Routine Electrocardiogram Research Articles

A cause of a periodic pulmonary edema: consumption of licorice syrup

The aim of this study is to evaluate patients with pulmonary edema due to periodical consumption of licorice syrup. The patients who consumed licoric syrup in recently and admitted to emergency department with dyspnea were examined comprehensive during Ramadan in 2011 and 2012. They underwent routine biochemical investigations, chest X-rays, and electrocardiogram assessment. In addition, cardiac function was examined using echocardiography. Information relating to patients detected with interstitial pulmonary edema was recorded, and all recorded data were evaluated. The number of patients diagnosed with pulmonary edema in the 2-month period was 82. Thirty two of these patients (39%) had a history of consumption of licorice syrup. At first assessment, the mean systolic blood pressure of the study participants was 160.5±18.3 mmHg (130-220), and diastolic blood pressure was 92.6 ±9.8 mmHg (75- 120). The mean sodium level was 143.2±3.47 mmol/L (134-149), potassium was 3.4±0.3 mmol/L (3,1-4,3), urea was 56.1±18.9 mg/dl (26-114), and creatinine was 1.1±0.27 mg/dL (0,6-1,8). The injection fraction of 12 patients was under 40%. Of the study participants, 19 were hospitalized in a coronary intensive care unit, while 13 were treated with an emergency department. All study participants recovered and were subsequently discharged from hospital. Excessive consumption of licorice syrup is a hidden cause of pulmonary edema and/or hypertension and therefore should be investigated for in individuals diagnosed with these conditions.

United in prevention-electrocardiographic screening for chronic obstructive pulmonary disease.

CONFLICT OF INTEREST: NONE DECLAREDIntroductionP-wave abnormalities on the resting electrocardiogram have been associated with cardiovascular or pulmonary disease. So far, “Gothic” P wave and verticalization of the frontal plane axis is related to lung disease, particularly obstructive lung disease.AimWe tested if inverted P wave in AVl as a lone criteria of P wave axis >70° could be screening tool for emphysema.Material and method1095 routine electrocardiograms (ECGs) were reviewed which yielded 478 (82,1%) ECGs with vertical P-axis in sinus rhythm. Charts were reviewed for the diagnosis of COPD and emphysema based on medical history and pulmonary function tests.ConclusionElectrocardiogram is very effective screening tool not only in cardiovascular field but in chronic obstructive pulmonary disease. The verticality of the P axis is usually immediately apparent, making electrocardiogram rapid screening test for emphysema.

Acute Clenbuterol Induces Hypotension, Atrioventricular Block and Cardiac Asystole in the Rabbit

Clenbuterol is a long-lasting β-adrenoceptor (β-AR) agonist and was once medicated as a bronchial dilatator, and is also used by body-building enthusiasts and athletes and in livestock breeding because of its anabolic effect on skeletal muscles and ability to promote lipolysis. Though prohibited from pharmacological uses, clenbuterol intoxication cases are frequently reported, and most of the cardiac symptoms are tachyarrhythmia. Here, we reported a different cardiovascular toxic response to clenbuterol. Using a rabbit model, we tested the dose-response pattern of the cardiovascular system to intravenous administration of clenbuterol. Routine arterial blood pressure (BP) and surface electrocardiogram (ECG) were monitored. We observed that clenbuterol at a lower dose (0.4 mg/kg, n = 3) did not significantly affect the ECG, but decreased the mean BP roughly by 15-18 mmHg. At a medial dose (3.6 mg/kg, n = 3), clenbuterol induced significant hypotension (mean BP dropped by about 30 mmHg), first-degree atrioventricular (AV) block and intermittent ectopic activities with a relatively slow rate. The hypotension and arrhythmia recovered slowly, and animals did not die. Higher-dose clenbuterol (10 mg/kg, n = 6) induced severe hypotension, second-degree AV block (Mobitz type II), 2:1 ventricular capture and progressive prolongations of P-R intervals and QRS duration, and the animals soon died of cardiac asystole. Different from other reports, we had not observed lethal tachyarrhythmia in all experiments except for the slight heart rate acceleration during the recovery stage of medial clenbuterol dosage. These results indicate that acute intravenous administration of clenbuterol has serious, dose-dependent cardiovascular toxicities and is even life threatening.

