclude that ictal EKG abnormalities other than sinus tachycardia are not unusual, especially in generalized seizures. These findings may be relevant to the phenomenon of SUDEP.

Electrocardiogram reference values for the buzzard in Spain.

Electrocardiographic reference values were established on apparently healthy buzzards (Buteo buteo) in Lugo (Spain) from March 1997 to June 1999. All birds were anesthetized with isofluorane and placed in dorsal recumbence. The standard and augmented unipolar limb leads electrocardiograms were recorded in 65 buzzards. The wave forms were analyzed in lead II at 50 mm/sec and at 1 cm = 1 mV to determine P, PR, QRS, T and QT durations and P, QRS and T amplitudes. The polarity of each wave form was tabulated in all leads. The mean electrical axis (MEA) for the frontal plane was calculated using leads II and III. The mean heart rate was 325.2 +/- 52.9 beats/min. In lead II, the P wave was positive, the dominant pattern of QRS complex was QS and the T wave was always positive. The average value of the MEA was -99.2 +/- 7.7 degrees. Establishment of normal electrocardiogram (EKG) values will facilitate a better understanding of EKG changes seen in many diseases of these birds.

EKG is Unreliable in Detecting Potentially Lethal Hyperkalemia in Hemodialysis (HD) Patients

It is speculated that the usual EKG manifestations of hyperkalemia are less frequent and less pronounced in HD patients than in those with normal renal function. We studied 74 consecutively selected stable HD patients to determine the prevalence of EKG changes of hyperkalemia. Predialysis serum electrolytes were measured and simultaneous 12-lead EKG obtained. Mean serum potassium concentration was 4.9±0.71 meq/L (range 3.3–6.7 meq/L). No study subject evinced arrhythmia or any of the typical EKG changes associated with hyperkalemia. There was no significant difference in T wave amplitude (F statistic = 2.1; P = 0.11) or T wave to R wave ratio (F statistic = 2; P = 0.12) between quartiles of serum potassium concentration. Also, T wave amplitude was equivalent in patients with serum potassium concentration >5.5 meq/L (7.1±4.1 mm) or >5.5 meq/L (5.2±3.5 mm)(P=0.13). Serum calcium concentration had an inverse relation with T wave amplitude (P=0.03) after adjustment for other factors (i.e., high serum calcium concentration was associated with low T wave amplitude). We conclude that HD patients with hyperkalemia may not exhibit the usual EKG sequella of hyperkalemia, possibly due to fluctuations in serum calcium level. Thus, the absence of EKG changes in hyperkalemic HD patients should be interpreted with caution.

Implications of symptomatic, hemodynamic, and EKG changes during exercise stress testing in patients with aortic stenosis: Relationship to coronary artery disease Luc M. Beauchesne, Kwan L. Chan, Kathy J. Ascah, Ian G. Burwash. University of Ottawa Heart Institute, Ottawa, Canada

Implications of symptomatic, hemodynamic, and EKG changes during exercise stress testing in patients with aortic stenosis: Relationship to coronary artery disease Luc M. Beauchesne, Kwan L. Chan, Kathy J. Ascah, Ian G. Burwash. University of Ottawa Heart Institute, Ottawa, Canada

Predicting the Need for Medical Intensive Care Monitoring in Drug-Overdosed Patients

Drug overdose (OD) is one of the most common single diagnoses admitted to medical intensive care units (MICUs). The diagnosis results in relatively little morbidity or mortality, suggesting a need to improve the methods utilized in deciding on MICU admission. Our objective in this study was to develop a quantitative system whereby the emergency room (ER) physician, with reasonable safety and ease, would be able to discriminate between the need for an ICU and a nonmonitored bed. We reviewed the charts of 216 consecutive MICU admissions for intentional OD involving 199 patients between the years 1995 and 1998. Clinical histories, vital signs, laboratory data inclusive of toxicologic analysis, and both APACHE II and Glasgow coma scores (GCS) were assessed from the ER and on transfer to the MICU 4–6 hours later. These scores, as well as individual components of the APACHE II score, were evaluated for significance. Of 216 admissions reviewed, 75 (35%) had MICU-requiring morbidity: intubation 61%, pneumonia 20%, arrhythmia or EKG changes 20%, and hypotension 3%. Mortality was 2.7%. The remaining admissions were for ICU monitoring due to lethargy, irritability, laboratory abnormalities, or simply based on the diagnosis of drug overdose. Urine examinations for drugs were positive in only 53%, with the most common agent identified being benzodiazepines (39%). Age, Apache II score, and GCS were significantly different between those patients who developed MICU-requiring morbidity and those who did not, as well as when comparing the morbidity with the mortality group. Receiver operator control (ROC) curves reveal that both the APACHE and GCS are excellent and equal predictors of morbidity, with a GCS of ≤ 12 having 88% sensitivity and 92% specificity in predicting MICU-requiring morbidity. We conclude that ER evaluation of GCS can be used to accurately assess and predict the need for MICU monitoring in drug overdose. OD patients with a persistent GCS of greater than 12 or who do not demonstrate any hemodynamic, infectious, or electrocardiographic complications in the ER do not require MICU admission.

