Nonspecific ST-segment Research Articles

Iatrogenic Delayed Cardiac Tamponade Secondary to Intrapericardial Hematoma after Dialysis Catheter Placement

An 84-year-old man affected by arterial hypertension, diabetes mellitus, chronic renal failure on dialysis, chronic ischemic heart disease, permanent atrial fibrillation, previous AICD implantation about one year before, was admitted to the intensive care unit because of typical chest pain and dyspnoea during dialysis treatment with nonspecific ST segment changes at ECG and mild increase of cardiac enzymes. A transthoracic echocardiogram was requested, and it demonstrated a big loculated paracardiac hematoma not easily distinguished from pleural source, with sprays of fibrin localized in correspondence of the free wall of the right ventricle determining a partial compression of the right ventricle with no signs of tamponade. Moreover, a chest CT scan with contrast medium was performed and it confirmed the presence of an intrapericardial hematoma located in correspondence of right heart chambers in the absence of contrast spearing post injection. Subsequently, during the following dialysis treatment the patient developed severe hypotension with chest pain, dyspnoea and paradox pulse treated with liquids infusion with prompt resolution of symptoms followed by a surgical drainage through midline sternotomy. The patient underwent operation and a large organizing thrombus was removed from the pericardial space anterolateral and inferior to the right atrium. The pericardium, which was not thickened, was not removed. His postoperative course was uneventful. This case shows that an intrapericardial hematoma several months following the initial bleeding can present with evolving clinical features and cause an impaired cardiac filling in condition of volume depletion such as dialysis treatment. Although two-dimensional echocardiography represents the first line diagnostic tool in this condition, chest CT scan with contrast medium is frequently used to evaluate patients for pericardial effusion and it is of value in these cases because it permits differentiation of an extracardiac from an intracavitary mass, precise determination of the extracardiac extent of a mass and characterization of a mass as a probable hematoma. Finally, we can conclude that a very low threshold for requesting complimentary imaging studies is essential for prompt diagnosis, and the selection of the diagnostic test depends on the urgency of the clinical presentation. Furthermore, the noninvasive information allowed the surgical team to plan an optimal approach to excising the mass.

Nonspecific ST-T changes associated with unsatisfactory blood pressure control among adults with hypertension in China: Evidence from the CSPTT study.

Nonspecific ST-segment and T-wave (ST-T) changes represent one of the most prevalent electrocardiographic abnormalities in hypertensive patients. However, a limited number of studies have investigated the association between nonspecific ST-T changes and unsatisfactory blood pressure (BP) control in adults with hypertension.The study population comprised 15,038 hypertensive patients, who were selected from 20,702 participants in the China Stroke Primary Prevention Trial. The subjects were examined with electrocardiogram test at the initial visit in order to monitor baseline heart activity. According to the results of the electrocardiogram (defined by Minnesota coding), the subjects were divided into 2 groups: ST-T abnormal and ST-T normal. Unsatisfactory BP control was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg following antihypertensive treatment during the 4.5-year follow-up period. Multivariate analysis was used to analyze the association between nonspecific ST-T abnormalities and unsatisfactory BP control.Nonspecific ST-T changes were common in hypertensive adults (approximately 8.5% in the study), and more prevalent in women (10.3%) and diabetic patients (13.9%). The unsatisfactory BP control rate was high in the total population (47.0%), notably in the ST-T abnormal group (55.5%). The nonspecific ST-T abnormal group exhibited a significantly greater rate of unsatisfactory BP control (odds ratio [OR] 1.20, 95% confidence interval [CI] [1.06, 1.36], P = 0.005]), independent of traditional risk factors, as demonstrated by multivariate regression analysis. Notable differences were further observed in male subjects (OR 1.51, 95% CI [1.17, 1.94], P = 0.002) and in patients with comorbid diabetes (OR 1.47, 95% CI [1.04, 2.07], P = 0.029).Greater rates of unsatisfactory BP control in hypertensive patients with electrocardiographic nonspecific ST-T abnormalities were observed, notably in the subcategories of the male subjects and the diabetic patients.

