Normal EKG Research Articles

Chagas Cardiomyopathy: Usefulness of EKG and Echocardiogram in a Non-Endemic Country.

BackgroundChagas disease (CD) is a major cause of cardiomyopathy in Latin America, and migration movements have now spread the disease worldwide. However, data regarding Chagas cardiomyopathy (CC) and the usefulness of echocardiography in non endemic countries are still scarce.Methods and resultsWe selected 485 patients in the chronic phase of CD from two Spanish settings. Data from physical examination, electrocardiogram (EKG), x-ray, and two dimensional transthoracic echocardiogram were recorded. Trypanosoma cruzi DNA was assessed by PCR in peripheral blood. Patients were stratified according to the Kuschnir classification and a combination of echocardiogram and electrocardiogram findings. Patients mainly came from Bolivia (459; 94.6%). One hundred and forty three patients (31.5%) had at least one electrocardiogram abnormality. Twenty seven patients (5.3%) had an abnormal echocardiography. Patients with abnormal echocardiography were older (47 (IQR 38–57) years vs 41 (IQR 38–57) years); p = 0.019) and there was a greater proportion of males (66.7% vs 29.7%); p<0.001). Among echocardiographic variables, diastolic dysfunction was associated with poor cardiac status. In the multivariate analysis, abnormal EKG and gender were associated with abnormal echocardiography. Echocardiography may be spared for males under 30 and females under 45 years old with normal EKG as the likelihood of having an abnormal echocardiography is minimal. Association between T. cruzi DNA in the peripheral blood and cardiac involvement was not observed.ConclusionCC rates in the studied population are low. Age and sex are important determinants for the development of CC, and with the EKG should guide echocardiogram performance.

Preoperative Electrocardiograms for Nonsyndromic Children With Hand Syndactyly

To examine the efficacy of preoperative electrocardiogram (EKG) screening for Timothy syndrome, a rare and fatal condition characterized by prolonged QT, in children referred for syndactyly release. We reviewed the records of nonsyndromic syndactyly patients seen by a hand surgeon at our institution between 2007 and 2013. All underwent a preoperative screening EKG for Timothy syndrome. We reviewed the medical records for demographics, presentation, EKG results, and operative findings, and calculated median age at the time of EKG and surgery and frequency distributions for sex, side affected, EKG result, and clinical finding. The mean patient charge for EKG and interpretation was calculated. We identified 128 syndactyly patients, 72% of which were boys. Median age at the time of EKG testing and syndactyly release was 1 year. A total of 92% of patients had normal EKG results; one patient exhibited a prolonged QT. Ten patients (8%) had further cardiac evaluation because of the EKG result and were found to be normal on repeat testing. No patient met QT threshold for Timothy syndrome and all patients were cleared for surgery. The minimum patient charge for EKG testing was $183. To improve patient safety, some have advocated preoperative EKG testing for all children undergoing syndactyly release to rule out Timothy syndrome. Analysis of our experience failed to yield an instance of Timothy syndrome over a 7-year period. Although EKG charges were relatively low, costs resulting from additional testing, cardiology consultation, and provider and parent time should be considered. Our study does not support routine EKG testing for children referred for syndactyly release, and we have abandoned this practice. Prognostic IV.

Electromechanical Relationship in Hypertrophic Cardiomyopathy

We examined whether there is a relationship between repolarization abnormalities on electrocardiography (EKG) and deformation abnormalities by echocardiography. Analysis of baseline EKGs and mechanical (echo-based deformation) changes was performed in 128 patients with a clinical diagnosis of hypertrophic cardiomyopathy (HCM). Patients with left ventricular hypertrophy (LVH) or repolarization abnormalities had higher septal thickness when compared to patients with normal EKG. Patients with EKG evidence of LVH or QTc prolongation had lower systolic velocity, systolic strain, systolic strain rate, late diastolic velocity, and late diastolic strain rate than patients with a normal EKG. Patients with strain pattern or ST depression/T-wave inversion had lower systolic velocity, systolic strain, systolic strain rate, early diastolic velocity, and late diastolic velocity when compared to patients with normal EKGs. LVH and repolarization abnormalities on surface EKG are markers of impaired systolic and diastolic mechanics in HCM.