Comparison of the diagnostic value between ECG and dynamic ECG for coronary heart disease arrhythmias

Objective To investigate and compare the clinical values of routine electrocardiogram and dynamic electrocardiogram in arrhythmia in coronary heart disease diagnosis.Methods 73 patients with coronary heart disease were collected and monitored by routine electrocardiogram and dynamic electrocardiogram,and two groups were e stablished including control group using routine electrocardiogram and observation group using dynamic electrocardiogram.The positive diagnosis rate and the specific diagnosis diresults of arrhythmia in coronary heart disease of both groups were compared.Results The positive diagnosis rate of arrhythmia in coronary heart disease of observation group(75.3％ ) was significantly higher than that of control group(54.8％ ) ( x2 =6.78,P ＜0.05).And the positive diagnosis rate of the observation group was also significantly higher than that of the control group in ventricular premature beats two,triple law,pairs of premature ventricular contractions,atrial premature beats two,triple law,atrial premature beats in pairs,atrioventricular block and paroxysmal ventricular tachycardia( all P ＜ 0.05 ).Conclusion Compared with routine electrocardiogram,the dynamic electrocardiogram in anrnythmia in coronary heart disease diagnosis could obtain higher positive diagnosis rate,and it is worthy of clinical application. Key words: Routine electrocardiogram; Dynamic electrocardiogram; Coronary heart disease; Arrhythmia

Tracking Down Atrial Fibrillation in the Stroke Unit

See related article, p 2689. Optimal treatment after stroke or transient ischemic attack (TIA) requires identification of atrial fibrillation (AF) if it is present. Standard antithrombotic therapy for patients not known to have AF consists of antiplatelet agents such as aspirin or clopidogrel.1 However, antiplatelet therapy is inferior to anticoagulant therapy for secondary stroke prevention in patients with AF.2,3 Therefore, failure to detect underlying AF as a cause of stroke or TIA results in inadequate antithrombotic therapy and an unnecessarily heightened risk of recurrent stroke. Despite the high stakes, diagnosing AF in patients with stroke or TIA can be difficult. A routine 12-lead electrocardiogram will readily identify persistent AF, but AF often takes an asymptomatic and paroxysmal form that eludes detection. In a study of patients with pacemakers or implanted defibrillators, those with new device-detected AF after stroke or TIA manifested this arrhythmia a median of 5 minutes per day, and most had no AF at all on >90% of days.4 Unfortunately, intermittent AF seems to pose the same risk of stroke as sustained AF.5 Recent data indicate that a single period of AF lasting only 6 minutes independently confers a heightened risk of stroke.6 To ensure appropriate antithrombotic therapy for secondary stroke prevention, these elusive forms of AF must be reliably ruled out. In line with …

Estudo de seguimento de utentes após realização de um eletrocardiograma em Medicina Geral e Familiar

FOLLOW-UP OF PATIENTS AFTER ROUTINE ELECTROCARDIOGRAM TESTING IN PRIMARY CARE Background: Electrocardiography (ECG) is commonly used in primary care to study and follow patients with cardiovascular di- seases. Aim: The purpose of this study was to assess changes in patient care after performance of an ECG during a primary care office visit. Methods: A prospective observational study was conducted at S. Joao Health Center, Oporto of all patients for whom an ECG was requested at primary care office visits over a two-year period, from 1/03/2007. Each time an ECG was requested, doctors recorded the reason for the test, the patient's symptoms, and past medical history. Electrocardiograms were saved for later ana- lysis. Clinical files were hand searched six months after the ECG to assess changes in patient care. A multinomial logistic regres- sion model was used to test associations between results of the ECG, classified by Novacode, and the indications for the test. Results: We studied 870 ECG, from 817 patients (56,4% females) with a median age of 57 years. The main reason for requesting an ECG was the presence of symptoms (48,5%). Analysis of the results of the ECG showed that 54,5% were interpreted as nor- mal, 35,9% had minor abnormalities, and 9,7% showed major abnormalities. Care of the patient remained unchanged after 67,9% of tests (CI95%: 64,8-70,0%), and referral for hospital care occurred after 5,7% (CI95%: 4,8-7,5%). In multivariate analysis, the decision to change patient care was significantly influenced by ECG results in patients in whom the test was requested for fol- low-up of known cardiovascular disease but not for those who reported symptoms at office visit. Conclusion: The ECG does not change the care of most patients who have the test done at an office visit. The greatest utility of the test was seen among patients with known cardiovascular risk factors or a past history of cardiovascular disease.