Natural history of cardiac involvement in myotonic dystrophy: correlation with CTG repeats.

The authors prospectively studied the natural course of cardiac involvement and its relationship to cytosine-thymine-guanine (CTG) expansion in 50 patients with myotonic dystrophy who were submitted to periodic cardiovascular EKG and EKG-Holter monitoring during a median follow-up of 56 months. Nineteen patients (38%) developed major EKG changes. CTG length was not correlated with the frequency of EKG abnormalities, but was inversely correlated with the age at onset of EKG abnormalities (p < 0.0001). CTG length influences the timing of cardiac complications in myotonic dystrophy.

Succinylcholine-Induced Hyperkalemia in Patients with Renal Failure: An Old Question Revisited

Succinylcholine-Induced Hyperkalemia in Patients with Renal Failure: An Old Question Revisited

Clinical utility of CKMB isoform determinations in patients who present to the Emergency Department with continuous or resolved chest pain

The object of this investigation was to demonstrate that the enhanced sensitivity of the diagnosis of acute myocardial infarction (AMI) using a more-inclusive criterion of CKMB Isoforms may detect earlier stages of AMI (designated Isoform Type 2) than the currently accepted marker for AMI by CKMB Isoform (designated Isoform Type 1) in a busy, urban Emergency Department (ED). Two features characterized the study of CKMB Isoforms in a prospective cohort of 223 ED patients: first, nontraumatic chest pain within 12 h before presentation, thought to be of ischemic etiology; and second, normal or nondiagnostic electrocardiogram (EKG). Patients were further divided into two groups characterized as either recent but resolved chest pain at ED visit, or ongoing or staccato chest pain. Sensitivity (S), specificity (SP), positive (PPV) and negative (NPV) predictive values, and 95% confidence intervals (CI) for AMI diagnosis were determined. Two criteria for AMI diagnosis by CKMB Isoforms were tested. The first and currently recommended criterion was identified as Isoform Type 1. An AMI diagnosis by Type 1 criterion requires both CKMB2≥2.6 IU/L and CKMB2/CKMB1≥1.7. The second criterion for AMI diagnosis was identified as Isoform Type 2, which is defined as either CKMB2≥2.6 IU/L or CKMB2/CKMB1≥1.7. Both Isoform types are predictive of AMI by the gold standard, and addition of EKG changes results in a small improvement. Type 1 demonstrates SP 0.94 (CI 0.90, 0.97) and NPV 0.90 (CI 0.86, 0.94), and Type 2 demonstrates S 0.90 (CI 0.80, 0.97) and NPV 0.97 (CI 0.93, 0.99) for AMI diagnosis. Type 2 criteria can confidently exclude the immediate risk of AMI in patients with resolved chest pain whereas in patients with continuous chest pain, Type 1 criteria may identify those at high risk for AMI.

Wolff-Parkinson-White Syndrome Simulating Inferior Myocardial Infarction in a Cocaine Abuser for Urgent Dilation and Evacuation of the Uterus

Wolff-Parkinson-White Syndrome Simulating Inferior Myocardial Infarction in a Cocaine Abuser for Urgent Dilation and Evacuation of the Uterus

Indigo Carmine-Induced Severe Hypotension

Indigo Carmine-Induced Severe Hypotension

Safety baseballs reduce ventricular fibrillation and EKG changes in a biological model of commotio cordis, sudden death from low energy chest wall impact

Safety baseballs reduce ventricular fibrillation and EKG changes in a biological model of commotio cordis, sudden death from low energy chest wall impact

Hyperosmotic-hyperoncotic solutions during abdominal aortic aneurysm (AAA) resection.