Citalopram-induced QTc prolongation: A brief review of the data

Recently, Forest Laboratories warned about QTc prolongation associated with the use of citalopram. After these reports, the FDA warned that citalopram should no longer be used at doses greater than 40 mg/day for patients ≤ 60 years of age or greater than 20 mg/day in patients over 60 years of age. As a result, providers and formulary managers were advised to reevaluate the use of citalopram to conform to current FDA guidelines. Clinicians have the option to: (1) maintain the patient on the current dose (no change), document that the current EKG (with QTc) is within a normal range and inform the patient of the current recommendations or (2) change the therapy, which consists of either a dose reduction or change to an alternate agent. It may be appropriate to keep a patient on current therapy above the FDA recommended maximum if proper documentation is maintained (e.g., past history of severe depression, normal EKG). Citalopram should be discontinued in patients who have persistent QTc measurements greater than 500 ms.

An uncommon case of right ventricular dilatation: ventricular noncompaction

Abstract A 32 years old asymptomatic woman had the echocardiographic finding of right ventricular dilatation and underwent a CMR in another institution which confirmed the findings; fat right ventricular wall infiltration was reported and Arrhythmogenic Right Ventricular Dysplasia was diagnosed; no arrhythmia was inducible by electrophysiologic test. The patient remained asymptomatic for eight years else; she came to our attention for control and because of normal EKG and absence of arrhythmias another CMR was performed. Examination showed right ventricular dilatation and mild systolic dysfunction, along with findings of right ventricular noncompaction; additionally typical left ventricular noncompaction was found. Right ventricular noncompaction should be included in the differential diagnosis of right ventricular dilatation. Due to the superior anatomic and physiologic definition, CMR is crucial in right ventricular evaluation. Old diagnosis of ARVD, if not entirely convincing, should be reevaluated.

Abstract 132: Cost-Effectiveness of Stress Echocardiography and Long-Term Outcomes in Framingham Risk Score Stratified Patients with Non-anginal Chest Pain, Normal ECG and Normal Cardiac Biomarkers

Background: We investigated cost-effectiveness of stress echocardiography (SE) and long-term outcomes in Framingham risk score (FRS) stratified patients referred for stress testing after having presented with non-anginal chest pain, normal ECG, normal cardiac biomarkers. Material and Methods: Of 619 consecutive patients, 238 patients with complete dataset were divided into groups based on the interquartile range of the FRS (Table). Cost per CAD diagnosis was inferred based on post-test likelihood of CAD assuming accepted clinical practice of cardiac catheterization in patients with a SE demonstrating inducible ischemia. Long-term outcomes were ascertained using the Social Security Death Index and hospital records. Cause of death was identified in all but 3 patients. Chi-square test and analysis of variance were used to analyse categorical and continuous variables. Results: Study population consisted of 48% females, 52+/- 12 years old, 23% diabetics, and 40% current smokers. Intermediate and high FRS patients were more likely to develop ischemia by SE (4% vs. 9% in higher FRS, p&lt;0.05, Table). When post-test likelihood of CAD was considered, four-fold higher relative value units (RVUs) per single case CAD diagnosis was needed in patients with low FRS (Table). No cardiovascular deaths were recorded during the mean follow-up of 60+/-12 months. While FRS≥0.216 was associated with 4-fold higher mortality, it was not affected by stress tests results. Most common causes of death were renal, pulmonary, and hepatic failure. Conclusion: In patients presenting with non-anginal chest pain, normal EKG and normal biomarkers, long-term follow-up suggests very low cardiovascular mortality. In this patient population further stratification by stress testing does not aid in predicting cardiovascular outcomes nor is it cost-efficient. For differences vs. CAD patients: p&lt;0.05; †) p&lt;0.01; ‡) p&lt;0.005; §) p&lt;0.001; blank - NS.

Abstract 286: Can the Functional Capacity Measured by Duke Activity Status Index Increase the Value of Imaging during Stress Testing?