Effect of baseline QTc interval prolongation on oncology clinical trial enrollment.

2612 Background: An increasing number of clinical trials in oncology require normal or near-normal intervals of electrocardiographic corrected QT (QTc) as an eligibility criterion. However the normal QTc reference range (conventionally defined as ≤450ms) has been developed in broad populations of patients, and it is unclear whether average QTc intervals are higher in adult cancer patients. Methods: All electrocardiograms (ECGs) performed for any indication at the Moffitt Cancer Center during a one-week period were reviewed. The QTc interval for each patient was calculated according to the Bazett and Fridericia formulas. Mean and median QTc intervals were calculated along with standard deviations. The percentage of QTc intervals above 450ms, 470ms, and 500ms were calculated and graded accordingly to the Common Terminology Criteria for Adverse Events v4.0 (CTCAE v4.0). The effects of gender on the QTc interval were also evaluated. Results: 257 patients underwent ECGs over a one-week period. A total of 90 patients (35%) had abnormally prolonged QTc. 50 patients (20%) had QTc prolongation >450 (≥ grade 1), 32 (12%) had QTc prolongation > 470 (≥grade 2) and 8 patients (3%) had QTc prolongation >500ms (≥grade 3) using the Bazett formula. The corresponding numbers according to the Fridericia formula were 23 (9%), 13 (5%) and 2 (1%) . The median QTc interval was 441 (Bazett) and 422 (Fridericia) with a standard deviation of 30 and 28 respectively. Women had a mean QTc of 438 (Bazett) versus 443 for men. Conclusions: A very large percentage of patients seen at a comprehensive cancer center have QTc intervals above the normal reference range on routine ECGs. The growth in number of trials requiring a normal QTc interval as an eligibility criteria suggests that an ever-larger number of patients are excluded from trial participation. Regulatory agencies may need to reconsider eligibility criteria that substantially restrict trial enrollment and that accrue patients who are not reflective of the general patient population.

Endoxifen for breast cancer: Multiple-dose, dose-escalation study characterizing pharmacokinetics and safety in metastatic breast cancer patients.

3089^ Background: Endoxifen is an active metabolite of tamoxifen, a drug used in the treatment of breast cancer. To be clinically effective, tamoxifen must be converted to endoxifen by CYP2D6. Direct administration of endoxifen would not be subject to pharmacogenetic variations or drug-drug interactions. Our preclinical studies (Breast Cancer Treat 122, 579-584, 2010) have validated the concept of using endoxifen for the treatment of breast cancer. In human (Clin. Pharmacol. Ther. 88, 814-817, 2010), the single oral doses tested up to 4 mg of endoxifen were safe, well tolerated and bioavailable. Methods: A multiple-dose escalating study was conducted in 3 cohorts and each cohort had 6 patients (18 metastatic breast cancer patients). Endoxifen at 3 dose levels (2, 4, or 8 mg) was given once daily for 28 days. Routine laboratory tests, vital signs and electrocardiograms were measured throughout the study. Blood samples for PK analysis were collected after 28 days post dose. Endoxifen in plasma samples was determined using LC-MS/MS. Results: Endoxifen was found to be safe up to 8.0 mg. At steady state, it displays dose-proportional PK with respect to Cmax and AUC ( see Table below). Conclusions: Multiple daily endoxifen doses of 4.0-8.0 mg resulted in endoxifen exposures that would be sufficient for effective therapy. The favorable safety and multiple-dose PK profile of endoxifen warrants further evaluation of safety and efficacy of endoxifen in breast cancer patients. [Table: see text]

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.