Radiofrequency ablation of ventricular fibrillation: correlation between electroanatomical mapping and gross pathology

A 61-year old gentleman with a past medical history of type-2 diabetes mellitus presented to hospital with breathlessness and ankle swelling for 1 week. He reported no chest pain. Resting electrocardiogram revealed sinus rhythm with non-specific ST segment changes, and his high sensitivity troponin T was elevated. An echocardiogram demonstrated severe left ventricular systolic dysfunction. Coronary angiography revealed severe multi-vessel coronary artery disease. …

Differential diagnosis of early repolarization and nonspecific ST-segment elevation

During the last years, because of the emergence of new algorithms to identify the early repolarization, clinicians are confused to define it on electrocardiography (ECG). It is very important to define the patients who are at the higher risk of life threatening arrhythmias. Presence of early repolarization is accepted as an arrhythmogenic factor. Therefore, the differential diagnosis between early repolarization and nonspecific ST-segment elevation should be clearly identified. Recently, Dr. Stefan Peters [ [1] Peters S. Differentiation between arrhythmogenic cardiomyopathy and early repolarization pattern: a case report with these two entities. Int. J. Cardiol. 2016; 215: 132-134 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ] reported an interesting case of a patient with both early repolarization and arrhythmogenic cardiomyopathy. However, we think that this finding may be due to not considering the diagnostic criteria of early repolarization which was recommended by the consensus document [ [2] Macfarlane P.W. Antzelevitch C. Haissaguerre M. Huikuri H.V. Potse M. Rosso R. Sacher F. Tikkanen J.T. Wellens H. Yan G.X. The early repolarization pattern: a consensus paper. J. Am. Coll. Cardiol. 2015; 66: 470-477 Crossref PubMed Scopus (248) Google Scholar ]. According to consensus document [ [2] Macfarlane P.W. Antzelevitch C. Haissaguerre M. Huikuri H.V. Potse M. Rosso R. Sacher F. Tikkanen J.T. Wellens H. Yan G.X. The early repolarization pattern: a consensus paper. J. Am. Coll. Cardiol. 2015; 66: 470-477 Crossref PubMed Scopus (248) Google Scholar ], the diagnosis of early repolarization should be made if all of the following criteria are met; a) presence of an end-QRS notch or slur on the downslope of a prominent R-wave. If there is a notch, it should lie entirely above the baseline. The onset of a slur must also be above the baseline, b) Jpeak (Jp) is ≥0.1 mV in 2 or more contiguous leads of the 12-lead ECG, excluding leads V1 to V3, and, c) QRS duration is <120 ms. In this interesting report by Dr. Peters [ [1] Peters S. Differentiation between arrhythmogenic cardiomyopathy and early repolarization pattern: a case report with these two entities. Int. J. Cardiol. 2016; 215: 132-134 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ], first ECG (Fig. 1 in the case report) seems as ECG noise rather than early repolarization. Additionally, the second ECG (Fig. 2 in the case report) does not meet the all of the criteria recommended by consensus document. Therefore, ST-segment elavation in this patient's ECG should be defined as nonspecific ST-segment elevation rather than early repolarization. The consensus document also recommended this definition [ [2] Macfarlane P.W. Antzelevitch C. Haissaguerre M. Huikuri H.V. Potse M. Rosso R. Sacher F. Tikkanen J.T. Wellens H. Yan G.X. The early repolarization pattern: a consensus paper. J. Am. Coll. Cardiol. 2015; 66: 470-477 Crossref PubMed Scopus (248) Google Scholar ]. Similar to our perspective, Biernacka et al. [ [3] Biernacka K.E. Piotr K. Krzysztof D. Olgierd W. Early repolarization in patients with arrhythmogenic right ventricular cardiomyopathy is not frequent phenomenon. Int. J. Cardiol. 2016; 222: 982-983 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ] demonstrated that early repolarization in patients with arrhythmogenic right ventricular cardiomyopathy is not a frequent phenomenon when the new diagnostic criteria of the early repolarization are used for its definition.

Association of Traditional Cardiovascular Risk Factors With Development of Major and Minor Electrocardiographic Abnormalities: A Systematic Review.

Electrocardiographic (ECG) abnormalities are prevalent in middle aged and are associated with risk of adverse cardiovascular events. It is unclear whether and to what extent traditional risk factors are associated with the development of ECG abnormalities. To determine whether traditional cardiovascular risk factors are associated with the presence or development of ECG abnormalities, we performed a systematic review of the English-language literature for cross-sectional and prospective studies examining associations between traditional cardiovascular risk factors and ECG abnormalities, including major and minor ECG abnormalities, isolated nonspecific ST-segment and T-wave abnormalities, other ST-segment and T-wave abnormalities, QT interval, Q waves, and QRS duration. Of the 202 papers initially identified, 19 were eligible for inclusion. We examined data analyzing risk factor associations with ECG abnormalities in individuals free of cardiovascular disease. For composite major or minor ECG abnormalities, black race, older age, higher blood pressure, use of antihypertensive medications, higher body mass index, diabetes, smoking, and evidence of left ventricular hypertrophy or higher left ventricular mass are the factors most commonly associated with prevalence and incidence. Risk factor associations differ somewhat according to types of specific ECG abnormalities. Because major and minor ECG abnormalities have important and independent prognostic significance, understanding the groups at risk for their development may inform prevention strategies focused on modifiable risk factors to reduce the burden of ECG abnormalities, which may in turn promote CVD prevention.

