Electrocardiographic Testing Research Articles

COVID-19 Infection and Myocarditis: A State-of-the-Art Systematic Review.

Background:COVID-19 was initially considered to be a respiratory illness, but current findings suggest that SARS-CoV-2 is increasingly expressed in cardiac myocytes as well. COVID-19 may lead to cardiovascular injuries, resulting in myocarditis, with inflammation of the heart muscle.Objective:This systematic review collates current evidence about demographics, symptomatology, diagnostic, and clinical outcomes of COVID-19 infected patients with myocarditis.Methods:In accordance with PRISMA 2020 guidelines, a systematic search was conducted using PubMed, Cochrane Central, Web of Science and Google Scholar until August, 2021. A combination of the following keywords was used: SARS-CoV-2, COVID-19, myocarditis. Cohorts and case reports that comprised of patients with confirmed myocarditis due to COVID-19 infection, aged >18 years were included. The findings were tabulated and subsequently synthesized.Results:In total, 54 case reports and 5 cohorts were identified comprising 215 patients. Hypertension (51.7%), diabetes mellitus type 2 (46.4%), cardiac comorbidities (14.6%) were the 3 most reported comorbidities. Majority of the patients presented with cough (61.9%), fever (60.4%), shortness of breath (53.2%), and chest pain (43.9%). Inflammatory markers were raised in 97.8% patients, whereas cardiac markers were elevated in 94.8% of the included patients. On noting radiographic findings, cardiomegaly (32.5%) was the most common finding. Electrocardiography testing obtained ST segment elevation among 44.8% patients and T wave inversion in 7.3% of the sample. Cardiovascular magnetic resonance imaging yielded 83.3% patients with myocardial edema, with late gadolinium enhancement in 63.9% patients. In hospital management consisted of azithromycin (25.5%), methylprednisolone/steroids (8.5%), and other standard care treatments for COVID-19. The most common in-hospital complication included acute respiratory distress syndrome (66.4%) and cardiogenic shock (14%). On last follow up, 64.7% of the patients survived, whereas 31.8% patients did not survive, and 3.5% were in the critical care unit.Conclusion:It is essential to demarcate COVID-19 infection and myocarditis presentations due to the heightened risk of death among patients contracting both myocardial inflammation and ARDS. With a multitude of diagnostic and treatment options available for COVID-19 and myocarditis, patients that are under high risk of suspicion for COVID-19 induced myocarditis must be appropriately diagnosed and treated to curb co-infections.

Ispitivanje uticaja vrste sporta na učestalost elektrokardiografskIh promena kod studenata Medicinskog fakulteta koji se bave sportom

Continuous physical activity leads to a series of adaptive changes to athletes' cardiovascular system, collectively called Athlete's heart. Recognizing such physiological ECG changes and distinguishing them from the pathological myocardium-related findings, play an important role in sudden cardiac death prevention among athletes. The aim of our study was to examine the effect of the type of sport on the frequency of electrocardiographic changes between two groups of subjects, football and volleyball players. The study included 47 subjects, students of the Faculty of Medicine, University of Belgrade, divided into two groups depending on type of sport they play. The first group consisted of 29 volleyball players, while the second group consisted of 18 football players. Anthropometric parameters: body height (BH), body weight (BW), body mass index (BMI), body fat percentage (%BF) were measured first. Resting electrocardiographic test was performed in supine position, using twelve-lead electrocardiograph. From obtained electrocardiograms (ECG), using the Seattle criteria for interpretation of ECG findings in athletes, following parameters were analyzed: heart rate, heart rhythm, rhythmicity, respiratory arrhythmia, cardiac axis, duration and amplitude of individual waves, segments and intervals, QTc, right and left atrial enlargement, isolated voltage criteria for left and right ventricular hypertrophy, incomplete right bundle-branch block, first degree AV block, second degree AV block-Mobitz type I (Wenckebach), and T wave inversion. Statistical analysis was performed using paired T-test and Chi square test, within the SPSS package. Results of the study showed higher values of amplitude of P wave in the V1 lead among football players (p=0.015), alongside significant difference in frequency of T wave inversion in leads V1-V3 (p=0.048). Volleyball players demonstrated significantly higher frequency of left atrial enlargement (p=0.019). Based on presented results, we can conclude that observed ECG changes indicate that different types of sports may lead both to changes in electrical activity of cardiac conduction system and myocardium.

