ST-T Wave Abnormalities Research Articles

Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases.

Takotsubo cardiomyopathy (TCM) is a condition that is characterized as a transient ventricular dysfunction in the absence of obstructive coronary artery disease (CAD) and is usually triggered by an acute medical illness or intense physical or emotional stress. Multiple cases of perioperative TCM (pTCM) have been reported from around the world, but a qualitative analysis of these cases has not yet been done. For this systematic review, we searched PubMed for case reports and case series of pTCM published from 1966 to April 2015 with the objective being to evaluate whether differences in demographics, clinical features and outcomes exist between pTCM and nonperioperative (npTCM), as well as to attempt to identify any predictors of the severe form of pTCM, which requires mechanical circulatory support (MCS) devices or leads to death. A total of 93 articles describing 102 cases were retrieved and reviewed. The findings were compared with the analysis of the International Takotsubo Registry by Templin et al and a systematic review of mainly non-perioperative TCM (npTCM) by Gianni et al. Although we were unable to identify definitive risk factors for pTCM, our review suggests that pTCM appears to occur in younger patients and with a lower likelihood of ST segment elevations and T-wave abnormalities than in npTCM. No demographic or clinical factors were identified that were predictive of more severe outcomes. As TCM in general can be a life-threatening event, it would therefore be prudent to consider pTCM within a differential diagnosis in any patient who decompensates in the perioperative period.

Effect of Chronic Hepatitis C Virus Treatment by Combination Therapy on Cardiovascular System.

BACKGROUNDThe prevalence of hepatitis C virus (HCV) in Egypt is quite high, and the combined oral direct-acting antiviral agents (DAAs) may have impressive results.OBJECTIVETo assess the cardiovascular effects of DAAs in patients with HCV.METHODSA total of 170 patients with HCV were divided into 2 groups: first group (100 patients) received triple combination therapy (pegylated interferon alfa, sofosbuvir, and ribavirin, whereas the second group (70 patients) received dual combination therapy (sofosbuvir and simeprevir). Group 1 patients were followed up for 1 year more than 3 visits, whereas group 2 patients were followed up for 6 months more than 2 visits; and the end point of the study was the development of a major cardiovascular event (eg, congestive heart failure, echocardiographic evidence of left ventricular dysfunction, occurrence of significant arrhythmias, or acute coronary syndrome). The following parameters were accomplished: medical history and clinical examination, electrocardiogram, echo-Doppler study, and laboratory investigations.RESULTSNo significant differences were found between the 2 study groups regarding demographic criteria. None of the both group patients had developed any major cardiac event. No significant changes were observed regarding ST-T wave abnormalities, arrhythmias, or QT interval. None of the both group patients developed echocardiographic regional wall motion abnormalities at baseline or at study end. Systolic function parameters showed minute nonsignificant changes over study visits. Diastolic function parameters showed nonsignificant changes between baseline and 6-month and 12-month visits.CONCLUSIONSThe DAAs used in combination regimen with interferon or used orally in combination do not significantly affect the cardio-vascular system.

The Rise and Fall of Cardiac Troponin T.

A 65-year-old man presented to the emergency department. He reported experiencing a 20-min episode of central chest pain with an aching character and no radiation. He had no significant past medical history. Serial electrocardiograms showed no ST segment or T-wave abnormalities. High-sensitivity cardiac troponin T (hs-cTnT)4 concentrations (Roche Elecsys, 99th percentile 14 ng/L, CV <10% at 13 ng/L) were …

Electrocardiographic predictors of peripartum cardiomyopathy.