Cardiac resuscitation in the operating room: Reflections on how we can do better

‘‘The man who comes to the hospital carrying his valise should walk out of the hospital carrying his valise.’’ These wise words were told to me long ago by a mentor who was advising me that our first obligation is to heal our patients and, in the course of that healing, to keep our patients safe from harm. That advice applies to all of medicine. Since their initial use, the administration of anesthetic agents has been accompanied with tremendous benefit and considerable risk. Not long after ether was introduced, the deaths of patients were reported, many young and undergoing minor procedures. As medical knowledge has developed, anesthesia has become safer, but risk remains. Cardiac arrest in the operating room, the most severe expression of that risk, remains an infrequent but catastrophic event, and many factors can contribute when it occurs. There are many causes of cardiac arrest in the operating room; nevertheless, reversible causes are of primary concern here, particularly those that may be related to the anesthetic. Cardiac arrest in the operating room is different from cardiac arrest occurring elsewhere in the hospital or outside the hospital environment. In the operating room, arrests are generally recognized quickly, mainly because of sophisticated physiologic monitoring, with pulse oximetry, capnography, and end-tidal CO2 complementing routine blood pressure and electrocardiogram measurements. Patients are in an ideal setting for the rapid administration of oxygen, often with secure controlled airways and immediate intravenous access. Defibrillators and resuscitation drugs are usually readily available along with personnel who are familiar with their use, and chest compressions can be initiated immediately. The foregoing factors taken together facilitate generally higher survival rates from operating room cardiac arrests, particularly if the arrest is related to anesthesia. Thus, general guidelines for treating cardiac arrest in general hospital wards or outside the hospital do not necessarily translate well to the operating room setting. In this issue of the Journal, two articles deal with an aspect of this problem. In their article, Moitra et al. focus on the treatment of cardiac arrest in the operating room. They specifically address how such events differ from their occurrence in other locations, and they provide an in-depth discussion of the special characteristics. They propose a set of algorithms designed to guide anesthetic care, first to avoid cardiac arrest and second to treat it if it should occur. Moitra et al. make a significant contribution to the management of this problem, but there is still a significant step to accomplish. Even armed with these modified algorithms, we still face a considerable challenge to make the algorithms easily usable in the clinical setting. In a recent editorial, de Caen and Bhanji extend the discussion on resuscitation to include children and infants, and they provide a practical update on pediatric resuscitation for the anesthesiologist. They concisely summarize the most current scientific evidence and expert opinion, and they encourage anesthesiologists to adopt the new rearrangement of the classic airway-breathing-circulation (ABC) approach to cardiopulmonary resuscitation (CPR) to a compression first approach, i.e., compressions-airwaybreathing, making CPR more consistent across age groups. Also in the current issue of the Journal, an article by Charapov and Naveen presents a case of prolonged and successful resuscitation of a patient undergoing an urgent abdominal procedure. The case report joins others in the W. R. Berry, MD (&) Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA e-mail: wberry@hsph.harvard.edu

Heart rate variability analysis of single channel electrocardiogram can help to differentiate high- risk patients with obstructive sleep apnea syndrome - a study on diagnostic accuracy

To evaluate the usefulness of heart rate variability analysis (HRV) analysis from the long duration electrocardiogram (ECG) recordings as a screening test for the diagnosis of moderate-to-severe obstructive sleep apnea syndrome (OSAS). Recordings from 87 patients who were admitted to sleep laboratory for polysomnographic study (PSG) were evaluated. Finally 30 cases with apnea-hypopnea index (AHI)≥15/hour included in patient's group (male/female: 22/8; mean age: 49±10 years) and 21 cases with AHI<5 were included in control group (male/female: 10/11; mean age: 48±11 years). From the ECG recordings taken as a part of PSG, time -domain and frequency -domain HRV parameters were evaluated and their accuracy in the diagnosis of OSAS was investigated using ROC analysis. Statistically significant differences were found in HRV variables in time- domain parameters such as SDNN, SDNN index; frequency-domain parameters VLF, LF, nuLF, nuHF, LF/HF and geometric parameter HRV triangular index values in between groups. Cut- off value of 16 for the HRV triangular index was found to be 50% sensitive and 85.7% specific with a positive likelihood ratio (LR) of 3.50% and negative LR of 0.58% When the total power was higher than 9.611, then the analysis sensitivity was 53.3%, specificity was 95.6%, positive LR was 11.2% and negative LR was 0.49% When the SDNN was higher than 83 then its sensitivity was 80%, specificity was 76.2%, positive LR was 3.36% and negative LR was 0.26% For the cut off value of 62 calculated for SDNN index, sensitivity was 73.3%, specificity was 85.7%, positive LR was 5.13% and negative LR was 0.31%, for the cut off value of 9.12 was calculated for VLF, sensitivity was 90.4% specificity was 50% positive LR was 1.81% and negative LR was 0.19%. Heart rate variability analysis done over routine single channel ECG data gathered through routine Holter applications may be helpful in distinguishing moderate-to-severe OSAS patients from mild OSAS patients and non-OSAS control subjects.