Adherence to Clinical Quidelines on Preoperative Assessment and Correction of Cardiovascular Risk in Non-cardiac Surgery

Surgical care is associated with a high risk of complications. In 2014 the updated joint ESC/ESA guidelines on preoperative assessment and perioperative management of patients were published to improve patient safety in non-cardiac surgery. The increase in the adherence to clinical guidelines promotes the improving of the healthcare quality and safety improvement.Aim. To study physicians' level of adherence to ESC/ESA clinical guidelines for preoperative assessment and perioperative management of patients.Material and methods. A retrospective observational study included 102 patients admitted to Moscow general hospital from 01.03.2019 to 30.06.2018 for elective surgery. All of them underwent preoperative examination in outpatient department of the hospital and had at least one concomitant disease requiring drug therapy. The medical records data on the preoperative examination and perioperative treatment with beta-blockers, HMG CoA reductase inhibitors and angiotensin-converting-enzyme (ACE) inhibitors/ angiotensin receptor blockers (ARBs) were analyzed for compliance with the ESC/ESA guidelines.Results. A standardized cardiac risks assessment was not documented in the results of preoperative examination. Electrocardiography (ECG), echocardiography and non-invasive stress tests were performed according to clinical guidelines in 100%, 77.8% and 25% of cases, respectively. Unnecessary ECG and echocardiography were prescribed in 50.5% and 72% of cases, respectively. Appropriate correction of ACE inhibitors/ARBs therapy was performed in 66.7% patients with congestive heart failure and only in 2.7% with arterial hypertension. In 19 patients with ischemic cardiac disease, 13 (84.2%) patients received HMG CoA reductase inhibitors and 16 (68.4%) ones received beta-blockers during hospitalization. Inappropriate omission of statins, beta-blockers and ACE inhibitors (ARBs) during hospitalization was registered in 22.2%, 11% and 4.9% patients, respectively.Conclusion. The number of inappropriate ECGs and echocardiographies, as well as incorrect treatment with beta-blockers, HMG CoA reductase inhibitors and ACE inhibitors (ARBs) in perioperative period evidence that the adherence of physicians to the clinical guidelines on preoperative assessment and perioperative management of patients remains low.It is reasonably to develop risk-based interdisciplinary protocols for preoperative examination, algorithms for interdisciplinary communication and interaction between specialists and the healthcare levels, as well as physicians' education for better adherence to clinical guidelines.

Silent Myocardial Ischemia in Type 2 Diabetic Patients Asymptomatic For Coronary Artery Disease: A Cross- Sectional Study

Background Coronary Artery Disease (CAD) is a common cause of premature morbidity and mortality in diabetics and is often asymptomatic because of silent myocardial ischemia (SMI). Early detection of SMI may prevent catastrophic cardiac events. Objective To study the prevalence of SMI in patients of type 2 diabetes mellitus (Type 2 DM), asymptomatic for CAD and to assess the role of conventional CAD risk factors in diabetic patients asymptomatic for CAD in the development of SMI. Methodology 102 cases of Type 2 DM without any clinical and electrocardiographic evidence of CAD, who attended a tertiary care hospital in North Delhi, over a period of one year, were studied for the present cross-sectional study. Detailed history, general physical examination, BMI, systemic examination and investigations like glycosylated hemoglobin (HbA1c), lipid profile, resting 12-leads electrocardiography (ECG) and treadmill test (TMT) were carried out. Results Out of 102 patients, TMT was found positive in 23 patients. It was positive in 12% among diabetic patients with duration of diabetes ≤5 years, 14.8% in patients with duration 6-10 years, 37.5% in patients with duration 10-15 years and 77.7% in patients with duration 16-20 years, respectively with p<0.001. Conclusion The prevalence of SMI in asymptomatic Type 2 DM without history of CAD is 22.54%. Duration of diabetes, presence of autonomic neuropathy (AN), dyslipidemia and HbA1c level are strong clinical predictors of SMI in asymptomatic Type 2 DM. Keywords: Silent myocardial ischemia; Type 2 Diabetes mellitus; Coronary artery Disease; Treadmill test Asymptomatic; Autonomic Neuropathy.