SummaryObjectiveTo identify potential electrocardiographic predictors of peripartum cardiomyopathy (PPCM).Methods:This was a case–control study carried out in three hospitals in Kano, Nigeria. Logistic regression models and a risk score were developed to determine electrocardiographic predictors of PPCM.Results:A total of 54 PPCM and 77 controls were consecutively recruited after satisfying the inclusion criteria. After controlling for confounding variables, a rise in heart rate of one beat/minute increased the risk of PPCM by 6.4% (p = 0.001), while the presence of ST–T-wave changes increased the odds of PPCM 12.06-fold (p < 0.001). In the patients, QRS duration modestly correlated (r = 0.4; p < 0.003) with left ventricular dimensions and end-systolic volume index, and was responsible for 19.9% of the variability of the latter (R2 = 0.199; p = 0.003). A risk score of ≥ 2, developed by scoring 1 for each of the three ECG disturbances (tachycardia, ST–T-wave abnormalities and QRS duration), had a sensitivity of 85.2%, specificity of 64.9%, negative predictive value of 86.2% and area under the curve of 83.8% (p < 0.0001) for potentially predicting PPCM.ConclusionIn postpartum women, using the risk score could help to streamline the diagnosis of PPCM with significant accuracy, prior to confirmatory investigations

Lack of Association of ST-T Wave Abnormalities to Congenital Heart Disease in Neonates.

ST-T wave (STTW) abnormalities have been described in 20-40% of normal newborns. We sought to describe the associations of these Electrocardiogram (ECG) abnormalities to perinatal course and congenital heart disease (CHD). A retrospective chart review was performed on all neonatal ECGs between January 2008 and March 2013 identified from electronic medical records. Electronic medical records were reviewed for perinatal course and maternal medical conditions. Neonates <37 weeks gestation, >3 days age, requiring hemodynamic support in the first 3 days, with oxygen saturation <90% on room air, or with arrhythmias and significant abnormalities of axis and voltage were excluded from the analysis. ST segment elevation or depression of >2 mm in at least one lead and flat or inverted T waves in at least one lead except aVR were considered abnormal. Statistical relationships were explored between STTW abnormalities, perinatal variables and CHD. ECGs were performed on 1043 neonates, of which 664 were included. STTW abnormalities were found in 236 (35.5%) neonates. T wave abnormalities were identified in 191 (28.7%), ST segment abnormalities in 77 (11.6%) and both on 32 (4.8%) neonates. No relationship was found between the ECG abnormalities and perinatal variables, except maternal cefazolin administration during labor. Noncritical CHD was diagnosed by echocardiography in 59/84; STTW abnormalities were seen in 17/59 (29%) patients with and 9/25 (34%) without noncritical CHD, P = .6. STTW abnormalities on ECG are commonly found in 35.5% of normal neonates and do not predict noncritical CHD.

Dizziness With Exertion In An Ice Hockey Athlete

HISTORY: 20 yo women’s ice hockey athlete with hx of absence seizures presents with dizziness, SOB & palpitations with exertion. Pt developed symptoms during first practice after winter break. Initially thought she was “out of shape”. When she could not continue due to symptoms she reported to the Athletic Trainer. Irregular rhythm noted; 140-150bpm. Remainder of the evaluation by AT was normal. Pt began to feel normal after 30 minutes in supine. Prior episode of mental status changes one month prior felt to be related to seizure disorder. No hx of syncope/pre-syncope, CP. PMH: Partial complex seizures dx 2nd grade, grand mal sz 2010. ROS: (-) recent fever, chills, illness. Meds: Keppra, recently started on Lamictal, Sorynx. Allergies: Dilantin (rash). SH: student, no ETOH/drugs. FH: F-HTN, valve dz. PHYSICAL EXAMINATION: WDWN; NAD; 120/60; HR 74; HEENT wnl; Thyroid nm; Cardiac- PMI nml, RRR, no M/R/G, normal HJR; Lungs clear; Abd nml; Ext nml. DIFFERENTIAL DIAGNOSIS: Cardiac vs Neurologic vs Metabolic vs Infectious TESTS AND RESULTS: Initial: Lab- CBC, Chem panel, TFTs nml. EKG- NSR, 53bpm, nml intervals, ST-T wave abnormalities Referral to Cardiology: Echo- nml valves, chambers, EF 45%, mild global LV hypokinesis WORKING DIAGNOSIS: Cardiomyopathy- Post-infectious, arrhythmia-induced, infiltrative, anomalous coronary, vs. CAD Additional Tests: CT angio- normal coronary arteries; Ca+ score 0; LVEF 43%; no evidence of RV dysplasia ETT- Resting PVC’s which normalize with higher levels exertion; Into Stage V Bruce asymptomatic 30d Holter monitor: NSR, avg HR 58 (40-169), 5312 PVC’s (6.8 %). 12 couplets. Multiform PVS’s noted MRI: Bi-ventricular mod enlargement, ED dimension 67mm, low nml systolic fn. No regional wall motion abnormalities. LV trabeculated myocardium, ratio 3:1. No perfusion defects. No myocardial delayed enhancement. EF 58% LV, 52% RV Labs: EBV panel, Coxsackie, Lyme, CMV, TFT’s, ESR/CRP, Chem panel, CBC, Iron studies FINAL DIAGNOSIS: Non-compaction Cardiomyopathy TREATMENT AND OUTCOMES: Pt referred to heart failure specialist. Pt initially treated with Beta-blocker, and dc OCP. Did not return to competitive sport. When seen by second specialist, dc B-blocker and initiated baby ASA and ACE inhibitor. Pt has been followed by second specialist.