Coronary arterial disease after electroconvulsive therapy: a case report

Objectives Unipolar depression (UPD) is a leading cause of global burden of diseases, particularly among the elderly, whose treatment may be challenging. In such cases, ECT is often recommended due to its safety and efficacy. This report presents a case of a 67-year-old male inpatient that developed a rare cardiac complication during ECT. Methods Clinical case report with patient’s consent and bibliographic review. Results A 67-year-old male inpatient with recurrent severe psychotic depression was hospitalized and ECT was indicated after failure of the pharmacological treatment. A comprehensive clinical pre-evaluation revealed only nonspecific ST-segment changes in electrocardiogram. During the 7th ECT session, it was observed transitory ST-segment depression followed by a discrete increase of plasma troponin I. Severe tri-vessel coronary artery stenosis was found and a percutaneous coronary angioplasty was performed, with satisfactory psychiatric and cardiac outcomes. Conclusions Unipolar depression (UPD) and cardiovascular disease are often coexistent conditions, especially among the elderly. In the current case, myocardial ischemia was detected lately during ECT therapy and its treatment allowed the UPD treatment to be completed adequately.

Electricity, Heart and ST-Segment Elevation: A Closer Look

Dear Editor,We read with great interest the article by Uyanik et al., entitled “Delayed ST-Segment Elevation Due to Electrical Injury Mimicking Acute Myocardial Infarction,” which was published recently in this journal. This case report was mentioning a young patient admitted with late-onset chest pain and ST-segment elevation following ele-ctrical injury (1). Although the case was presented precisely, some points merit further highlighting.Abnormal electrocardiography (ECG) may be found in approxi-mately 31% of patients following an electric shock (2). Non-specific ST-segment changes and sinus tachycardia are the most commonly reported ECG findings; QT prolongation, bundle branch block, atrial and ventricular fibrillation, and atrial and ventricular premature con-tractions are also detected. As referred to in this case report, ST-seg-ment elevation with or without myocardial involvement may follow electrical injury.In a clinical setting, ST-segment elevation on ECG may be related with many conditions, such as myocardial infarction, early repolariza -tion, electrolyte imbalance, and pericarditis. In this case, myocardial infarction may easily be excluded, since cardiac biomarkers are nor-mal and ST elevation is not consistent with myocardial infarction. In this case, ECG shows diffuse and concave ST elevation (elevated at the J point) with the exception of V1 and aVR. In acute myocardial infarction, ST elevation is also accompanied by reciprocal ST depres-sions. In the case of early repolarization, ST elevation is most often present in the mid- to lateral chest leads (V3-V6), and the majority of subjects with early repolarization has no ST deviations in the limb leads. So, early repolarization would be excluded in this patient, who has pronounced ST elevation on D2, D3, and aVF.Zeana describes a 65-year-old electrocuted subject who experi-enced precordial pain, serous enzymes of negative myocardial necro -sis, and ST elevation during 2 weeks of hospitalization (3). These fin-dings suggest the possibility of widespread pericardial involvement. In the case presented by Uyanik et al., pericardial involvement seems to be the most possible cause of ST changes in the admission ECG. This ECG shows us sinus bradycardia with diffuse concave ST elevati-on except for V1 and aVR. ST depression in V1 and aVR is also a typical finding for acute pericarditis. Late-onset chest pain also supports this condition. However, addition of a follow-up ECG of the patient to the report would be more valuable for confirmation of this diagnosis. In our opinion, pericarditis deserves discussion as a possible diagnosis in the aforementioned case.