Value of a comprehensive exercise echocardiography assessment for patients with hypertrophic cardiomyopathy

Background: Exercise echocardiography (ExE) may assess left ventricular (LV) systolic and diastolic function, LV outflow tract (LVOT) obstruction, and mitral regurgitation (MR). We aimed to evaluate the prognostic value of these assessments during exercise in patients with hypertrophic cardiomyopathy (HCM).Methods: LV systolic function, LV-derived filling pressures, LVOT gradients, and MR were prospectively evaluated during treadmill ExE in 285 patients with HCM and preserved LV ejection fraction (EF) (≥50%). Recordings were obtained at rest and peak exercise for LV systolic function and at rest and post-exercise for LVOT gradients, MR, and ratio of early LV inflow velocity to early tissue Doppler annulus velocity (E/e´).Results: Thirty-seven patients (13%) had LVOT obstruction at rest, and 76 (27%) developed exercise-induced LVOT obstruction. New wall motion abnormalities were detected in 38 patients (13%). E/e´>14 was observed in 129 patients at rest (45%) and in 134 at post-exercise (47%). Corresponding figures for significant MR (moderate or severe) were 21 (7%) and 17 (6%). During follow-up (3.9 ± 2.5 years), 27 patients had a hard event, 39 a combined event (hard plus new atrial fibrillation or syncope), and 58 a combined event or intervention. Exercise electrocardiographic testing, exercise LVEF, and the combination of positive ExE and increased E/e´ with exercise predicted outcome. The worst event rate corresponded to patients with raised E/e’ values at post-exercise and positive ExE (annualized hard event-rate of 5.9%).Conclusions: A comprehensive assessment during ExE is feasible for patients with HCM and preserved LV systolic function, and provides significant incremental prognostic information.

Exercise electrocardiography combined with stress echocardiography for predicting myocardial ischemia in adults.

Myocardial ischemia (MI) has the highest mortality rate in the world. Traditional noninvasive MI examinations include exercise electrocardiography tests (EETs) and stress echocardiography (SE). Treadmill and dobutamine tests are commonly used as stress protocols. In the present study, 278 patients with suspected MI were examined, 66 of whom were diagnosed with MI and 212 did not show evidence of MI by coronary angiography (CAG)/coronary CT angiography (CCTA). All patients underwent clinical EET and SE evaluations prior to CAG/CCTA. All groups were compared based on specific clinical parameters including age, sex, blood pressure, heart rate, blood oxygen saturation, underlying conditions and ejection fraction/fraction shortening. The data indicated superior diagnostic efficiency of the combined EET+SE method for the diagnosis of suspected MI compared with either EET or SE alone. The sensitivity/specificity/positive predictive value and negative predictive value for detecting MI were excellent compared with those of traditional examinations. The diagnostic efficiency of the combination analysis may reduce the prevalence of MI and medical costs. The present study provided novel insight for the development of methods that may be used for MI detection and prediction.

A NOVEL APPROACH TO HEART ATTACK PREDICTION IMPROVEMENT VIA EXTREME LEARNING MACHINES CLASSIFIER INTEGRATED WITH DATA RESAMPLING STRATEGY

The heart attack is a disorder that is frequently seen in low-income countries and causes the death of many people. Cardiologists benefit from electrocardiography (ECG) tests to determine this condition. Supervised classification algorithms are frequently used and provide very successful results in computer-aided diagnostic systems. In this study, a new approach to predict a heart attack is proposed for classification via extreme learning machines (ELM) integrated with the resampling strategy. This study aims to reveal a new diagnostic system that will increase the success of current studies. The study has three basic steps. In order to determine the features that will ensure the system’s optimized operation, firstly, the ReliefF feature selection method was applied to the data set, and then, the system was modeled by different classifiers via resampling. Besides, the as-proposed approach was applied to the breast cancer data to test the accuracy of the current system. The as-obtained results from both Statlog (heart disease) and the breast cancer data were seemed to be more successful than the studies in the literature. Thus, the as-proposed system reveals a successful and effective approach that can be applied in clinical data sets.