Preparticipation Athletic Screening Including an Electrocardiogram: An Unproven Strategy for Prevention of Sudden Cardiac Death in the Athlete

One of the fundamental principles of evidence-based medicine is that clinical practice should be based on evidence derived from sufficiently robust data to ensure that the benefits, risks, and costs of an intervention are known. Although intuitively appealing, athletic screening programs with routine electrocardiograms (ECGs) followed by restriction of at-risk individuals have not been demonstrated to be effective in decreasing the inherent risk of athletic sudden death. The incremental use of a screening ECG to a history and physical examination remains debatable because of insufficient evidence to conclusively resolve the issue. Long-term outcomes with a large group of athletes undergoing screening and restriction are limited to a small number of observational trials. One supports and many do not support ECG screening with athletic restriction of at-risk athletes. Although programs and policies to decrease sudden death are laudable, they need further evaluation before being implemented on a large-scale basis. Currently, athletes are best protected by a strategy of secondary prevention with improvements in resuscitation and emergency action plans.

Electrocardiographic Predictors of Out-of-Hospital Sudden Cardiac Arrest in Patients With Coronary Artery Disease

Sudden cardiac arrest (SCA), due mainly to coronary artery disease (CAD), is a leading cause of death. To identify electrocardiographic and clinical differences between patients with CAD with and without SCA, 87 victims of SCA with CAD were compared with 131 patients with CAD without SCA. Patients' latest routine electrocardiograms and clinical variables were compared. Patients with CAD with and without previous myocardial infarctions (MIs) were included. Patients with SCA had a higher incidence of echocardiographic evidence of left ventricular hypertrophy and/or heart failure than controls. The median left ventricular ejection fractions for patients with SCA with and without previous MIs were 0.30 (interquartile range 0.24 to 0.41) and 0.41 (interquartile range 0.25 to 0.56). The median time between the last electrocardiographic assessment and SCA was 59 days (interquartile range 29 to 137). Regarding electrocardiographic characteristics, in patients with and without previous MIs, QRS width (odds ratio 1.032, 95% confidence interval 1.012 to 1.053, p = 0.002, and odds ratio 1.035, 95% confidence interval 1.015 to 1.056, p = 0.001) was the only significant predictor of SCA. In conclusion, in patients with CAD, regardless of a previous MI, a longer QRS width and echocardiographic parameters consistent with heart failure are associated with SCA, even in patients with ischemic cardiomyopathy currently not eligible for an implantable cardioverter-defibrillator.

Transient Horner’s syndrome as sign of intrapetrous carotid dissection in a migrainous patient