Electrophysiologic features of fetal ventricular aneurysms and diverticula.

Congenital ventricular wall defects are very rare and include congenital ventricular aneurysms (CVAs) and diverticula (CVDs). We report a series of five fetuses: three with CVAs and two with CVDs referred due to fetal arrhythmia. In addition to routine fetal echocardiography, fetal magnetocardiography (fMCG) was used. The literature in CVA and CVD is reviewed. Incessant premature ventricular contractions (PVC), mainly bigeminy and trigeminy were found in three fetuses with CVAs and in one with CVD, who also had ventricular couplets. The other fetus with CVD, referred because of PVCs, had only sinus tachycardia. ST elevation was noted in two. Fetal movement had a variable impact on PVCs. Postnatal evaluation demonstrated two persistent left ventricular aneurysms and one persistent right CVD; one CVD resolved at 35-week gestation. Two neonates had incessant PVCs. Both arrhythmias resolved spontaneously while being treated with propranolol. FMCG is complementary to echocardiographic imaging. In fetuses with left ventricular wall defects, additional electrophysiological diagnosis can be made by fMCG, including the complexity of ventricular ectopy, arrhythmic response to fetal movement, presence of ST-T wave abnormalities, and atrial amplitude increases. Prenatal risk factor assessment using fMCG can additionally support post-natal treatment and follow-up.

Association of Changes in Fitness and Body Composition with Cancer Mortality in Men

Both baseline cardiorespiratory fitness and adiposity predict the risk of cancer mortality. However, the effects of changes in these two factors over time have not been evaluated thoroughly. The aim of this study was to examine the independent and joint associations of changes in cardiorespiratory fitness and body composition on cancer mortality. The cohort consisted of 13,930 men (initially cancer-free) with two or more medical examinations from 1974 to 2002. Cardiorespiratory fitness was assessed by a maximal treadmill exercise test, and body composition was expressed by body mass index (BMI) and percent body fat. Changes in cardiorespiratory fitness and body composition between the baseline and the last examination were classified into loss, stable, and gain groups. There were 386 deaths from cancer during an average of 12.5 yr of follow-up. After adjusting for possible confounders and BMI, change hazard ratios (95% confidence intervals) of cancer mortality were 0.74 (0.57-0.96) for stable fitness and 0.74 (0.56-0.98) for fitness gain. Inverse dose-response relationships were observed between changes in maximal METs and cancer mortality (P for linear trend = 0.05). Neither BMI change nor percent body fat change was associated with cancer mortality after adjusting for possible confounders and maximal METs change. In the joint analyses, men who became less fit had a higher risk of cancer mortality (P for linear trend = 0.03) compared with those who became more fit, regardless of BMI change levels. Being unfit or losing cardiorespiratory fitness over time was found to predict cancer mortality in men. Improving or maintaining adequate levels of cardiorespiratory fitness appears to be important for decreasing cancer mortality in men.