Background: The incidence of abnormal myocardial perfusion imaging (MPI) has been reported to be very low in patients exercising &gt;10 metabolic equivalents (METs) without ST depression on EKG. We sought to determine if the Duke Activity Status Index (DASI), which predicts functional capacity(FC), can determine who benefits the most from exercise stress testing (EST) with MPI. We hypothesized that DASI-predicted FC of &lt;10 METs will identify patients with a higher likelihood of abnormal MPI. Methods: DASI questionnaire was prospectively administered to 163 patients without prior history of coronary artery disease (CAD) referred for EST with MPI. DASI was used to predict METs by dividing the total score by 3.5. The study population was divided based on DASI score&gt;35 (corresponding to METs&gt;10) to determine the relationship with abnormal MPI. Abnormal MPI was defined as a summed stress score (SSS) &gt;0 or left ventricular ejection fraction (LVEF) &lt;45%. These cutoffs were used to identify any abnormalities that may occur in this population without prior diagnosis of CAD. Results: Among the 163 patients, 52% were males, mean age was 53±10 years, 14% were diabetic, 93% had atypical symptoms and 74% had normal baseline EKG's. Mean DASI-predicted METS was 13.3±3.5 and mean measured METS was 10.4±3.0. There was a strong correlation between DASI-METS and measured METS (Spearman's rho=0.47; p&lt;0.001). DASI was &gt;35 in 128 (79%) and ≤35 in 35 (21%) patients, respectively. Abnormal MPI was noted in 8 patients (7 abnormal SSS, 1 abnormal EF). SSS was&gt;0 in 3 out of 128 (2%) in the DASI &gt;35 group compared to 4 of 35 (11%) in the DASI≤35 group (p&lt;0.05). LVEF&lt;45% was noted as an isolated abnormality in 1 patient with DASI&gt;35. All patients with DASI&gt;35 had a low-risk scan. High-risk scan (SSS&gt;8 and LVEF&lt;45%) was noted in 3 patients with DASI≤35. Conclusions: In patients without prior CAD referred for EST with MPI, DASI can help increase the value of MPI by identifying a subset that will benefit more from MPI. Patients with a DASI≤35 have a significantly higher likelihood of having both abnormal MPI and severely abnormal MPI. Functional capacity should be considered in addition to pretest probability of CAD and baseline EKG in evaluating the appropriateness of stress testing with imaging. Studies with larger sample sizes are warranted to validate this approach.

Cardiotoxicity of 5-fluorouracil in patients with gastrointestinal cancer.

689 Background: 5-fluorouracil (5-FU) is a agent of chemotherapy that has been associated with cardiotoxicity infrequently. The reports shown incidence of clinically apparent 5-FU cardiotoxicity in 1.6% for patients receiving 5-FU alone or in combination with another agents. Methods: We investigated the clinical characteristics of 5-FU cardiotoxicity in patients with gastrointestinal cancer treated in instituto nacional de enfermedades neoplasicas (INEN) Lima - Peru between October 2009 and October 2010. Results: Between October 2009 and October 2010, were evaluated 240 cases with gastrointestinal cancer treated with 5-FU alone or plus combinations with another chemotherapy agent, 8 cases (3.3%) had cardiotoxicity. 37.5 % had history of cardiovascular disease, 3 patients had a history of hypertension and 1 patient diabetes mellitus plus hypertension. 50% (4 patients ) had normal EKG prior to treatment, 25% (2 patients) had no EKG, In 12.5% (1patient) had sinus tachycardia and another patient had ventricular extrasystoles were detected. After chemotherapy infusion 75% (6) had changes in the EKG. In 8 patients was observed as the main symptom chest pain with radiation to left arm or upper back, without elevated cardiac enzymes. 87.5% (7 patients ) had symptoms after 6 pm. And the duration of symptoms was 48 hours in 62.5% (5 patients), 12.5% (1patient ) in 24 hours and 6 hours in 12.5% (1 patient). One patient died of acute heart failure and had history of hypertension and diabetes mellitus and received the combination cisplatin - 5-FU. Conclusions: The eight cases reports confirm the potential cardiotoxicity of 5-FU and argues the need for cardiovascular assessment by a specialist before the start of treatment in addition to cardiac monitoring in patients during treatment, especially in patients with risk factors especially in the first cycle, women and at night. The mechanism of 5-FU cardiotoxicity is not fully elucidated. Coronary spasm is the most accepted hypothesis.