Diagnosis of Acute Myocardial Infarction on Computed Tomography Angiogram

A 68-year-old white man, an active smoker with hypertension and hyperlipidemia, presented to the emergency department with substernal chest pain. His chest pain began acutely 2 hours earlier, was described as intense pressure radiating to the back, 10/10 in severity with associated diaphoresis, nausea, and vomiting. Chest pain persisted despite sublingual nitroglycerin and subsequent intravenous nitroglycerin and morphine. He remained hemodynamically stable, and the results of his clinical examination were unremarkable. His initial ECG demonstrated nonspecific ST-segment changes (Figure 1). Serial ECGs remained unchanged; a posterior ECG was not performed. Initial cardiac enzymes were also nondiagnostic. …

Cardiac involvement of lung cancer mimicking myocardial infarction

A 58-year-old man (a heavy smoker), without prior medical history, was admitted to the Department of Cardiology in the emergent diagnosis of acute coronary syndrome with ST segment elevation in the third hour of retrosternal pain. The initial ECG revealed sinus rhythm 85/min, left anterior fascicular block, QS pattern in V1–V3 with ST-segment elevation in the leads V2 through V6 (up to 2 mm in V2–V3), with symmetric negative T waves in the leads I, aVL, V2–V5 (Fig. 1). Laboratory tests, except for a small leukocytosis (11 × 109/L, N to 10 × 109/L), and elevations of troponin T (30 ng /L, N to 14 ng/L), were within normal limits. Urgent coronary angiography was performed, which showed critical changes in the distal circumflex branch narrow artery (< 2 mm), with no significant haemodynamic atherosclerosis in other arteries. Due to the location of the stenosis and artery calibre, coronary angioplasty was not performed. Despite typical pharmacological treatment, pain relief was not achieved. The subsequent ECG recorded persistent ST-segment elevation with negative T waves in precordial leads, without a change in troponin values (the II. troponin: 27 ng/L and the III: 28 ng/L). Based on radiological images of the chest, a tumour in the left lung with obliteration of the left heart border was suspected. Transthoracic echocardiography demonstrated the presence of a tumour sized 10 × 7 × 11 cm with involvement of the pericardium (without evidence of fluid), and probably the anterior wall of the left ventricle. To differentiate the cardiac mass, we performed cardiac magnetic resonance imaging and confirmed an anterior mediastinal tumour, causing extensive atelectatic changes in the left lung and infiltrating the anterior wall of the left ventricle (Figs. 2, 3). The patient was referred to the oncology centre where metastatic small cell carcinoma of the left lung was diagnosed. Three months after the start of chemotherapy, the patient died. The most common neoplasms associated with cardiac metastasis are lung cancer, oesophageal cancer, lymphoma, breast cancer, leukaemia, stomach cancer, and melanoma. Their symptomatology is largely dependent on the size of the tumour and its location. Myocardial infiltration by tumour cells may lead to the occurrence of arrhythmias and cardiac conduction, and less non-specific ST segment changes. In this case, the clinical and ECG changes initially showed a myocardial infarction with ST segment elevation anterior wall. However, subsequent ECGs, serial measurements of cardiac troponin and results of imaging studies did not confirm the initial diagnosis. In the era of invasive treatment of myocardial infarction, it is necessary to consider other causes of ST-T changes in the ECG and increased troponin values. Extended cardiac diagnosis and a multidisciplinary approach are often necessary to determine the correct diagnosis.

Prognosis of nonspecific ST-segment changes, T wave abnormalities and Q waves in patients visiting emergency departments for acute decompensated heart failure: a cohort study

Purpose: To determine the risk of 30-day mortality associated with specific ECG abnormalities in patients visiting emergency departments (ED) with acute decompensated heart failure (ADHF). Methods: Population-based prospective cohort of 9,017 HF patients, visiting EDs between 2004-2007 in Ontario, Canada. We evaluated ST depression, Q waves, T wave inversions or its combinations in the presenting ECG. We used multivariable logistic regression models to adjust for variables in the EHMRG score and other variables of clinical importance, including troponin I levels. Patients with major ECG alterations were excluded from the final analysis. Results: ECG alterations were present in 54.9% of the subjects. The mean age was 75.84±11.79 years, 53.4% were female, and 52.7% had HF of ischemic etiology. The prevalence of diabetes and arterial hypertension was 38.2 and 66.4%, respectively and 27% of the patients were discharged home from the ED. In the overall cohort, the presence of T wave inversion (adjusted odds ratio [OR]: 1.34; 95% Confidence interval [CI]: 1.02-1.74) and the concomitancy of ST depression + Q wave (OR: 1.92; CI: 1.14-3.24) were independently associated with mortality. Meanwhile, in patients with ischemic etiology, the presence of ST depression (OR: 1.87; CI: 1.18-2.95) and the combinations of ST depression + Q wave (OR: 2.36; CI: 1.23-4.55) and ST depression + T wave inversion (OR: 1.63; CI: 1.06-2.50) were significant. Moreover, in patients that were discharged home, the presence of combined ST depression + T wave inversion was associated with a poor prognosis (OR: 2.26, CI: 1.13-4.49). Conclusions: Isolated or combined minor ECG alterations were associated with an increased risk of mortality at 30 days in patients presenting to ED with ADHF. These findings are particularly relevant in patients with ischemic etiology, where ST depression was independently associated with mortality. The ECG may assist in clinical decision making of decompensated patients with heart failure in the setting of the ED.