Evolution of electrocardiographic abnormalities in association with neuromuscular disorders and survival in left ventricular hypertrabeculation/noncompaction.

Left ventricular hypertrabeculation/noncompaction (LVHT) is frequently associated with neuromuscular disorders (NMDs) and electrocardiographic (ECG) abnormalities. The prognostic relevance of newly developed ECG abnormalities in LVHT and its dependency on NMD is largely unknown. Aim of the following retrospective cohort study in LVHT patients was thus to assess the development of new ECG abnormalities and its dependency on NMD and survival. Included were patients in whom (a) LVHT was diagnosed between 1995 and 2011, (b) baseline ECG recordings (bECG), and (c) follow-up ECG recordings (fECG) were available. Survival status was assessed in June 2013. Included were 105 patients (mean age 55 years, 36 females, 67 with NMD). The interval between bECG and fECG was 3.6 years. ECG abnormalities increased in 46%, were unchanged in 44% and decreased in 11%. Increase was associated with age (59 years vs 49 years, P = 0.0169), exertional dyspnea (79% vs 53%, P = 0.013), heart failure (81% vs 47%, P = 0.0149), a left ventricular end-diastolic diameter >57 mm (76% vs 43%, P = 0.004) and a left ventricular fractional shortening <25% (68% vs 42%, P = 0.0429). New ECG abnormalities were ST-T wave abnormalities (n = 35), left anterior hemiblock (n = 6) and Q waves (n = 6). During 71 months, 40 patients died. Multivariate analysis identified age, male gender, "constant" (in bECG as well as fECG) atrial fibrillation, disappearance of atrial fibrillation, development as well as disappearance of low voltage ECG, increase of QRS width, constant QRS width >120 ms and constant tall QRS complexes as predictors for mortality. LVHT-patients develop frequently new ECG abnormalities of prognostic relevance.

Abstract 18568: Normal Angiographic Appearance of the Coronary Arteries is Common in Antiphosopholipid Syndrome Patients Presenting With Acute Coronary Syndrome

Background: Antiphospholipid syndrome (APLS) is known to be associated with Acute Coronary Syndrome (ACS) due to coronary artery thrombosis or embolism. Because individual cases of ACS with normal angiographic appearance of the coronary arteries have been reported in this population, we aimed to determine the prevalence of this presentation amongst patients with known APLS at our institution. Methods: Our institutional database was queried for all patients testing positive for antiphospholipid antibodies (n=575) between 2000 and 2012. From this sample, we identified 46 patients having cardiac catheterization. ACS (n=32) was defined as the presence of angina chest pain, ECG with ST segment or T-wave abnormalities and troponin-I &gt; 0.1 mg/dL. Results: Normal appearing coronary arteries, without evidence of atherosclerosis or embolism, were found in 8 patients (52±7 years, 5 female) with APLS (lupus anticoagulant n=5; anti-cardiolipin n=5; anti-B2-GP1 n=3) presenting with ACS. All 8 patients had history of prior arterial (stroke n=5) or venous thrombosis (n=3). Median troponin-I was 0.30 mg/dL [range 0.15, 0.50]. One subject was found to have diffuse coronary artery spasm, which reversed following administration of intra-coronary nitroglycerine. One patient had a regional wall motion abnormality in a single territory and another patient had global ventricular dysfunction. Median left ventricular ejection fraction was 60% [range 30, 60]. Conclusions: A high proportion of patients with APLS presenting with ACS did not have evidence of either coronary thrombosis or embolism on angiography. This clinical presentation is suspicious for either coronary artery spasm or myopericarditis.