Phase II Biologic Effects Trial of Recombinant Interleukin-11 (rhIL-11, Neumega) in Moderate or Mild Hemophilia A or Von Willebrand Disease Unable to Use DDAVP,

Abstract 3308▪▪This icon denotes a clinically relevant abstract Background:DDAVP is the treatment of choice for individuals with type 1 von Willebrand disease (VWD), although 20% are unresponsive, and of the 80% who do respond, the VWF increase is transient, as endothelial stores are depleted after 3 days. Further, administration requires a 30- minute intravenous infusion in a medical facility. Plasma-derived concentrates may be used in these settings, but are more costly and have potential risk of transmissible infection. We recently demonstrated that recombinant human IL-11 (rhIL-11, Neumega®), a gp-130 signaling cytokine with hematopoietic and anti-inflammatory activity, increases VWF activity up to 2-fold when given daily by subcutaneous injection, with levels persisting each day it is given, and reduces menstrual and postoperative bleeding. The effects of rhIL-11 in individuals with VWD unresponsive or allergic to DDAVP, or hemophilia A, however, have not been evaluated. Methods:We conducted a phase II trial to evaluate the safety and biologic effects of rhIL-11 in VWD patients unresponsive or allergic to DDAVP (VWD-Un) or mild hemophilia A (HemA). rhIL-11 was given subcutaneously at 25 μg/kg daily for 4 days in the non-bleeding state, followed on day 4, 30 minutes after rhIL-11, by one dose of DDAVP intravenously, 0.3 μg/kg, if not contraindicated (pt. 2). Fluid restriction was recommended. Fluid status was assessed by height, weight, and exam. Pre- and post-dosing laboratory assays included the VWD profile, VWF multimers by SDS gel electrophoresis, and platelet VWF mRNA by qPCR. Results:The results of the first six subjects, including three with VWD (one type IIB and two type 1 VWD), VWF:RCo 0.10–0.20 U/ml, and three with mild hemophilia A, F.VIII 0.08–0.12 U/ml, are presented. All subjects were healthy, with no hypertension or cardiac disease, and all had normal physical exams and normal EKGs. By day 4, among VWD-Un subjects, there was a 1.2-fold increase in VWF:RCo (15±3% vs. 12±0%); a 1.6-fold increase in VWF:Ag (22±8% vs.14±6%); and a 1.3-fold increase in VIII:C (34±36% vs. 27±10%), as compared with pre-rhIL-11 levels (Figure). Following DDAVP (except pt. 2), there was an additional 2.0-fold, 1.7-fold, and 2.6-fold increase in VWF:RCo, VWF:Ag, and VIII:C, respectively. Among HemA subjects, by day 4, there was a 1.8-fold increase in VWF:RCo (160±25% vs. 88±12%); a 1.8-fold increase in VWF:Ag (182±28% vs.99±18%), p<0.01; and a 1.5-fold increase in VIII:C (21±8% vs. 14±5%), as compared with pre-rhIL-11 levels. Following DDAVP, there was an additional 1.5-fold (p<0.01), 1.7-fold, and 2.8-fold (p<0.05) increase in VWF:RCo, VWF:Ag, and VIII:C, respectively. The drug was well tolerated well with less than grade 1 mild conjunctival erythema, local erythema and tenderness at the injection site; in one subject transient hyponatremia, Na 129 meq/L, occurred after excess oral fluid intake for diabetic hyperglycemia, which resolved with fluid restriction. Discussion:These data suggest that rhIL-11 increases VWF and VIII levels modestly in VWD patients unresponsive/allergic to DDAVP, and in mild hemophilia A, suggesting the potential use in treatment of clinical bleeding in these disorders.SubjectsDiagnosisVWF:RCo(%)VWF:Ag(%)VIII:C(%)PreDay4DDAVPPreDay4DDAVPPreDay4DDAVP1. 25/FI-VWD12±021±945±2612±525±6*49±1637±1810±6125±36*2. 22/FIIBVWD12±012±0ND25±335±18ND37±1286±13†ND3. 25/FI-VWD12±012±032±0*4±06±0*26±157±05±0*54±344. 25/MHemA78±5121±25227±11*81±7139±3*207±6*10±019±0*78±12*5. 31/MHemA73±3151±43191±2580±6171±9*222±20*25±137±174±4*6. 51/MHemA112±42208±0*324±60135±3235±13*273±44*7±08±0*24±8**p< 0.001;†p< 0.01. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Brugada Syndrome Unmasked by Fever