G29 A Case of Phylloid Hypomelanosis – a Rare But Specific Presentation of Chromosomal Mosaicism

This 18 month old boy presented with a history of hypopigmented macular lesions, mild neurodevelopmental delay and recurrent episodes of acrocyanosis with tachycardia and increased tone. The cutaneous lesions developed...

Syncope and intermittent Brugada ECG pattern

Brugada syndrome is a rare syndrome, with an estimated prevalence in Europe of 1–5/10000 population, whose initial clinical presentation can be sudden death. Although it has a characteristic electrocardiographic pattern, this can be intermittent. The authors present the case of a 32-year-old man, with no family history of syncope or sudden death, who went to the emergency department for syncope without prodromes. The initial electrocardiogram (ECG) in sinus rhythm documented an isolated and non-specific ST-segment elevation in V2. During further diagnostic studies, a repeat ECG revealed type 1 Brugada pattern. This pattern was later seen in a more marked form during a respiratory infection. The patient subsequently underwent electrophysiological study, followed by implantation of an implantable cardioverter-defibrillator (ICD), with an episode of ventricular fibrillation converted via ICD shock two months after implantation.

Síncope e padrão de Brugada intermitente

Brugada syndrome is a rare syndrome, with an estimated prevalence in Europe of 1-5/10 000 population, whose initial clinical presentation can be sudden death. Although it has a characteristic electrocardiographic pattern, this can be intermittent. The authors present the case of a 32-year-old man, with no family history of syncope or sudden death, who went to the emergency department for syncope without prodromes. The initial electrocardiogram (ECG) in sinus rhythm documented an isolated and non-specific ST-segment elevation in V2. During further diagnostic studies, a repeat ECG revealed type 1 Brugada pattern. This pattern was later seen in a more marked form during a respiratory infection. The patient subsequently underwent electrophysiological study, followed by implantation of an implantable cardioverter-defibrillator (ICD), with an episode of ventricular fibrillation converted via ICD shock two months after implantation.

Abstract WP428: Cardiopulmonary Response to Ischemic Stroke Varies by Stroke Location

Introduction: Ischemic stroke is associated with electrocardiographic and cardiac enzyme changes indicative of stunned myocardium. It is unknown if acute pulmonary edema occurs independent of cardiac dysfunction in ischemic stroke or in association with particular vascular distributions. Hypothesis: Ischemic strokes in the posterior fossa are associated with acute pulmonary edema independent of stroke related cardiac dysfunction. Methods: This is a retrospective study of ischemic stroke patients treated over two years at a tertiary medical center, including patients with basilar artery stroke (N=18), RMCA (N=31) and LMCA (N=27) distribution strokes involving the insula, and TIA controls (N=67). Of the 143 patients, 53% were female, 45% were black, 40% had a history of stroke or TIA, and 73% had hypertension. Discharge diagnosis, brain imaging, and review of chest x-rays (by two blinded reviewers) were used to determine the proportion of patients within each group with evidence of pulmonary edema. Cardiac variables including ejection fraction, serum troponin levels (&gt;0.06 ng/mL), non-specific ST segment changes and QTc prolongation (&gt;460ms) were compared between groups. Results: Patients with basilar artery occlusions and associated ischemic stroke developed pulmonary edema during their hospitalization more frequently than control patients (0.67 vs. 0.01, P&lt;0.0001). There were no signs of stunned myocardium or CHF as indicated by elevated troponin, altered echocardiography, or QTc prolongation for the basilar group. None of the patients in the basilar group with pulmonary edema had altered echocardiography. Patients with RMCA and LMCA distribution strokes were noted to have a higher frequency of pulmonary edema compared to the controls (0.23, P=0.0012; 0.41, P=0.002), at a proportion less than the basilar group (for RMCA, P=0.005; LMCA, P=0.13,). The proportions of patients with elevated serum troponin and QTc prolongation were significantly greater for RMCA (0.41 vs. 0.05, P=0.0008; 0.40 vs.0.16, P=0.017) and LMCA (0.33 vs. 0.05, P=0.008; 0.36 vs. 0.16, P=0.046) patients relative to controls. Conclusion: Pulmonary edema occurs independently of cardiac stunning or dysfunction in patients with basilar artery occlusions.