A largely positive perioperative fluid balance during both elective and emergency abdominal aortic aneurysm repair (AAA) may put patients at risk of developing left ventricular failure and may thus contribute to morbidity. In the present paper we report on a prospective study using hyperosmotic-hyperonocotic solutions (HHS) infused during clamping of the aorta, for the prevention of declamping shock, and the associated reduction in perioperative fluid requirements. The major aim of this paper was to determine the efficacy of an HHS infusion when given over 20 minutes and to detect possible adverse effects of HHS. For perioperative fluid replacement 12 patients received crystalloid solutions with HHS [250 ml of 7.2% NaCl combined with either 6% Dextran (n = 3), 6% Hydroxyethylstarch (HES, n = 4) or 10% HES (n = 5)]. In 16 controls, crystalloids with 1000 ml of HES 10% were infused. Patients were invasively monitored and hemodynamic parameters frequently assessed during the operation, which were statistically analyzed in relation to the start of the fluid loading during clamping of the aorta. One patient showed an anaphylactoid reaction to HES, otherwise no side effects of HHS were observed during infusion (no hypotension, no pathological EKG changes). Plasma sodium and chloride concentration as well as osmolality rose resulting in an osmotic gradient and a desired intravascular volume expansion. Prior to declamping pulmonary capillary wedge pressure had increased to the desired value of > 13 mmHg and < 18 mmHg. Oxygen delivery was significantly elevated upon HHS and remained so post declamping, whereas no change was observed in controls. During clamping systemic vascular resistance was significantly decreased, but was unchanged in controls. The perioperative fluid balance of patients receiving HHS was 2471.0 +/- 948.6 ml, which was significantly less than + 3386.7 +/- 1247.9 ml of controls (P < 0.01). We suggest that HHS opens new perspectives in perioperative fluid management of both elective and emergency AAA repair, since hemodynamic parameters are improved and the overall fluid balance is less positive, thus decreasing the likelihood of edema formation. Moreover, the previously described positive microcirculatory effects of HHS may be particular beneficial in some high-risk patients.

Transient Myocardial Ischemia during General Anesthesia with Isoflurane: Case report

Myocardial ischemia occurs when myocardial oxygen availability is inadequate to meet metabolic requirements. The common cause of myocardial ischemia is atherosclerotic epicardial coronary arteries. Isoflurane is a potent small vessel-type coronary vasodilator and has the potential for causing regional myocardial ischemia in patients with coronary disease, but it's still controversial. We experienced a case of transient myocardial ischemia during general anesthesia with isoflurane. The patient was a 51 year- old male who underwent a direct clipping of an anterior communicating artery aneurysm. There was no specific abnormality on preoperative laboratory tests except for mild mitral valve regurgitation on the cardiac echocardiogram. He had once experienced several minutes of sudden severe chest tightness just 3 months before admission, but it had subsided without any specific treatment. One hour after beginning of operation, abnormal EKG changes such as ST-T elevation, QRS widening, VPC, ventricular tachytcardia and ST-T depression appeared and then normalized within 2 minutes with stopping isoflurane and using isosorbide dinitrate. He discharged 12 days later without complications. After discharge, Tread-mill test, SPECT and 2D echocardiogram were performed but there was no any evidence of coronary artery disease. (Korean J Anesthesiol 1997; 33: 974∼978)

Relationship of emotional behaviors induced by electrical stimulation of the hypothalamus to changes in EKG, heart, stomach, adrenal glands, and thymus.

The relationships of hypothalamically elicited emotional behaviors to their accompanying pathophysiological effects were examined as a model of how complex "emotional behaviors" may be related to fundamental psychosomatic disorders. Twenty-two unanesthetized adult cats were studied. EKG alterations and histological changes in the heart, stomach, adrenal glands, and thymus were related to the specific stereotypical emotional behaviors that could be elicited by hypothalamic stimulation in tamed subjects. Restlessness, threat, and searching-biting behaviors were evoked by electrical stimulation of the anteromedial, ventromedial, and lateral hypothalamus, respectively. The occurrence of cardiac arrhythmias, ST and/or T (ST-T) changes in the EKG, histological damage to myocardium, gastric erosion, and adrenal hyperplasia were generally observed in the restlessness and threat groups but not in the searching-biting group. The pathophysiological effects were similar in the restlessness and threat groups with no specific EKG change or organ effect attributable to either site of stimulation. Hypothalamically elicited restlessness or threat behaviors in cats are each associated with cardiac, gastric, and adrenal pathophysiologies.