ECG Response: November 26, 2013

HomeCirculationVol. 128, No. 22ECG Response: November 26, 2013 Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBECG Response: November 26, 2013 Originally published26 Nov 2013https://doi.org/10.1161/CIRCULATIONAHA.113.007077Circulation. 2013;128:2419IntroductionECG Challenge: A 22-year-old graduate student presents to student health because of palpitations that have been present for ≈2 hours. They occurred after she was jogging. She states that she has had similar palpitations in the past, but they were usually of a briefer duration. An ECG (ECG A) is obtained during the palpitations. Adenosine is administered, and this terminates the arrhythmia. A second ECG (ECG B) is obtained thereafter.Download figureDownload PowerPointECG A: The rhythm is regular at a rate of 190 bpm. The QRS-complex duration is normal (0.08 s), and there is a normal morphology and axis between 0° and +90° (positive QRS complex in leads I and aVF). The QRS amplitude is increased, with an S wave in lead V2 that is 20 mm (]) and an R wave in lead V6 that is 30 mm ([) (total=50 mm). Although this meets 1 of the criteria for left ventricular hypertrophy (ie, SV2+RV6≥45 mm in a subject <45 years of age), the QRS-complex amplitude or voltage is likely normal in this young healthy woman who is likely thin and has no lung disease. ST-segment depression is noted in leads II, aVF, and V3 to V6 (^). These are likely related to the rapid rate, although subendocardial ischemia should be considered. The QT/QTc intervals are normal (240/430 ms). There are no obvious P waves seen before or after any of the QRS complexes. However, there is notching (that appears to be negative) of the ST segment, seen best in leads III, aVF, and V6 (). There is also a positive waveform at the end of the QRS complex in lead aVL (). These notches are P waves and therefore this is a short RP tachycardia. Causes for a short RP tachycardia include sinus tachycardia, atrial tachycardia, ectopic junctional tachycardia, atrial flutter, typical atrioventricular nodal tachycardia, or an atrioventricular tachycardia. However, the cause for this tachycardia cannot be definitively established.ECG B: After the tachycardia has been terminated by adenosine, there is a regular rhythm at a rate of 76 bpm. The QRS-complex duration is increased (0.14 s), and the morphology does not resemble either a typical right or left bundle-branch block. Indeed, the upstroke of the QRS complex is slurred (), and there is positive concordance (ie, tall R wave) across the precordium (→). This is abnormal and is not seen with normal conduction through the His-Purkinje system, but rather reflects direct myocardial activation, as seen with a paced complex, ventricular complex, or preexcited complex. There is a P wave before each QRS complex (+), and the P wave is positive in leads I, II, aVF, and V4 to V6. Hence, there is an underlying normal sinus rhythm. The PR interval is constant; however, it is short (0.12 s). The short PR interval and the widened QRS complex are characteristic of a Wolff-Parkinson-White pattern. The slurred upstroke is known as a delta wave. There are diffuse ST-T–wave abnormalities (^). However, because initial myocardial activation occurs via the accessory pathway and not the normal His-Purkinje system, abnormalities of the left ventricle cannot be reliably established on the ECG. Therefore, the ST-T–wave changes are related to preexcitation and not a primary problem of the myocardium. Because this patient has Wolff-Parkinson-White, the narrow QRS complex tachycardia seen in ECG 11A is termed orthodromic atrioventricular reentrant tachycardia. In this situation, antegrade activation of the ventricles is via the normal AV node His-Purkinje system, whereas the retrograde conduction back to the atria is via the accessory pathway.FootnotesCorrespondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Reyes M Opening Borders: African Americans and Latinos Through the Lens of Immigration, SSRN Electronic Journal, 10.2139/ssrn.2477900 November 26, 2013Vol 128, Issue 22 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.113.007077PMID: 24276877 Originally publishedNovember 26, 2013 PDF download Advertisement SubjectsElectrocardiology (ECG)

Surgical Unroofing of an Anomalous Right Coronary Artery Arising From the Posterior Left Sinus of Valsalva

A 25-year-old male patient presented with sudden collapse due to a cardiac arrest during physical exercise. An electrocardiogram revealed ST-T wave abnormalities. A coronary catheterization and complementary computer tomography angiography showed an anomalous right coronary artery arising from the posterior left sinus of Valsalva. A successful surgical unroofing was performed.