We report the case of a patient that, during a migraine attack presented a transient Horner’s syndrome (HS), secondary to a spontaneous intrapetrous carotid artery dissection (IPCAD). Migraine is a common disorder with a pathophysiology that is incompletely understood. Migraine is considered a functional disorder of the brain, however, there are evidences linking migraine to the vascular system [1]. Endothelial dysfunction, altered vascular reactivity and hypercoagulability are reported in patients with migraine [2]. Migraine with aura seems to increase the risk of ischemic stroke [3] with unclear mechanisms. One link may be cervical artery dissection (CAD), since the association between M and CAD has been suggested [4]. Among CAD, spontaneous IPCAD is a rare occurrence, by far rarer than extracranial dissection, probably related to the anatomic localization that determinate the immobility of the petrous carotid portion fixed in the carotid canal [4]. A 36-year-old female presented with a moderate headache associated with 2-mm left ptosis and 2-mm anisocoria (left pupil smaller) without other neurological signs. The degree of anisocoria was enhanced in dim light, while visual fields and tonometry were normal. She had a positive family history for migraine without aura (MO). Past medical history was unremarkable. The patient did not present any cerebrovascular risk factor. When she was 17 years old, she started suffering from MO (ICHD-II criteria, [5]). The attacks were characterized by moderate, rarely severe, pulsating pain, aggravated by efforts. The pain was usually localized unilaterally in the periorbital right or left region and lasted 6–8 h. She reported nausea, rarely vomiting, phono and photophobia during the attacks. NSAIDs showed a good response. The attack associated with HS did not differ from the usual ones; pain was moderate, pulsating, localized in left fronto-temporal region and associated with phono and photophobia. Brain MRI with gadolinium and neck MRI with fat suppression were reported as negative; intracranial angio-MRI evidenced IPCAD on the left side (Fig. 1a, c). No etiological or predisposing factors to the dissection were disclosed, in particular, no clinical signs of Marfan’s syndrome were present. An occasional precipitating factor could have been the cough, secondary to a pharyngitis presented by the patient few days before hospital admittance. Routine blood counts, blood chemistry, coagulation studies, chest X-ray, electrocardiogram, transthoracic echocardiography and ophthalmology assessment were negative. A patent foramen ovale was excluded by a negative transcranial Doppler sonography with bubble test. Therapy with ASA was started; the subjective and neurological symptoms including HS disappeared in 48 h. A follow-up a month later evidenced a recanalization of the left carotid artery (Fig. 1b, d) and the patient was asymptomatic. The mechanisms by which migraine increase the risk of ischemic stroke could be resumed in the following points: (1) migraine may directly cause an ischemic stroke F. Maggioni (&) C. Disco G. Zanchin Department of Neurosciences, Headache Center, University of Padua, Via Giustiniani 5, 35128 Padua, Italy e-mail: ferdinando.maggioni@unipd.it

Primary Prevention of Sudden Cardiac Death of the Young Athlete: The Controversy About the Screening Electrocardiogram and Its Innovative Artificial Intelligence Solution

The preparticipation screening for athlete participation in sports typically entails a comprehensive medical and family history and a complete physical examination. A 12-lead electrocardiogram (ECG) can increase the likelihood of detecting cardiac diagnoses such as hypertrophic cardiomyopathy, but this diagnostic test as part of the screening process has engendered considerable controversy. The pro position is supported by argument that international screening protocols support its use, positive diagnosis has multiple benefits, history and physical examination are inadequate, primary prevention is essential, and the cost effectiveness is justified. Although the aforementioned myriad of justifications for routine ECG screening of young athletes can be persuasive, several valid contentions oppose supporting such a policy, namely, that the sudden death incidence is very (too) low, the ECG screening will be too costly, the false-positive rate is too high, resources will be allocated away from other diseases, and manpower is insufficient for its execution. Clinicians, including pediatric cardiologists, have an understandable proclivity for avoiding this prodigious national endeavor. The controversy, however, should not be focused on whether an inexpensive, noninvasive test such as an ECG should be mandated but should instead be directed at just how these tests for young athletes can be performed in the clinical imbroglio of these disease states (with variable genetic penetrance and phenotypic expression) with concomitant fiscal accountability and logistical expediency in this era of economic restraint. This monumental endeavor in any city or region requires two crucial elements well known to business scholars: implementation and execution. The eventual solution for the screening ECG dilemma requires a truly innovative and systematic approach that will liberate us from inadequate conventional solutions. Artificial intelligence, specifically the process termed "machine learning" and "neural networking," involves complex algorithms that allow computers to improve the decision-making process based on repeated input of empirical data (e.g., databases and ECGs). These elements all can be improved with a national database, evidence-based medicine, and in the near future, innovation that entails a Kurzweilian artificial intelligence infrastructure with machine learning and neural networking that will construct the ultimate clinical decision-making algorithm.