Feasibility of a combined mobile-health electrocardiographic and rapid diagnostic test screening for Chagas-related cardiac alterations

Abstract Background Chronic Chagas cardiomyopathy (CChC) is the most common cause of death related to Chagas disease (CD), and it develops in 20–30% of infected individuals. However, access to both CD testing and basic cardiac care is often limited in rural deprived areas, hyperendemic for CD. Purpose To assess the feasibility of a combined mobile-health (m-Health) electrocardiographic (ECG) and rapid diagnostic test (RDT) screening for Chagas-related cardiac alterations in a remote rural village of the Bolivian Chaco, where a high prevalence of CChC is expected. Methods A representative sample of 140 healthy volunteers were consecutively enrolled in a rural Bolivian Community in February 2019. Demographic and clinical data were recorded through a standardized questionnaire. All patients performed an ECG by D-Heart, a validated low-cost hospital grade 8 and 12 lead smartphone portable ECG, and a serologic testing by Chagas Stat-Pak® (CSP). RDTs were read locally while ECGs were sent to a Cardiology clinic which transmitted reports within 24 hours from recording. Results Among 140 people (54 men, median age of 38 [23–54] years), 98 (70%, 95% CI 62.4–77.6) were positive for T. cruzi infection with CSP, with a linear, age-dependent, increasing trend (p<0.001). Overall, 25 individuals (18%) showed ECG abnormalities, compatible with CD. Prevalence of ECG abnormalities was significantly higher in T. cruzi infected individuals (22 vs 7%, p=0.032). None of the study participants had performed an ECG test prior to enrolment. ECG abnormalities included Bundle Branch Blocks (n=8), 1st Degree Atrioventricular blocks (n=3), rhythm disturbances (n=5), pathologic Q waves (n=2), fragmented QRS (n=5) and low QRS voltage (n=2). Twenty-two patients with a positive CSP testing and possible CD-related ECG abnormalities were recalled from Camiri Community and referred to Gutierrez Hospital for chest X-ray and treatment initiation. At multivariate analysis, positive CSP results (OR 4.75, 95% CI 1.08–20.96, p=0.039) and smoking habit (OR 4.20, 95% CI 1.18–14.92, p=0.027) were confirmed as independent predictors of ECG abnormalities. For 6-day screening for a community of 150 inhabitants, the overall start-up amount was projected to 4.82$/patient and to 8.23$/patient when operative costs (i.e. on-site nurse and healthcare assistant with remote physician on call) were included. Conclusions Combined D-Heart® ECG and RDTs screening proved a reliable and effective low-cost strategy to identify patients at high risk of disease and in need of further cardiologic assessment, in a rural, highly endemic environments of the Bolivian Chaco. Onsite and m-Health programmes should be encouraged to support early diagnosis of CD and CChC and provide access to targeted therapy to maximize treatment benefits prior to advanced cardiac involvement. Funding Acknowledgement Type of funding source: None

Cardiac Screening for High Risk Sudden Cardiac Death in School-Aged Children.

Sudden cardiac death (SCD) is an uncommon but significant cause of death in the young. Citywide cardiac screening of school-aged children has been performed in Taipei since 1989. In this study, we investigate the efficacy of this screening method for identifying those at high risk of SCD. This study analyzed the data from the results of cardiac screening for school-aged children in Taipei from 2003 to 2014. The cardiac screening included: Stage I, questionnaire surveys, simplified phonocardiography test and simplified electrocardiography (ECG) test; Stage II, physical examination and auscultation by a pediatric cardiologist for all children who had abnormal findings in stage I screening; Stage III, referral to a pediatric cardiologist for further examinations. Logistic regression and decision tree analyses were performed. A total of 566,447 students were screened, of whom 685 were identified as being at high risk of SCD. The most common causes of being at high risk of SCD included Wolff-Parkinson-White syndrome, long QT syndrome, cardiomyopathy and Marfan's syndrome. Using logistic regression analysis, the simplified ECG test was identified as being the most effective tool (odds ratio = 16.4, p < 0.001) and past history as the second most crucial factor (odds ratio = 3.95, p < 0.001) for detecting a high risk of SCD. Decision tree analysis showed that serial studies with a past history and the simplified ECG test could accurately identify those at high risk of SCD. Questionnaire survey and simplified electrocardiography test-based cardiovascular screening in school-aged children can identify those at high risk of SCD.