Cytomegalovirus Ileitis in an Immunocompetent Host

Purpose: Cytomegalovirus (CMV) virus belongs to the Herpesviridae family. Intestinal manifestations are rare, but cases of gastrointestinal bleeding and perforation have already been reported, usually in immunocompromised hosts. In immunocompetent patients, CMV infection is generally asymptomatic. Methods: We present here the case of a previously healthy 31 year-old man with severe epigastric pain which revealed being CMV ileitis. Results: The patient was admitted to our center with severe malaise, fever and sudden onset of epigastric pain. Abdominal CT scan and gastroscopy were entirely normal. However, colonoscopy with ileal intubation showed moderate ileitis and the immunohistochemical staining and markers revealed the presence of CMV on ileal biopsies. Serological detection of viral antigen was also positive. The patient did not have any diarrhea, intestinal hemorrhage nor perforation. On day eight of hospitalization, he developped right upper quadrant pain with a predominant elevation in aminotransferases and transient drop in albumin, but no other sign of liver dysfunction. CMV hepatitis was diagnosed as traditional blood workup for another cause of liver disease was negative. Ophthalmologic evaluation showed no sign of retinitis. He was also momentarily short of breath with troponin T enzymes elevation, nonspecific ST segment abnormalities with a 4 mm pericardial effusion but no myocardial dysfunction, as can be seen in CMV pericarditis. He improved over 15 days and was discharged with simple analgesia. No CMV antiviral was prescribed. One month later, he was readmitted for paresthesias and lower limbs weakness and was diagnosed with post-infectious polyradicular sensitive disease confirmed with increased conduction time on somatosensory evoked potentials (SEPs). He was treated with high dose methylprednisolone and recovered most of his deficits. He was then evaluated in immunology to investigate the possibility of an immune disorder explaining the severe manifestations of this CMV primo-infection and the investigation results revealed no immunological deficit. Conclusion: In conclusion, severe CMV primo-infection is rare in immunocompetent hosts but can manifest with ileal disease with severe abdominal pain. It can also give other organ-specific complications as can be seen in immunodeficient hosts.

Electrocardiogram in Pneumonia

Findings on electrocardiogram may hint that pulmonary embolism (PE) is present when interpreted in the proper context and lead to definitive imaging tests. However, it would be useful to know if electrocardiographic (ECG) abnormalities also occur in patients with pneumonia and whether these are similar to ECG changes with PE. The purpose of this investigation was to determine ECG findings in patients with pneumonia. We retrospectively evaluated 62 adults discharged with a diagnosis of pneumonia who had no previous cardiopulmonary disease and had electrocardiogram obtained during hospitalization. The most prevalent ECG abnormality, other than sinus tachycardia, was minor nonspecific ST-segment or T-wave changes occurring in 13 of 62 (21%). Right atrial enlargement occurred in 4 of 62 (6.5%). QRS abnormalities were observed in 24 of 62 (39%). Right-axis deviation and S(1)S(2)S(3) were the most prevalent QRS abnormalities, which occurred in 6 of 62 (9.7%). Complete right bundle branch block and S(1)Q(3)T(3) pattern occurred in 3 of 62 (4.8%). ECG abnormalities that were not present within 1 month previously or abnormalities that disappeared within 1 month included left-axis deviation, right-axis deviation, right atrial enlargement, right ventricular hypertrophy, S(1)S(2)S(3), S(1)Q(3)T(3), low-voltage QRS complexes, and nonspecific ST-segment or T-wave abnormalities. In conclusion, electrocardiogram in patients with pneumonia often shows QRS abnormalities or nonspecific ST-segment or T-wave changes. ECG findings are similar to ECG abnormalities in PE and electrocardiogram cannot assist in the differential diagnosis.