712-6 Detecting Myocardial Stunning During CABG Surgery with Myocardial Contrast Echocardiography (MCE)

During cardiac surgery, differentiating between ischemic and non-ischemic LV dysfunction is critical for prognosis and therapeutic strategies. We hypothesized that flow determined with myocardial contrast echo and wall motion analysis would enable identification of stunned myocardium. Twelve patients who received aortic root injections of Albunex R contrast during elective CABG surgery were compared to 14 matched controls for contrast agent safety. CPK enzymes, EKG, and hemodynamics were measured (pre- and post-op) for 72 hr. Baseline wall motion was scored (0–4) in contrast patients from 4 equally divided LV mid-papillary, short-axis regions and after CPB at the following intervals: 15, 30, 60 min.; 12 hr.; 5–8 days; and 30 days. Recorded images were analyzed off-line by 3 observers blinded to outcome. Contrast enhancement of myocardial perfusion at the time of surgery was also assessed in equally divided LV regions from the short-axis, LV echo image. Relationships between flow and function were described based on acute function (AF) (the avg. of scores at 15, 30, and 60 min after CPB). chronic function (CF) (the avg. of scores at 12 hr., 5 days, and 30 days), and intraoperative flow score. There were no significant differences pre- and post-op between control and contrast groups with respect to CPK enzymes, EKG changes, and hemodynamics. When coupled to function, flow was measured 60% of the time (29 of 48) Four relationships of flow and function were defined (function score of 0–2 = abnormal; 3–4 = normal): Normal AF = 3–4 flow normal CF = 3–4 Stunned AF = 0–2 flow nomal CF = 3–4 Hyperdynamic AF = 3–4 flow abnormal CF = 0–2 Other (post-op event) AF = 3–4 flow normal CF = 0–2 Relationship of Flow and Function by Region Region Normal Stunned Hyper Other Anterior 7 6 - - 1 Posterior 9 6 3 - - Septal 7 5 - 2 - Lateral 6 5 - 1 - 76% 10% 10% 4% Differentiation of non-ischemic and ischemic LV dysfunction appears possible with MCE and wall motion analysis. Myocardial stunning occurred 10% of the time after elective CABG surgery. Intraoperative flow and chronic function after CABG surgery are strongly linked (96%).

1001-26 Local Dissolution of Intracoronary Thrombus with Urokinase Using the Dispatch™ Catheter: Clinical Studies

The Dispatch™ Catheter is a new local drug delivery device which allows for the prolonged infusion of therapeutic agents at an angioplasty site while still maintaining distal coronary perfusion. To determine the efficacy of this device in dissolving intraluminal clot with local urokinase infusion, 29 patients with thrombus-containing stenoses were treated with the Dispatch™ catheter either prior to (n = 16) or following (n = 13) coronary angioplasty or directional atherectomy. The study group consisted of 15 males and 14 females with a mean age of 58.1 years. Clinical diagnoses included unstable angina (n = 14), acute myocardial infarction (n = 11) or post infarction angina (n = 4). Urokinase was infused at either 10,000 unitlcc (n = 22) or 30,000 units/cc (n = 7) at 0.5 cc/min for up to 30 minutes. All coronary angiograms were analyzed to determine Thrombus Score (0 – 3), TIMI flow, and quantitative coronary measurements pre and post Dispatch™ therapy. (Thrombus Score: 0 = no thrombus, 1 = possible thrombus, 2 = definite thrombus &lt; 3 mm, 3 = definite thrombus &gt; 3 mm). Infusions of urokinase for 30 mins were well tolerated in 25 patients without adverse clinical, hemodynamic or electrical sequelae. In the remaining 4 patients, limited infusions were tolerated only for 2.5, 5, 6 and 11 mins because of chest pain with EKG changes secondary either to sidebranch occlusion or inadequete distal perfusion. For the entire study group, Thrombus Score decreased from 2.0 ± 0.7 to 0.5 ± 0.8, TIMI Flow increased from 2.1 ± 1.3 to 3.0 ± 0.0, and minimal lumen diameter increased from 0.70 ± 0.59 to 1.58 ± 0.51 mm (all p &lt; 0.01). Distal embolization, no-reflow, and abrupt closure were not observed in any patient. Reduction of thrombus-containing stenoses and dissolution of intracoronary thrombus can be rapidly achieved in patients with infusions of limited quantities of urokinase with the Dispatch™ catheter. Sidebranch occlusion and inability to dilate coronary stenoses with inadequate distal perfusion may limit the duration of drug infusion with this device.