Brugada syndrome (BS) is a cardiac rhythm disturbance that predisposes patients to sudden cardiac death. Brugada is classically described with specific electrocardiographic (EKG) findings of ST elevation and right bundle branch block in precordial leads and is an often unrecognized contributor to sudden cardiac death. We present a case of BS with cyclic EKG findings in a febrile 20-year-old active duty, Vietnamese male who presented following a witnessed syncopal event. His classic findings of Brugada pattern on EKG demonstrated reversibility with clinical defervescence. In patients with a suggestive history, a normal EKG cannot definitively rule out BS as the Brugada pattern can be unmasked by stress, which in this case was represented by a pneumonia-induced fever.

Head Injury - Soccer

HISTORY: A 20-year-old male college soccer player suffered a head injury during the second half of a varsity game. While attempting to head a ball his head forcefully collided with his opponent's head. He was brought to the sideline where he was found to have amnesia to the event and was confused. His only reported symptom was a headache. The neurologic exam was non-focal. He reported to training room for physician evaluation three days later. At that time he continued to have lack of memory of events occurring between 1 pm and 6 pm on the day of event. He otherwise was symptom free. Past medical and social histories were negative. He denied the use of medications, prescription or otherwise. PHYSICAL EXAM: Evaluation in the training room revealed a blood pressure of 146/80 and a pulse of 58. Cardiac exam showed a regular rate and rhythm. There were no murmurs. Three word recall was appropriate. He was able to recite the months of the year in reverse without hesitation. Cranial nerves 2-12 were intact. Reflexes were 2+ in the upper and lower extremities bilaterally. Strength was 5/5 in bilateral upper and lower extremities. There was a negative Romberg test. Finger to nose test as well as heel, toe and heel-to-toe walking were all appropriate. DIFFERENTIAL DIAGNOSIS: 1. Concussion 2. Idiopathic hypertension 3. Thyrotoxicosis 4. Traumatic brain injury induced hypertension 5. Autonomic dysfunction syndrome TESTS AND RESULTS: CBC: within normal limits BMP: within normal limits UA: within normal limits EKG: within normal limits ImPACT: (performed 7 days after injury) no significant difference when compared to baseline FINAL/WORKING DIAGNOSIS: Traumatic brain injury induced hypertension TREATMENT AND OUTCOMES: Athlete was symptom free by day 3 status post injury. At that point he was progressed per protocol for return to play following concussion. Review of patient's records revealed a normal blood pressure at time of pre-participation exam at the beginning of current season. Between days 3 and 10 post injury his blood pressure was monitored by the athletic trainer. Readings during that period ranged from 132-150/80-90. During training room evaluation at day 10 further testing was performed. From that point forward his blood pressure remained less than 140/90 and he was allowed to continue to compete. He continues to be closely monitored.

IS NORMAL ELECTROCARDIOGRAM A PREDICTOR OF ABSENCE OF CLINICALLY SIGNIFICANT NON-CORONARY STRUCTURAL HEART DISEASE?

Background: Electrocardiogram (EKG) is a simple, office-based, readily available, non-invasive, cheap initial test for evaluation of structural heart disease. Clinicians frequently perform further expensive cardiac imaging studies, including Transthoracic Echocardiography (TTE), Transesophageal Echocardiography (TEE), Cardiac Magnetic Resonance Imaging (cMRI) and cardiac computed tomography (CT) in evaluation of structural heart disease. Our aim was to test the hypothesis that a completely normal EKG predicts absence of clinically significant structural heart disease, and any imaging, apart from being a component of ischemia work up, may not be needed.