Association of isolated minor non-specific ST-segment and T-wave abnormalities with subclinical atherosclerosis in a middle-aged, biracial population: Coronary Artery Risk Development in Young Adults (CARDIA) study

Isolated minor non-specific ST-segment and T-wave abnormalities (NSSTTAs) are common and known to be independent electrocardiographic risk markers for future cardiovascular disease (CVD) events. The association of NSSTTA with subclinical atherosclerosis is not well defined, but has been postulated as a potential mechanism of association with future clinical events. We studied participants from the Year 20 examination of the middle-aged, biracial CARDIA cohort. This examination included measurement of traditional risk factors, 12-lead electrocardiograms (ECGs), coronary artery calcium (CAC) measurement and common carotid intima-media thickness (CC-IMT). ECGs were coded using both Minnesota Code (MC) and Novacode (NC) criteria. Isolated minor STTA was defined by MC as presence of MC 4-3, 4-4, 5-3, or 5-4, and by NC as presence of NC 5.8. ECGs with secondary causes of STTA (i.e., LVH) were excluded. Multivariable logistic regression was used to determine the cross-sectional association of isolated minor NSSTTAs with CAC and CC-IMT. The study sample consisted of 2175 participants with an average age of 45 years (57% female and 43% Black). Isolated NSSTTAs were present in 5.1% of males and 6.3% of females. No association was observed between NSSTTA and CAC. After multivariable-adjustment for traditional CVD risk factors, the presence of isolated minor NSSTTAs remained significantly associated with the extent of CC-IMT (odds ratio 1.25 (1.06-1.48), p < 0.01). This association remained significant after further adjustment for CAC. Isolated minor NSSTTAs were associated with the extent of CC-IMT, but not with CAC, in this middle-aged biracial cohort. Further study is needed to elucidate potential mechanisms for these findings.

Hypothermia Secondary to Ziprasidone Use in a Man With Schizophrenia

To the Editor: Various case reports have been published showing atypical antipsychotics as causing hypothermia, but there are very few cases of hypothermia with ziprasidone. Hypothermia is caused by an imbalance of dopamine and 5-HT2 receptors.1 We present a case of a schizophrenic unmarried white man who developed profound hypothermia on ziprasidone treatment. Case report. Mr A, a 59-year-old patient with DSM-IV-TR schizophrenia who was receiving ziprasidone 80 mg twice daily, presented to the emergency department from his assisted living facility as poorly responsive and lethargic. In the emergency department, he was determined to have an oral temperature of 87°F. At admission, Mr A was listless but could respond to commands. On physical examination, he was able to follow commands, but his pupils were sluggishly reactive. His electrocardiogram showed sinus bradycardia and nonspecific ST segment changes. His vital signs included blood pressure of 100/65 mm Hg, pulse of 60 bpm, respirations of 19/min, oral temperature of 87°F, and rectal temperature of 85°F. His medical history was significant only for schizophrenia for the past 15 years and cataracts, and he received only ziprasidone 80 mg twice daily for the last 3 years. He did not have history of hypothyroidism, stroke, diabetes mellitus, ischemic heart disease, adrenal insufficiency, or arthritis, which could predispose him to hypothermia. Complete blood cell counts and comprehensive metabolic panel were normal. Urine drug screens performed were negative. Cardiac enzymes and thyroid panel findings were within the normal range. His blood gas measurements included a pH of 7.31, Pco2 of 49, Po2 of 121 on 1 L of O2, and Hco2 of 28. Computed tomography scan of the head revealed no abnormalities, and chest x-ray showed no masses or pneumonias. The patient was admitted to the intensive care unit with warmed saline infusion, humidified oxygen, and other conservative measures such as warming blankets. The psychiatry department was consulted, and Mr A’s ziprasidone was discontinued as it was suspected to have caused the hypothermia as no other offending agent was recognized. He was normothermic by day 5 and was discharged to the assisted living facility thereafter. He was followed up later in the outpatient clinic and subsequently never developed hypothermia. Dopamine acts to lower the body temperature, and 5-HT2 receptors tend to increase the body temperature. Atypical antipsychotics are more potent inhibitors of 5-HT2 than the dopamine receptor,2,3 so they tend to lower the body temperature more than they increase it.4 However, according to a World Health Organization database,5 ziprasidone should cause fewer cases of hypothermia in patients as compared to other atypical antipsychotics because of its 5-HT1A receptor agonism. A total of 51% of all cases of antipsychotic-induced hypothermia were found in patients with schizophrenia. Only 11% each were observed in patients with bipolar disorder, dementia, and mental retardation.5 Loffler et al6 discuss use of high-dose ziprasidone and lorazepam in patients who developed hypothermia on treatment with other atypical antipsychotics. As of January 2007, only 8 cases of ziprasidone-induced hypothermia were noted, whereas there were more for risperidone (129 cases), clozapine (68 cases), olanzapine (44 cases), quetiapine (21 cases), and aripiprazole (11 cases).6 Hypothermia in schizophrenic patients is considered to be a possible link between antipsychotics and unexplained death.7,8 Other conditions in psychiatric patients that can increase the risk of hypothermia include nocturnal enuresis, seizure disorder, debilitating physical illness, and mental retardation.8 Second-generation antipsychotic–induced hypothermia has been reported. Although ziprasidone is known to cause lesser hypothermia because of its 5-HT1 agonism, and milder dopamine antagonism, it should still be used cautiously in patients with schizophrenia. Development of hypothermia in a patient maintained on predisposing drugs warrants its discontinuation and consideration of alternative drugs. Combination drugs should also be suspected if a patient is taking ziprasidone in conjunction with other medications.9