Heart rate variability as a potential diagnostic tool to predict compensatory hyperhidrosis after sympathectomy in patients with primary focal hyperhidrosis.

BackgroundPrimary focal hyperhidrosis (PFH) is associated with autonomic nervous activity, and studies investigating this association in patients with PFH are very important. Heart rate variability (HRV) is a simple and noninvasive electrocardiographic test showing activity and balance in the autonomic nervous system, which consists of sympathetic and parasympathetic components. The aims of this study are to investigate associations between autonomic nervous activity and hyperhidrosis characteristics using HRV and to investigate the association between HRV findings and compensatory hyperhidrosis (CH) after sympathectomy.MethodsFrom March 2017 to March 2020, 105 subjects with PFH who underwent preoperative HRV tests and sympathectomy were analyzed. All subjects underwent bilateral thoracoscopic sympathectomy. T2 sympathectomy was conducted for craniofacial hyperhidrosis, and T3 sympathectomy was conducted for palmar hyperhidrosis. The following HRV parameters chosen to investigate the association between hyperhidrosis and autonomic nervous activity were measured by time and frequency domain spectral analysis: (I) time domain: standard deviation of normal-to-normal interval (SDNN) and square root of mean squared differences of successive normal-to-normal intervals (RMSSD), (II) frequency domain: total power (TP) of power spectral density, very low frequency (VLF), low frequency (LF), and high frequency (HF). HRV parameters were analyzed according to hyperhidrosis type (craniofacial vs. palmar type), sweat reduction, and CH after sympathectomy. In addition, the independent HRV parameters influencing CH after sympathectomy were investigated with multivariate analysis.ResultsCraniofacial hyperhidrosis was significantly more prevalent in the old age group (P<0.001). Sweat reduction after sympathectomy was significantly more prominent in palmar hyperhidrosis (P=0.037), and CH after sympathectomy was more prominent in craniofacial hyperhidrosis (P<0.001). Palmar type patients exhibited significantly larger SDNN, RMSSD, TP, LF, and HF than craniofacial type patients (all P<0.001). There were no significant differences in any HRV parameters according to sweat reduction after sympathectomy. Low-degree CH was associated with significantly larger SDNN, RMSSD, TP, LF, and HF than high-degree CH (P<0.001, P<0.001, P=0.002, P=0.001, and P<0.001, respectively). Multivariate analysis showed that HF and age group were associated with CH after sympathectomy (P=0.007 and P=0.010, respectively).ConclusionsThis study shows that HRV can provide useful insight into the pathophysiology of PFH and enhance preoperative risk stratification of CH. Large-scale, prospective studies are required to determine the predictive value of HRV in patients at risk for subsequent CH after sympathectomy.

Classification of Cardiac Arrhythmias Using Feed Forward Neural Network

Arrhythmias are abnormal rhythms of heart. An irreparable damage is caused due to arrhythmias like Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF). Timely detection of such fatal arrhythmias is vital for the successive application of defibrillation therapies. Heart diseases are diagnosed using different types of tests. Electrocardiography (ECG) testing is one of most efficient and non-invasive method among all. The defined algorithms used for detection and classification of arrhythmias are based on surface Electrocardiogram analysis. However, in this research, an algorithm based on shape statistical and spectral kurtosis features is presented. In this algorithm, shape statistical features along with spectral kurtosis features are applied to the classifier to classify and detect the type of arrhythmia. Various performance measure like accuracy, executiontime and comparison of various performance functions like MSE, SSE, SAE, MAE along with training functions like Trainrp, Trainbr, Trainscg, Trainlm is done in order to identify the most excellent neural network models. The results shows an average accuracy of 90.57% with Feed Forward neural network (FFNN) as the most excellent neural network (NN) for classification of cardiac arrhythmia. The ultimate objective of this algorithm is to contribute as a coherent heart diagnostic and arrhythmia detection tool.