A Retrospective Study of Serum Levels and Electrocardiographic Effects of Nortriptyline in Children and Adolescents

Objective We retrospectively evaluated a large pediatric population treated with nortriptyline (NT) in an outpatient psychopharmacology clinic to assess pharmacokinetic and electrocardiographic (EKG) effects. Methods: A systematic search revealed 82 children and adolescents treated naturalistically with NT. All patients with available EKGs and serum NT levels were included in the series with the exception of those receiving concomitant antipsychotic agents. Forty-three percent of subjects were receiving medications in addition to NT. Results Patients received an average (±SE) NT dose of 2.0 ± 0.1 mg/kg yielding mean serum NT levels of 105.5 ± 7.4 ng/mL. There was a linear relationship of NT dose (mg/kg) to serum NT levels ( r = 0.50, p < 0.0001). NT treatment resulted in small increases in heart rate, and PR, QRS, and QTc intervals (all ps < 0.01), of similar magnitude in children and adolescents. Individuals with the highest baseline EKG indices had the least amount of change in those indices with NT treatment. There were only a few statistically significant associations between NT dose or serum NT levels and EKG parameters. NT treatment was significantly associated with the onset of asymptomatic sinus tachycardia (heart rate > 100 beats per minute), and prolongation of the EKG QRS (>100 msec) and QTc (>440 msec) intervals. Conclusions; These findings suggest: (1) NT has a predictable dose to level relationship, (2) the effect of NT on the EKG in this age group is mild and similar to that reported with other tricyclic antidepressants, and (3) there are few age-specific differences in NT-induced EKG changes. J. Am. Acad. Child Adolesc. Psychiatry, 1993, 32, 2:270–277.

The heart in Becker muscular dystrophy, facioscapulohumeral dystrophy, and Bethlem myopathy.

We report a study, assessing involvement of the heart in 33 familial cases of Becker muscular dystrophy (BMD), 31 familiar cases of facioscapulohumeral (FSH) dystrophy, and 27 familial cases of Bethlem myopathy. In the patients with BMD, correlations of myocardial involvement with age and extent of musculoskeletal involvement were made. We performed physical examination, chest x-ray, electrocardiographic (EKG), and echocardiographic examination on all patients, and continuous EKG Holter-monitoring in the patients with FSH dystrophy. Thirteen patients with BMD (45%) showed EKG changes similar to those found in Duchenne muscular dystrophy. Only 1 of the 13 individuals with cardiac involvement was wheelchair-bound. We found no evidence of cardiac changes in the patients with FSH dystrophy. In Bethlem myopathy, only 1 patient had a form of hypertrophic cardiomyopathy (asymmetrical septal hypertrophy).

Fluoxetine in Children and Adolescents with Mood Disorders: A Chart Review of Efficacy and Adverse Effects

ABSTRACT The charts of 31 hospitalized children and adolescents (ages 9-18 years) with major mood disorders were retrospectively reviewed to examine the efficacy and side effects of treatment with fluoxetine. After treatment for a mean duration of 35 days, clinical improvement was seen in 74% of these patients; 54% had "much" to "very much" improvement as measured by the Clinical Global Impression scale (CGI). The most common adverse effects were hypomania-like symptoms (23%), irritability (19%), gastrointestinal upset (13%), and insomnia (13%). No EKG changes, blood pressure changes, anticholinergic symptoms, sedation, weight changes, or seizures were observed. None of the patients experienced an increase in suicidal or parasuicidal behavior. Discontinuation of the fluoxetine treatment occurred in 28% of cases, most commonly because of increasing irritability and hypomania-like symptoms. The hypomania-like effects included a constant sense of silliness, increased activity, poor sleep, increased energy, an increase in the stream of thoughts (racing thoughts), or socially intrusive or obnoxious behavor. Fluoxetine triggered symptoms suggestive of hypomania in all four of the depressive bipolar patients.

Evolution of the electrocardiographic changes in patients with hypertrophic cardiomyopathy

In 75 patients with hypertrophic cardiomopathy (HCM) followed for a mean period of 5.5 years (range 2-20 years), evolution of the electrocardiographic (EKG) changes was assessed. Progression of EKG abnormalities occurred in 35 patients (47%). It was manifested by an increase in precordial QRS voltage in 33 patients, development of new P-wave mitral in 11 patients, and development or disappearance of pathologic Q waves in 14 patients. With follow-up times greater than 5 years, 5-8 years, and greater than 8 years, EKG progression was present in 27, 41, and 80% of patients, respectively. Age less than 30 years at the beginning of study and left ventricular outflow obstruction predisposed to EKG progression within 5-8 years. Patients with progressive EKG changes were more prone to experience clinical deterioration than those without EKG progression (63 vs. 15%, p less than 0.001). With chronic verapamil administration, progression of EKG abnormalities occurred insignificantly less often than with propranolol treatment (35 vs. 64%, p = 0.20). It is concluded that with long-term follow-up, HCM tends to progress in a significant proportion of adult patients.