Isolated Nonspecific ST-Segment and T-Wave Abnormalities in a Cross-Sectional United States Population and Mortality (from NHANES III)

Most clinicians regard isolated, minor, or nonspecific ST-segment and T-wave (NS-STT) abnormalities to be incidental, often transient, and benign findings in asymptomatic patients. We sought to evaluate whether isolated NS-STT abnormalities on routine electrocardiograms (ECGs) are associated with increased risk of cardiovascular mortality (CM) and all-cause mortality (AM) in a cross-sectional United States population without known coronary artery disease. We included all adults 40 to 90 years of age without known coronary artery disease or risk equivalent based on history and laboratory values, enrolled in the NHANES III from 1988 to 1994, with electrocardiographic data available, and a total follow-up period of 59,781.75 patient-years. NS-STT abnormalities were defined by Minnesota Coding. Subjects were excluded if their mortality data were missing or if they had major electrocardiographic abnormalities, heart rate >120 beats/min, nonsinus rhythm, cardiac infarction/injury score ≥ 20 on ECG, left ventricular hypertrophy by Minnesota Codes 3.1 and 3.3, or patient-reported history coronary artery disease, congestive heart failure, stroke, diabetes, or peripheral arterial disease. The remaining 4,426 subjects were stratified by presence or absence of NS-STT abnormalities. Mortality was judged based on International Classification of Diseases, Tenth Revision coding linked to the National Death Index. Cox proportional hazard ratio was used for multivariate analysis, showing that CM (hazards ratio 1.71, 95% confidence interval 1.04 to 2.83, p = 0.04) and AM (hazards ratio 1.37, 95% confidence interval 1.03 to 1.81, p = 0.02) were significantly higher in the isolated NS-STT abnormalities group. In conclusion, isolated NS-STT abnormalities on ECG were associated with a higher incidence of CM and AM in this large nationally representative cross-sectional cohort without known coronary artery disease or coronary artery disease risk equivalents.

Review of the literature: The longest documented left main coronary artery

Fig. 1. Coronary angiography in right cranial position. The left main coronary artery (LMCA) ranges from 3 to 6 mm in diameter and may be up to 10 to 15 mm in length in human.We report a casewith the longest angiographically documented LMCA (44 mm) in a patient with stable angina pectoris. And additionally, we aim to review the literature about the longest LMCA. The LMCA arises from the superior portion of the left aortic sinus and courses behind the right ventricular outflow tract and usually bifurcates into two terminal branches: LAD and LCx branches. Rarely the LMCA is absent and the LAD and LCX originated directly from the aortic sinus [1]. The LMCA is generally considered to be between 5 and 15 mm. Reig andPetit [2], in their anatomical study (one-hundred human hearts taken from autopsies), reported that the longest leftmain trunk was 23 mm long and the average length was 10.8±5.5 mm. In addition, they found a case with a LMCA length of 39 mm, but it had originated in the right aortic sinus and had a retroaortic course. Recently, it was reported three cases with long LMCA in our country [3–5]. A 61-year-old woman was presented to our hospital with stable angina pectoris. Her ECG was consistent left anterior hemi-block and T wave inversion on lateral derivation. The patient had been taking two anti-hypertensive (ACE inhibitor and beta-blocker) drug and statin treatment. There was non-specific ST segment depression in exercise testing and anterior reversible perfusion defect was found inmyocardial perfusion imaging. Coronary angiography was performed in Avrupa Safak hospital. Non-critically stenoses at LCx and RCA were found. LAD was normal. But, LMCA was strikingly lengthy (44 mm). (Figs. 1 and 2). Maximal medical treatment was planned for our patient. Although a short LMCA has been considered a risk factor in the development of coronary arteriosclerosis, no relationship has been described