Pediyatrik COVID-19'da Elektrokardiyografi Değişiklikleri ve Laboratuvar Parametrelerinin Değerlendirilmesi

Objective: Cardiac involvement of Coronavirus 19 disease (COVID-19) may be reflected by electrocardiographic (ECG) changes. ECG changes that may occur in hospital admission for COVID-19 in children have not yet been fully evaluated. Materials-Methods: We examined 83 children admitted to our hospital with proven COVID-19. A detailed clinical examination, 12-lead ECG and laboratory tests were recorded. And then all laboratory parameters were evaluated by age. Results: P wave amplitude was normal in 77.1% and high in 22.9% of study population. There was a significant difference in white blood cell (WBC), lymphocyte, neutrophil, aspartate aminotransferase (AST), lactate dehydrogenase (LDH), D-dimer values between the group with P wave amplitude normal and the high group. 13.3% of patients had first degree AV block and 86.7% did not. There was a significant difference between the groups in WBC, lymphocyte, D-dimer, AST values. In our study, there was right ventricular hypertrophy (RVH) in the ECG of 17 cases. There was a significant difference in WBC, lymphocyte, D-dimer, LDH, AST values between groups with and without RVH. In addition, there were positive correlations among V1R, V6S, V1 R / S ratio and WBC, lymphocyte, D-dimer, creatinine kinase (CK), creatinine kinase isoform MB (CK-MB), LDH, AST values. Conclusions: Pathological ECG findings were associated with laboratory values used in the course of the disease. We think that ECG is a test in the course of COVID-19 in children, which may make important contributions to clinicians to manage the patients when interpreted correctly.

Results of catheter ablation in patients with idiopathic premature ventricular contractions depending on the use of fluoroscopy

Premature ventricular contractions (PVC) is a very common type of arrhythmia. Some patients require surgical treatment. The search for the safest methods of surgical treatment is an important research task.Aim. To evaluate the efficacy and safety of catheter ablation in patients with idiopathic ventricular arrhythmias depending on the implementation of X-ray control.Material and methods. The study included 183 patients admitted to the Federal Center for Cardiovascular Surgery for elective surgery, with frequent idiopathic PVC and indications for surgical treatment of arrhythmia. In the majority of patients with idiopathic PVC, the central origin of ectopia is the right ventricular outflow tract (RVOT). The patients were divided into two groups: group 1 (n=90) — patients with idiopathic PVC after fluoroscopy-guided radiofrequency ablation (RFA); group 2 (n=93) — patients after RFA without fluoroscopy. All patients underwent electrocardiography, echocardiography, and electrophysiological testing. All patients before and after RFA underwent 24-hour Holter monitoring.Results. Among patients of group 1, the initial success of RFA was 62,2%, and in group 2 — 71% (p=0,21). Surgery complications were registered in 3,3% and 4,3% of patients of groups 1 and 2. No deaths have been reported. The duration of surgery did not depend on the use of fluoroscopy. Among patients with failed initial RFA, the effectiveness of subsequent interventions was 88,6%. The greatest efficiency of initial RFA was observed when the ectopic ventricular focus was located in RVOT The lowest efficiency of RFA was observed when the focus was located in the left ventricular papillary muscles.Conclusion. RFA in patients with idiopathic PVC without fluoroscopy does not increase the complication rate and the duration of surgery and have a comparable efficacy compared to fluoroscopy-guided RFA.

Rölatif El Kavrama Gücü İndeksi ile Kronotropik Cevap İndeksi ve Kalp Hızı Toparlanma İndeksi İlişkili mi?

Introduction: This study evaluated the relationship between relative handgrip strenght index (rHGSi) as well as chronotropic response index (Cri) and heart rate recovery index (HRRi), which are the prognostic parameters of treadmill exercise. Patients and Methods: In total, 490 patients who were recommended to undergo the exercise electrocardiographic test were recruited in this study. The participants were divided into two groups based on both Cri (normal and low CRi groups) and rHGSi (high and low rHGSi groups). Results: The treadmill exercise time, peak heart rate, and metabolic equivalents were higher in the high rHGSi group than in the low rHGSi group. In addition, the 1st minute HRRi and Cri were higher in the high rHGSi group than in the low rHGSi group. The treadmill exercise time, basal and peak heart rate, metabolic equivalents, and 1st minute HRRi were significantly lower in the low CRi group than in the normal Cri group. rHGSi was considered an independent predictor of low chronotropic response index. Based on a bivariate analysis, a statistically significant positive correlation was observed between Cri and rHGSi. Similarly, there was a positive association between rHGSi and 1st minute HRRi. Conclusion: rHGSi might be a practical and effective tool in cardiovascular risk stratification.