TCP SYN‐based DDoS attack on EKG signals monitored via a wireless sensor network

AbstractInternet distributed denial of service (DDoS) attacks are known to exhaust computing resources of a computer. In many cases, even if the attack is not sufficiently strong to completely crash a computing system, its adverse effects can be devastating for the information being processed on the system. When such information is too critical as an electrocardiogram (EKG) signal, the signal itself becomes vulnerable to such attacks also. In this experimental paper, we evaluate the adverse effects of TCP SYN‐based DDoS attacks on EKG signals remotely collected by using wireless sensor networks (WSNs). In lab, we deployed two applications (Serial Forwarder and Oscilloscope GUI) to display the EKG signal on remote monitoring station. Such EKG signal was delivered by a WSN (motes running a modified version of OscilloscopeRF with an analog channel enabled and TOSBase) to collect and send the EKG data. It was found that even though the computing resource of the remote computer running the applications to display the EKG signals was almost exhausted under a DDoS attack, the system was still responding (alive) and displaying the collected EKG signal. However, the normal EKG signal pattern was distorted due to the resource exhaustion caused by the DDoS attack, which in turn made the EKG signal unreliable for medical diagnosis and remote monitoring. In order to understand effect of TCP SYN attack on the EKG signal pattern, the attack was launched at different loads in a controlled lab environment. Finally, an Intrusion Prevention System was deployed in the network to mitigate the adverse effects of attack in the network in an attempt to recover a good EKG signal. Copyright © 2011 John Wiley &amp; Sons, Ltd.

Cardiac events and cardiac T2* in Egyptian children and young adults with β-thalassemia major taking deferoxamine

Cardiac events and death are not uncommon in adults with beta-thalassemia (b-TM) taking deferoxamine (DFO) monotherapy because of poor compliance and possibly the less effectiveness of DFO in controlling cardiac iron overload. We sought to assess compliance with DFO, the percentage of shift to other iron chelators, and the occurrence of cardiac siderosis, and cardiac events and death in b-TM patients on DFO monotherapy. Prospective, observational, 10-year follow-up of patients attending Ain Shams Thalassemia Unit, Cairo, Egypt. For all b-TM patients aged 2-18 years attending the unit during January 1998 and taking DFO, we recorded all cardiac events (whether fatal or not) during January 2008. All patients still on DFO monotherapy and with a normal EKG and not showing symptoms or signs suggestive of heart failure (HF) were evaluated for cardiac siderosis by T2*. Of 412 patients, only 126 (31%) were still taking DFO monotherapy (only 43% of those were compliant), 136 were taking combined DFO and deferiprone (DFP), 72 were taking DFP and 32 were taking deferasirox (DFX). Twenty-one were lost to follow-up and 25 died (10 cardiac). Eight of ten cardiac deaths and 12 of 15 non-cardiac deaths were in the DFO monotherapy group. Those taking DFO monotherapy with no HF and left ventricular ejection fraction (LVEF) by T2* >56% had a median age of 19 years and 56% were males; cardiac T2* was less than 20 ms in 30 (22%), 10-20 ms in 20 (14.7%) and less than 10 ms in 10 (7.3%). LVEF ranged from 58%-76% (median 64%). Forty percent of T2* patients less than 10 ms were compliant with DFO. Fifty-eight percent of patients on DFO monotherapy were noncompliant, but even compliance did not prevent severe cardiac siderosis and most cardiac events (whether fatal or not) that occurred in the DFO monotherapy group.

E0709 Speckle tracking based circumferential strain analysis to evaluate mechanical function of heart during ventricular pacing: an experimental study on open chest instrumented pigs

AimsThis study aims at assessing ventricular pacing (VP) mechanical change by using global circumferential strain and segmental circumferential strain of speckle tracking imaging.MethodsSeven adult pigs, weighting 30.8±3.6 kg, were sedated,...

ADENOSINE STRESS PERFUSION IMAGING AND PREDICTION OF MYOCARDIAL ISCHEMIA IN PATIENTS WITH HYPERTENSION AND LOW-RISK CHEST PAIN IN THE EMERGENCY SETTING: PP.8.339