ST-T Wave Abnormality in Lead aVR and Reclassification of Cardiovascular Risk (from the National Health and Nutrition Examination Survey-III)

Electrocardiographic lead aVR is often ignored in clinical practice. The aim of this study was to investigate whether ST-T wave amplitude in lead aVR predicts cardiovascular (CV) mortality and if this variable adds value to a traditional risk prediction model. A total of 7,928 participants enrolled in the National Health and Nutrition Examination Survey (NHANES) III with electrocardiographic data available were included. Each participant had 13.5 ± 3.8 years of follow-up. The study sample was stratified according to ST-segment amplitude and T-wave amplitude in lead aVR. ST-segment elevation (>8 μV) in lead aVR was predictive of CV mortality in the multivariate analysis when not accounting for T-wave amplitude. The finding lost significance after including T-wave amplitude in the model. A positive T wave in lead aVR (>0 mV) was the strongest multivariate predictor of CV mortality (hazard ratio 3.37, p <0.01). The addition of T-wave amplitude in lead aVR to the Framingham risk score led to a net reclassification improvement of 2.7% of subjects with CV events and 2.3% of subjects with no events (p <0.01). Furthermore, in the intermediate-risk category, 20.0% of the subjects in the CV event group and 9.1% of subjects in the no-event group were appropriately reclassified. The absolute integrated discrimination improvement was 0.012 (p <0.01), and the relative integrated discrimination improvement was 11%. In conclusion, T-wave amplitude in lead aVR independently predicts CV mortality in a cross-sectional United States population. Adding T-wave abnormalities in lead aVR to the Framingham risk score improves model discrimination and calibration with better reclassification of intermediate-risk subjects.

Coronary artery calcification and ECG pattern of left ventricular hypertrophy or strain identify different healthy individuals at risk

To improve risk stratification for development of ischaemic heart disease, several markers have been proposed. Both the presence of coronary artery calcification (CAC) and ECG pattern of left ventricular hypertrophy/strain have been shown to provide independent prognostic information. In this study, we investigated the association between established risk factors, ECG measurements and the presence of coronary artery calcification. A random sample of healthy men and women aged 50 or 60 years were invited to the screening study. Established risk factors were measured. A noncontrast computed tomographic (CT) scan was performed to assess the CAC score. ECG analysis included left ventricular hypertrophy (LVH) using the Sokolow-Lyon criteria and the Cornell voltage × QRS duration product, and strain pattern based on ST segment depression and T-wave abnormalities. The association between the presence of CAC, clinical variables and ECG findings was evaluated by means of multivariate logistic regression. Of 1825 invited individuals, 1226 accepted the screening. The prevalence of hypertension was 50%. Hypertensive patients frequently had LVH and/or strain when compared with nonhypertensive individuals (21 vs. 14%, P < 0.0001) as well as CAC (52 vs. 38%, P < 0.0001). In multiple logistic regressions analyses, there was no association between the ECG abnormalities and the presence of CAC. There appears to be no relationship between CAC and ECG-suspected LVH and/or strain. We propose that these markers identify different individuals at risk and together may have additive prognostic value.