A New Diagnostic Algorithm for Examining Patients with Suspected Chronic Coronary Syndrome: Questions Remain?

In the new recommendations of the European Society of Cardiology for Chronic Coronary Syndrome, a new diagnostic algorithm is proposed in patients with suspected coronary artery disease (CAD). The purpose of this algorithm was to propose a solution of the accumulated problems in the diagnosis of CAD, in particular, a high frequency of negative non-invasive tests and unchanged coronary arteries during invasive coronary angiography. The new diagnostic algorithm includes a revision of the pre-test probability scale, the introduction of the concept of clinical probability, clarifies the role of various non-invasive tests with the central role of non-invasive testing for myocardial ischemia. However, due to the lack of data on a number of key issues, significant gaps remain that impede the use of this algorithm in practice. This review is devoted to the consideration of problematic issues of the proposed algorithm, while a critical analysis of the algorithm itself and an assessment of recent publications are carried out. Various aspects of the application of a new scale for assessing pre-test probability, determining the clinical probability of CAD, the choice of non-invasive and invasive diagnostic tests, the place of the load electrocardiography test in the diagnosis of coronary heart disease are examined in detail. Gaps in the evidence base and limitations of the algorithm are considered, as well as the possibility of its use in Russian conditions. This review can help in adapting new recommendations to domestic conditions, as well as help practitioners to use it in their daily work.

Effects of trimetazidine on ventricular remodeling in coronary artery disease patients with left ventricular hypertrophy: the rationale and design of a randomized controlled trial

BackgroundTrimetazidine is a metabolic anti-ischemic agent, which increases the tolerance of cardiomyocytes to ischemia. However, few studies have explored the effect of trimetazidine on ventricular remodeling in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) with left ventricular hypertrophy (LVH).MethodsIt is a randomized, placebo-controlled trial, and we propose to recruit one hundred and twenty-four CAD patients undergoing PCI with LVH during a 12-month period. They will be randomized to receive either trimetazidine (35 mg twice a day) or placebo in the following 12 months after PCI. Blood tests, echocardiography, symptom of angina and major adverse cardiovascular events (MACEs) will be collected at follow-up visit at 3 and 12 months. The primary end point will be the left ventricular remodeling measured by left ventricular mass index (LVMI) at 3- and 12-month follow-up compared with the baseline. The secondary end points will be the symptom of angina assessed by Seattle Angina Questionnaire, myocardial ischemia measured by 6-min walk test and exercise electrocardiography test, as well as MACEs (defined as a composite of death, myocardial infarction, stroke, recurrent angina, re-hospitalization, change of viable myocardium).DiscussionThis study aims to demonstrate the effect of trimetazidine on left ventricular remodeling and myocardial ischemia in CAD patients undergoing PCI with LVH. Trimetazidine treatment is likely to improve the left ventricular remodeling, symptoms of angina and myocardial ischemia. It might also reduce the risk of MACEs in CAD patients undergoing PCI with LVH.Trial registrationhttp://www.chictr.org.cn, Chinese Clinical Trial Registry (ChiCTR1800017876). Registered on 19 Aug 2018.

Guidance on Minimizing Risk of Drug-Induced Ventricular Arrhythmia During Treatment of COVID-19: A Statement from the Canadian Heart Rhythm Society

The COVID-19 pandemic has led to efforts at rapid investigation and application of drugs which may improve prognosis but for which safety and efficacy are not yet established. This document attempts to provide reasonable guidance for the use of antimicrobials which have uncertain benefit but may increase risk of QT interval prolongation and ventricular proarrhythmia, notably, chloroquine, hydroxychloroquine, azithromycin, and lopinavir/ritonavir. During the pandemic, efforts to reduce spread and minimize effects on health care resources mandate minimization of unnecessary medical procedures and testing. We recommend that the risk of drug proarrhythmia be minimized by 1) discontinuing unnecessary medications that may also increase the QT interval, 2) identifying outpatients who are likely to be at low risk and do not need further testing (no history of prolonged QT interval, unexplained syncope, or family history of premature sudden cardiac death, no medications that may prolong the QT interval, and/or a previous known normal corrected QT interval [QTc]), and 3) performing baseline testing in hospitalized patients or those who may be at higher risk. If baseline electrocardiographic testing reveals a moderately prolonged QTc, optimization of medications and electrolytes may permit therapy. If the QTc is markedly prolonged, drugs that further prolong it should be avoided, or expert consultation may permit administration with mitigating precautions. These recommendations are made while there are no known effective treatments for COVID-19 and should be revisited when further data on efficacy and safety become available.