Background: Adenosine-Miocardial Perfusion Imaging (A-MPI) in patients (pts) with Chest Pain (CP) with or without hypertension, and low-risk acute CP is questionable. Methods: CP patients (n = 82, age 68 y., 33 with hypertension with normal EKG and Troponin underwent A-MPI given i.v. at 140 mcg/min/kg for 6-min., and technetium-99m-sestamibi at 3rd-min. Gated images were analyzed for reversible perfusion defects and for wall motion abnormalities. Patients with positive images were submitted to angiography, otherwise they were discharged. End-point: coronary stenoses ≥50% or Coronary Events (CE) at follow up (sudden death, myocardial infarction or revascularization). Results:The 82 pts enrolled presented hypertension 40%, diabetes mellitus 16%, hypercholesterolemia 18%, smoke 3%, familiarity 16%; body mass index > 30 16%. Overall, 21 (26%) pts showed positive A-MPI, and 11 (52%) reached the endpoint (age 67 y.). 4 pts showed CE; 7 needed revascularization. Of note 10 pts with hypertension had positive A-MPI (30%), and 5 reached the endpoint (age 70 y.). Only 1 patient had CE and 4 pts needed revascularization. Overall, 59 pts showed normal A-MPI and 1 had CE. Thus, in our series of pts, the negative predictive value (NPV) and sensitivity (Sens.) of A-MPI to detect CAD or CE were very high (98%, and 92%, respectively), moreover positive predictive value (PPV), specificity (Spec.) and diagnostic accuracy (Acc.) were 52%, 86%, 87%, respectively. Of note 23 pts with hypertension had normal A-MPI and 1 had CE at follow-up. Thus, in this subset of hypertensive pts, the NPV and Sens. of A-MPI for CAD or CE were 96%, and 88%, respectively; moreover PPV, Spec., and Acc.were 70%, 88%, 88%, respectively. PPV of A-MPI was double in pts with hypertension as compared to pts without. Conclusions. PPV of A-MPI was up to double in pts with hypertension as compared to pts without. Optimal diagnostic strategy could be likely submitting CP pts with hypertension to this valuable test, economizing in time consuming and costs.

The Role of Hyperbaric Oxygen to Platelet Aggregation in Diabetic Patients Type II (NIDDM)

Prevalency of Diabetes Mellitus in Indonesia has tendency to be increased from year to year. Hyperbaric Oxygenation (HBO) has been used as treatment of Diabetes Mellitus's complication especially diabetic gangrene. But the effect of HBO to the rheology's disfunction especially platelet's aggregation in the patients of NIDDM was investigated. The randomized pretest-posttest design was used in this study. An experimental laboratory study was performed at Naval Health Institution in Surabaya. 32 patients of NIDDM,women, 40–75 years old, normal physic's diagnosa, normal thorak's photo, normal EKG, normal Ear Nose and Throat, Diabetes Mellitus's family's record, normal weight (BMI), blood glucose level didn't exceed 400 mg/dl (including controlled DM FBG &lt; 120 mg/dl dan 2 H BG &lt; 160 mg/dl), NIDDM, normal level of HbA1c (4–5,9), as long as this research they couldn’t take their Oral Hipoglikemic Agent, Oral Anti Trombotic, vitamin C and vitamin E. They are divided into 2 group: group of HBO 100% O 2,4 ATA for 3x30 minutes with interval 5 minutes to inhalate air once a day daily for 5 days subsequently and the extraction of data (PAT) had been held before oxygenation hyperbaric therapy at the first day and the end of fifth days, in control group only giving 20% O2 with the pressure 1 ATA for 90 minutes once a day daily for 5 days subsequently and the extraction of data (PAT) had been held before normoxia normobaric therapy at the first day and the end of fifth days. The results were significant decrease of the platelet’s aggregation level especially percent of aggregation after 5 days from 76,56 ± 8,06 become 69,13 ± 6,03. Latent Periode has also decrease from 28,75 ± 3,87 become 25,75 ± 2,82. Speed of Aggregation has also decrease from 66,25 ± 3,17 become 62,50 ± 3,44. Index of Aggregation has also decrease from 0,763 ± 0,071 become 0,581 ± 0,083. Using paired t-test, it could be seen the decrease of Latent Periode (p= 0,001) and index of aggregation (p= 0,000) significantly after exposure of oxygenation hyperbaric HBO 2,4 ATA 100% O 3×30 minutes with interval 5 minutes inhalate air once a day for 5 days,subsequently. Speed of aggregation (p = 0,022) and percent of aggregation (p= 0,013) are nonsignificantly. The conclusion of this research is that oxygenation hyperbaric 2,4 ATA 100% O2 3×30 minutes with interval 5 minutes inhalate air once a day for 5 days,subsequently could decrease latent periode, speed of aggregation, index of aggregation and percent of aggregation in NIDDM