Electrocardiographic changes during oesophagogastroscopy

Oesophagogastroduodenoscopy (EGD) should be very safe, but there are many potential hazards, although the rate of serious complications is small. There are so many complications that can arise during this procedure. Most of these complications involve the respiratory or cardiovascular systems, especially in sick or sedated patients.The aim of this study was to determine the various electrocardiographic changes that can occur at different stages of diagnostic EGD and to determine their severity. The study is a descriptive one which was carried out at the endoscopy unit of Ladoke Akintola University of Technology Teaching Hospital, (LAUTECH), Osogbo, Osun State. Consecutive patients who were referred for oesophagogastroduodenoscopy (EGD) over a 3-month period and who consented to take part in the study were recruited. The electrodes of a portable electrocardiographic (ECG) machine (model Cardiovit AT_1ECG Machine) were attached to the patients accordingly and remained fixed till the end of the procedure. ECG recordings were done at baseline, postpremedication, during intubation and 5 minutes postprocedure. The results of the study were analyzed using simple descriptive statistical methods such as range, mean and standard deviation for continuous variables, and numbers and percentages for discreet variables. Twenty-six (26) patients were studied, comprising 14 (53.8%) males and 12 (46.2%) females. The mean age of the patients was 47.19 ± 14.42 years. Three (11.5%) patients had tachycardia at the beginning of the procedure, while 13 (50%) patients developed tachycardia postpremedication and during the procedure, whereas 17 (65.4%) patients had tachycardia at the end of the procedure. Only one patient had bradycardia. Various ST-T wave abnormalities were observed at each stage of the procedure. Conduction abnormality was observed in 8 (30.8%), 9 (34.6%), 7 (26.9%) and 5 (19.2%) patients at rest, post-premedication, during the procedure and postprocedure respectively. Premature ventricular complexes (PVC) were observed in 4 (15.4%), 5 (19.2%), 4 (15.4%), and 4 (15.4%) patients at rest, post-premedication, during the procedure and post procedure respectively. This study has shown that, although ECG abnormalities do occur during EGD, these abnormalities are not severe enough to warrant specific interventions or discontinuation of the procedure.

Prognostic significance of baseline ST-T-wave abnormalities in diagnostic stress echocardiography

The aim of this study was to determine whether resting ST-T wave abnormalities (ST-Ta) provide incremental prognostic information in patients with no history of coronary artery disease undergoing dobutamine stress echocardiography (DSE). We evaluated 1308 consecutive patients without previous myocardial infarction (MI) or revascularization who underwent DSE. Ischemia was defined as new or worsening wall motion abnormalities. End points during follow-up were all-cause death and cardiac death/nonfatal MI. ST-Ta were detected in 162 (12%) patients. The incidence of ischemia was higher in patients with baseline ST-Ta than patients without [74 (46%) vs. 327 (28%), P=0.00001]. During a follow-up of 4.6 ± 3 years, cardiac death/nonfatal MI occurred in 42 (26%) patients with resting ST-Ta and in 157 (14%) patients without resting ST-Ta (P<0.001). Patients with ST-Ta had a higher annual cardiac death/nonfatal MI rate compared with patients without, both in the presence of normal DSE (3.2 vs. 1.4%, P=0.01) as well as abnormal DSE (5.3 vs. 3%, P<0.001). In a Cox proportional modeling, resting ST-Ta added incremental value over clinical and stress echocardiographic data for the prediction of death (global χ 125, 140, 150, respectively; P<0.05) and cardiac death/nonfatal MI (global χ 79, 100, 111, respectively; P<0.05). Baseline ST-Ta are associated with an increased risk of cardiac death/nonfatal MI and all-cause mortality, incremental to clinical data and DSE results. The associated risk is persistent among patients with normal DSE.

Prognostic significance of serial Q/ST-T changes by the Minnesota Code and Novacode in the Atherosclerosis Risk in Communities (ARIC) study

To compare the value of serial electrocardiographic (ECG) changes by the two most widely used ECG classification systems-the Minnesota Code (MC) and Novacode (Nova) for the prediction of subsequent coronary heart disease (CHD) and total mortality. We studied 12-lead ECGs from 12,477 participants (average age 54 years at baseline; 58% women; 76% non-Hispanic white) in the Atherosclerosis Risk in Communities (ARIC) Study, who were free of CHD at baseline in 1987, had both good-quality ECGs at baseline and at first study-scheduled follow-up visit, and had ECG QRS duration <120 ms. A total 2119 participants died (17%), including 280 CHD deaths during an average 17-year follow up. Cox regression models assessed outcome associated with significant serial ECG changes by MC and Nova separately. For CHD death the hazard ratio was 6.8 (95% CI 3.5-13.3) for incident Nova myocardial infarction (MI), and 5.7 (95% CI 2.7-11.9) for MC-MI in a multivariable model adjusted for clinical and demographic characteristics, and ECG left ventricular hypertrophy. The increased risk for total mortality doubled for both Nova and MC serial ECG MI. Major evolving ST-T wave abnormalities alone were associated with a ≥132% increased risk for CHD death and a 50% increased risk for total mortality by either Nova or MC. ECG serial change by both MC and Nova are equally valuable predictors for future fatal cardiac events and total mortality and hence equally useful prognostic indicators in clinical trials and epidemiological studies.