Canagliflozin improves glycaemic control over 28 days in subjects with type 2 diabetes not optimally controlled on insulin

Canagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor that is being investigated for the treatment of type 2 diabetes mellitus (T2DM). This was a randomized, double-blind, placebo-controlled, parallel-group, 28-day study conducted at two sites, in 29 subjects with T2DM not optimally controlled on insulin and up to one oral antihyperglycaemic agent. Subjects were treated with canagliflozin 100 mg QD or 300 mg twice daily (BID) or placebo. Safety, tolerability, pharmacokinetic characteristics and pharmacodynamic effects of canagliflozin were examined. Glucose malabsorption following a 75-g oral glucose challenge was also examined. Canagliflozin pharmacokinetics were dose-dependent, and the elimination half-life ranged from 12 to 15 h. After 28 days, the renal threshold for glucose excretion was reduced; urinary glucose excretion was increased; and A1C, fasting plasma glucose and body weight decreased in subjects administered canagliflozin (A1C reductions: 0.19% with placebo, 0.73% with 100 mg QD, 0.92% with 300 mg BID; body weight changes: 0.03 kg increase with placebo, 0.73 kg reduction with 100 mg QD, 1.19 kg reduction with 300 mg BID). Glucose malabsorption was not observed with canagliflozin treatment. There were no deaths, serious adverse events or severe hypoglycaemic episodes. The incidence of adverse events was similar across groups. There were no clinically meaningful changes in routine laboratory safety tests, vital signs or electrocardiograms. In subjects receiving insulin and oral antihyperglycaemic therapy, canagliflozin was well tolerated without evidence for glucose malabsorption, had pharmacokinetic characteristics consistent with once-daily dosing, and improved glycaemic control.

Prevalence of electrocardiographic abnormalities in an unselected young male multi-ethnic South-East Asian population undergoing pre-participation cardiovascular screening: results of the Singapore Armed Forces Electrocardiogram and Echocardiogram screening protocol

Resting 12-lead electrocardiograms (ECGs) have been employed in the pre-participation evaluation of young asymptomatic subjects to detect pre-existing heart diseases. Although the incorporation of routine ECG in pre-participation screening remains controversial, there is increasing evidence that cardiomyopathies and ion channelopathies have ECG changes as the initial manifestation. The causes of sudden cardiac death in young people show significant geographical variation. We aim to determine the prevalence and spectrum of ECG abnormalities in a young male South-East Asian population. The Singapore Armed Forces Electrocardiogram and Echocardiogram (SAFE) protocol is an ECG-based pre-participation cardiac screening programme modelled after the Italian system. From October 2008 to May 2009, a total of 18 476 young male conscripts (mean age 19.5 years old, range 16-27) underwent mandatory pre-enlistment medical screening at a single medical facility. Subjects with abnormal ECG findings were classified into two groups: Group A had ECG changes that fulfilled a pre-specified checklist to screen for hypertrophic cardiomyopathy and were referred for transthoracic echocardiogram; Group B had other ECG abnormalities [such as Brugada pattern, Wolff-Parkinson-White (WPW) pattern, long QTc] and were referred for secondary screening at a tertiary institution. Of the 18 476 subjects screened, 7.0% (n= 1285) had ECG abnormalities. Of note, 19 (0.10%) had Brugada pattern, 25 (0.14%) had WPW pattern, and 31 (0.17%) had prolonged QT interval on ECG. The prevalence of ECG abnormalities was significantly higher in Chinese than in South Asians (7.2 vs. 5.7%, P= 0.003). The prevalence of ECG abnormalities in a young, South-East Asian male population was 7.0%. There were significant ethnic differences, with ECG abnormalities more prevalent in Chinese than in South Asians (7.2 vs. 5.7%, P= 0.003). The inclusion of universal ECG, in addition to history and physical examination, may increase the sensitivity of a cardiovascular screening programme. Knowledge of the spectrum and prevalence of ECG abnormalities and disease conditions would be pivotal in designing customized screening programmes.

Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care

The purposes of this article are to explore the mechanism of sudden cardiac death (SCD) in young athletes and examine how preparticipation screenings help identify precipitating cardiac abnormalities. Electrocardiogram (ECG) testing has been implicated to play an important role in detecting subtle abnormalities that may cause SCD, but the routine implementation of this diagnostic tool remains a debate among experts. This report was compiled by reviewing the scientific literature on SCD in athletes, preparticipation exams, and current screening guidelines using CINAHL, MEDLINE, and PubMed search engines. Although the American Heart Association guidelines do not include ECG testing for preparticipation screenings, the implementation of routine ECG testing for preparticipation sports physicals is effective in preventing SCD in athletes. Primary care providers should be aware of current guidelines for screening patients for heart diseases that predispose them to SCD and their legal obligations to be sure these athletes are safe. The implementation of ECG testing will assist in the decision whether to disqualify an athlete from participation as a result of preexisting cardiac conditions, and ultimately preventing the untimely death of a young athlete.

Subclinical left ventricular dysfunction revealed by circumferential 2D strain imaging in patients with coronary artery disease and fragmented QRS complex

Fragmented QRS (fQRS) complexes on a routine 12-lead electrocardiogram were associated with adverse cardiac events, including sudden death in patients with coronary artery disease (CAD). To investigate the relationship between the fQRS complex and global and regional left ventricular (LV) functions in patients with CAD. The study consisted of 176 patients (68 ± 9 years; 145 [82%] men) with CAD with narrow QRS duration and preserved LV ejection fraction (>45%). All patients underwent detailed 2-dimensional speckle-tracking echocardiography to determine global and segmental (basal, middle, and apical) LV strains and strain rates and were prospectively followed-up in the outpatient clinic. Fifty-five patients (31%) had fQRS complexes. Global, middle, and apical LV longitudinal, radial, and circumferential strains and strain rates were significantly lower in the fQRS group than in the non-fQRS group (all P <.05). Multivariate logistic regression analysis revealed that the fQRS complex was associated with decreased global circumferential strain (odds ratio 1.19; 95% confidence interval 1.06-1.33; P = .003) and multivessel disease (odds ratio 3.69; 95% confidence interval 1.35-10.08; P = .011). Kaplan-Meier analysis revealed that event-free survival for cardiac events was significantly lower in the fQRS group than in the non-fQRS group (P = .036). Our results demonstrated that the fQRS complex in patients with CAD with preserved LV ejection fraction was associated with subclinical global and regional LV dysfunctions as detected by 2-dimensional speckle-tracking imaging, and the results also predicted adverse cardiac events.

Vertical P-wave axis: the electrocardiographic synonym for pulmonary emphysema and its severity

BackgroundThe correlation between vertical P-wave axis (P-axis > 60°) and pulmonary emphysema was investigated on a very large controlled series to see if P-axis verticalisation as lone criterion can be effectively used to screen emphysema in general population. Correlation between degrees of P-axis verticalisation and the severity of the obstructive lung disease (as per global initiative for chronic obstructive lung disease [GOLD] criteria) was also studied to see if this criterion can be used for gross quantification of the chronic obstructive pulmonary disease (COPD) in routine clinical practice. Materials and methodsAround 6500 unselected, routine electrocardiograms (ECGs) were reviewed which yielded 600 ECGs with vertical P-axis in sinus rhythm. 635 ECGs from the same continuum were selected with P-axis ≤60° matched for patient's age and sex serving as controls. Charts were reviewed for the diagnosis of COPD and emphysema based on medical history, pulmonary function tests, and imaging studies. ResultsPrevalence of emphysema in patients with vertical P-axis was strikingly higher than in the control group: 85% vs 4.4%. The sensitivity and specificity of vertical P-axis for diagnosing emphysema was 94.76% and 86.47%, respectively. Vertical P-axis and forced expiratory volume (FEV1) were inversely correlated (Pearson correlation coefficient=−0.683). Prevalence of severe COPD was strikingly higher in patients with P-axis > 75° as compared to the group with P-axis 60°–75°: 96.3% vs 4.6%. Close to 80% of the emphysema patients with P-axis > 85° had very severe disease (FEV1 < 30%). ConclusionP-axis verticalisation is highly effective for screening emphysema and degree of verticalisation provides a gross quantification of the disease.