Risque de trouble du rythme et électrisation par courant domestique

Analysis of domestic low-voltage (220-240 V) electrical injury in children admitted to a pediatric emergency department to illustrate the low risk of initial or delayed risk of arrhythmia. Retrospective study between 2001 and 2008 analyzing all children aged less than 15 years admitted for a low-voltage electrical injury. The data collected were age, sex, time and circumstances of the accident, time and day of admission, transport modalities, presence of risk factors for arrhythmia (transthoracic current, wet skin, tetany, loss of consciousness or neurological symptoms, and initial EKG abnormalities), injuries, EKG, muscular and/or cardiac enzyme values, progression and complications. For statistical analysis, data were entered in Microsoft Excel tables. Analysis was done with StatView5.1 (SAS Institute) and Epi Info 6.04fr (VF, ENSP epiconcept). In the descriptive analysis, the data are presented as mean values with SD, median and range. Forty-eight children were included. The mean annual number of admissions was equal to 6 (range, 3-12). The mean age was 6.2 + or - 4.3 years (median, 4.6 years). There was a male predominance: the overall sex ratio was 1.5, i.e., 3 before the age of 2 and 2.6 before the age of 10. The electrical injury occurred after contact with a wire or a connected cord or after the introduction of a metallic object in a wall socket. Ten children had risk factors of arrhythmia (mainly wet skin or thoracic pain). Twenty-nine children suffered from burns to the extremities (digits and hands, 70 %). At admission, 45 children had an EKG performed. The initial EKG was considered abnormal in 8 cases showing: sinusal tachycardia (n=4), incomplete right bundle branch block (n=4), and V(1) negative T waves (n=1). The EKG normalized within the first 12h. Hospitalization for cardiac monitoring was required for 18 children. No delayed arrhythmia occurred. In a mean time of 3.5h after the accident, a troponin dosage was given to 15 children and was normal in all cases. One child developed rhabdomyolysis and evolved without needing dialysis. After a low-voltage electrical injury, initial arrhythmia is not frequent, with often a nonspecific and transitory EKG expression; delayed arrhythmia is very rare. Children presenting to the emergency department after such an electrical accident, who are asymptomatic, without any risk factors for arrhythmia (wet skin, tetany, vertical pathway of the current, preexistent cardiological conditions, loss of consciousness) and with a normal initial EKG do not require cardiac monitoring.

Simplified Pediatric Electrocardiogram Interpretation

We describe a simplified method for interpreting a pediatric electrocardiogram (EKG). The method uses 4 steps and requires only a few memorized rules, and it can aid health care providers who do not have immediate access to pediatric cardiology services. Most pediatric EKGs are normal. However, both abnormal and normal EKGs should be sent to a pediatric cardiologist for later, confirmatory interpretation.

Circadian and Gender Effects on Repolarization in Healthy Adults: A Study Using Harmonic Regression Analysis

Sudden cardiac death and myocardial infarction have a circadian variation with a peak incidence in the early morning hours. Increased dispersion of repolarization facilitates the development of conduction delay necessary to induce sustained arrhythmia. Both QT-dispersion and T-wave peak to T-wave end (TpTe) have been proposed as markers of dispersion of myocardial repolarization. Forty healthy adults (20 women), age 35-67 years old, with normal EKGs, echocardiograms, stress tests, and tilt-table tests were analyzed during a 27-hour hospital stay. EKGs were done at eight different time points. QT-intervals, QT-dispersion, and TpTe were measured at each time point. Harmonic regression was used to model circadian periodicity, P < 0.05 was considered significant. The composite QT-interval was longer in women than in men (416 + or - 17 msec vs 411 + or - 20 msec, respectively, P = 0.006). The QT-dispersion among all leads was greater in men than women (37 + or - 13 msec vs 30 + or - 11 msec, respectively, P < 0.0001); a similar difference was found in the precordial leads. Harmonic regression showed that QT-dispersion had a significant circadian variation, primarily in men. In men, the maximum QT-dispersion occurred at 6 AM (45 + or - 15 msec). TpTe also had a significant circadian variation that was not affected by gender in the majority of leads. A circadian variation exists in the dispersion of myocardial repolarization, as measured by both TpTe and QT-dispersion. Men and women have a different circadian variation pattern. Further studies regarding the mechanisms and clinical implications are needed.