Impact of Age on Risk Factors and Clinical Manifestations of Acute Coronary Syndrome: Observations From the Coronary Care Unit of Sulaimani, Iraq

Background: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI ) are common types of acute coronary syndrome which are associated with the risk factors of age, obesity, hypertension, and diabetes. Objective: The present study aimed to examine the effects of age on the risk factors and clinical symptoms of acute coronary syndrome. Methods: A cross-section prospective study was conducted on 125 patients with acute coronary syndrome chosen by non-probability convenience sampling method in the coronary care unit in Sulaimani, the Kurdistan region of Iraq. Acute coronary syndrome types were diagnosed through clinical presentations, electrocardiography (ECG), and troponin test. Data was collected using a researcherbased checklist through face-to-face interviews. Results: The results indicated that males were the dominant group. The age group 45-65 had the highest prevalence rate of acute coronary syndrome. The most frequent risk factors for acute coronary syndrome were hypertension (54.4%), dyslipidemia (52%), smoking (42.4%), and diabetes mellitus (38.4%). Typical chest pain was found to be the most frequent clinical presentation (88%). There was a significant difference between the age groups in terms of the effect of age on typical and atypical symptoms; however, neither age nor typical/atypical symptoms had a significant effect on type of acute coronary syndrome. Similarly, family history, hypertension, diabetes mellitus, obesity, smoking, physical inactivity, and dyslipidemia had no effect on type of acute coronary syndrome. Conclusion: Age is a predictive factor for acute coronary syndrome, but family history, hypertension, diabetes mellitus, obesity, smoking, physical inactivity, and dyslipidemia cannot predict acute coronary syndrome.

An eHealth System for Monitoring the Relapse of Salmonella Typhi in Outpatients.

Typhoid fever remains a major health problem in developing countries: According to the World Health Organisation, there are 21 Million cases worldwide and 222,000 typhoid-related deaths occurring annually [1]. Mobile monitoring systems have been proposed for observing patient's physiological signals; these hardware and software solutions are broadly categorised as Healthcare Sensor Networks (HSNs). Since no two patients are alike with regards to biometric parameters and access to healthcare professionals can be difficult because of geography or scarcity of resources, monitoring must be observed in situ. Various serological and culture diagnostic tests for enteric fever exist, including the Widal test [44], TUBEX [45], ELISA [46] and the Gold Standard Blood Culture test [32]. The limitations of these existing conventional tests include lack of speed, sensitivity, and specificity, ambiguity in the classification of symptoms, diagnosis by inexperienced healthcare workers and the fact that they are predominantly clinic-based tests. Critical to typhoid care is outpatient support after the completion of courses of antibiotics, and the two to three-week reoccurrence period is crucial in aftercare. Our research is designed for patients during this period. In this paper, we propose a mobile-based monitoring methodology, which uses vital signs monitoring apparatus, which is configured to recognise the characteristics of typhoid recurrence. Key to our design is the implementation of sensors for body temperature monitoring and physiological testing through galvanic skin response (GSR), electrocardiographic testing (ECG) and electromyography (EMG). The paper introduces an invaluable tool for (i) software programmers and algorithm designers working with biometric HSNs and (ii) practitioners working in public health monitoring and disease prevention.

ARM EXERCISE ELECTROCARDIOGRAPHIC STRESS TESTING VERSUS REGADENASON MYOCARDIAL PERFUSION IMAGING AND EXERCISE TREADMILL TESTING FOR CLINICAL OUTCOME PREDICTION

Arm exercise electrocardiographic stress testing (ARM) is an alternative to regadenoson myocardial perfusion imaging (RMPI) for patients unable to perform leg exercise but has never been directly compared to RMPI or treadmill exercise (ETT) for clinical outcome prediction. All symptomatic veterans