Electrocardiographic Changes in Centenarians: A Study on 42 Subjects and Comparison with the Literature

Background: Aging is associated with extensive and pervasive changes in cardiovascular structure and function, which may result in electrocardiographic alterations. The typical modifications seen in an electrocardiogram (ECG) in elders are: prolonged PR and QT intervals, QRS left-axis deviation and microvolt T wave. Several studies have included elderly people, but not long-living elderly and centenarians in particular who represent an increasing part of the population. Objective: The aim of this study was to investigate the electrocardiographic findings in a population of centenarians and to compare the results with the few studies present in the literature. Methods: We analyzed 42 healthy centenarians (12 males, 30 females; average age 101.43 ± 1.80 years) living in Messina, a municipality of Eastern Sicily, in Italy. They were clinically and functionally evaluated. All ECGs were analyzed by a single observer blind to clinical data. We assessed survival by phone recall. Results: PR interval mean duration was 190 ± 3.3 ms, QRS 90 ± 1.4 ms, QTc interval mean duration was 370 ± 3.5 ms. Entirely normal ECG recordings were found in 7 centenarians (16.6%). The most frequently observed abnormalities included left-axis deviation and left anterior hemiblock in 16 centenarians (38.09%), left ventricular hypertrophy and aspecific ST-T wave abnormalities in 13 subjects (30.95%). We found no statistically significant differences between men and women. The mean age at death was 102.44 ± 2.45, and we did not find significant differences in age at death in long-living elderly in relation to different electrocardiographic findings. Comparing our results with two previous studies in the literature, the first conducted in Switzerland [Cornu: Rev Med Suisse Rom 1979;99:107–113] and the second in Nebraska [Lakkireddy et al.: Am J Cardiol 2003;92:1249–1251], we found a higher frequency of left ventricular hypertrophy that was compatible with the prevalence of hypertension in our centenarians (33.3%). Moreover, we did not find left bundle branch block, and the frequency of premature beats was remarkably less than that observed in the Swiss and US studies. Conclusions: Considering the increasing rate of centenarians, we believe that the results of the present study on electrocardiographic changes in centenarians may also be useful in clinical practice.

Gender Differences Between the Minnesota Code and Novacode Electrocardiographic Prognostication of Coronary Heart Disease in the Cardiovascular Health Study

The Minnesota Code (MC) and Novacode (Nova) are the most widely used electrocardiographic (ECG) classification systems. The comparative strengths of their classifications for Q- and ST-T-wave abnormalities in predicting coronary heart disease (CHD) events and total mortality have not been evaluated separately by gender. We studied standard 12-lead electrocardiograms at rest from 4,988 participants in the Cardiovascular Health Study. Average age at baseline was 73 years, 60% of participants were women 85% were white, and 22% had a history of cardiovascular disease or presence of ECG myocardial infarction by MC or Nova. Starting in 1989 with an average 17-year follow-up, 65% of participants died and 33% had incident CHD in a cohort free of cardiovascular disease at baseline. Of these, electrocardiograms with major Q-wave or major ST-T abnormalities by MC or Nova predicted increased risk for CHD events and total mortality with no significant differences in predictability between men and women. The study also found that women had fewer major Q-wave changes but more major ST-T abnormalities than men. However, there were no gender differences in predicting CHD events and total mortality. In conclusion, ECG classification systems for myocardial infarction/ischemia abnormalities by MC or Nova are valuable and useful for men and women in clinical trials and epidemiologic studies.

A Rare Case of Fatal Hyponatremia Due to a Combination of Psychotropic Polypharmacy and Hypothyroidism

A Rare Case of Fatal Hyponatremia Due to a Combination of Psychotropic Polypharmacy and Hypothyroidism