Standard ECG Recordings Research Articles

The acute effect of palonosetron on ECG parameters in patients with cancer.

e19686 Background: The 5-hydroxytryptamine 3 receptor antagonists are used for the prevention and treatment of chemotherpy and radiotherapy-induced emesis. Despite their effectiveness and safety profile, it was reported in many studies that they may cause electrocardiographic changes related to heart rate and repolarization. The purpose of this study is to determine acute influence of paronosetron on ECG parameters in cancer patients. Methods: Forty-seven cancer patients with normal cardiac function who received paronosetron for the prevention of chemotherapy/radiotherapy induced emesis were enrolled into this prospective study. Standard 12-lead ECG recordings were performed at baseline and 30 min after palonosetron administration. P wave durations and corrected QT intervals were measured; P wave dispersion (Pd) and QTc dispersion were calculated. Statistical comparison of quantitative data was performed by paired sample t test. A P value of <0.05 was considered to be statistically significant. Results: In comparison with baseline, no statistically significant change in any ECG parameters, including QT and RR intervals, P wave durations, Pd and QTd, was observed after infusion of Palonosetron. Conclusions: In this study palonosetron did not show any ventricular and atrial arrhythmogenic effect because of repolarization abnormalities.

Zoledronic acid and atrial fibrillation in cancer patients

Treatment with a bisphosphonate was found to be associated with a significantly increased risk for atrial fibrillation (AF) in a few studies. A recent study showed that once-yearly infusions of intravenous zoledronic acid (ZA) significantly increased the risk of serious AF in postmenopausal women with osteoporosis. This study was conducted to determine the frequency of atrial fibrillation among cancer patients receiving the standard treatment of ZA. Patients with bone metastases who presented to our outpatient clinic for any reason (routine control, chemotherapy, or ZA administration) were included in the study. All patients had been receiving 4 mg ZA at 4-week intervals, with each dose administered over 15 min. A short survey was completed and standard 12-lead ECG recordings were obtained. One hundred and twenty-four cancer patients with documented bone metastases were evaluated. Mean age of the patients was 55 ± 13.0 years, 60% of the patients were female. Forty-one percent of the patients had breast cancer, 18% had non-small cell lung cancer, and the remainder had other solid tumors. Mean duration of ZA administration was 13.4 ± 15.0 months. Mean total cumulative dose was 54 ± 15.0 mg per patient. Sixty patients (48%) had previously been treated with anthracycline-containing regimens, and 37 (30%) had received chest radiotherapy that might affect the heart. Twenty-three percent of the patients had hypertension, 10% had diabetes mellitus, 3.7% had myocardial infarction history, 1.9% had congestive heart failure, and 1% had valvular disease; 10.5% were current smokers and 32% ex-smokers. On ECG evaluation, we observed normal sinus rhythm in 58%, sinus tachycardia in 15%, sinus bradicardia in 3.2%, and ventricular extrasystole in 5.7% of the patients. There was no AF in any of the cases. There was no increase in the risk of AF frequency in cancer patients who were treated with intravenous ZA, although most of the patients had additional risk factors including previous treatment with cardiotoxic agents or with chest radiotherapy. We believe that the risk of AF is negligible in this patient population and does not affect treatment decisions.

Bayesian Approach to Patient-Tailored Vectorcardiography

For assessment of specific cardiac pathologies, vectorcardiography is generally considered superior with respect to electrocardiography. Existing vectorcardiography methods operate by calculating the vectorcardiogram (VCG) as a fixed linear combination of ECG signals. These methods, with the inverse Dower matrix method the current standard, are therefore not flexible with respect to different body compositions and geometries. Hence, they cannot be applied with accuracy on patients that do not conform to the fixed standard. Typical examples of such patients are obese patients or fetuses. For the latter category, when recording the fetal ECG from the maternal abdomen the distance of the fetal heart with respect to the electrodes is unknown. Consequently, also the signal attenuation/transformation per electrode is not known. In this paper, a Bayesian method is developed that estimates the VCG and, to some extent, also the signal attenuation in multichannel ECG recordings from either the adult 12-lead ECG or the maternal abdomen. This is done by determining for which VCG and signal attenuation the joint probability over both these variables is maximal given the observed ECG signals. The underlying joint probability distribution is determined by assuming the ECG signals to originate from scaled VCG projections and additive noise. With this method, a VCG, tailored to each specific patient, is determined. The method is compared to the inverse Dower matrix method by applying both methods on standard 12-lead ECG recordings and evaluating the performance in predicting ECG signals from the determined VCG. In addition, to model nonstandard patients, the 12-lead ECG signals are randomly scaled and, once more, the performance in predicting ECG signals from the VCG is compared between both methods. Finally, both methods are also compared on fetal ECG signals that are obtained from the maternal abdomen. For patients conforming to the standard, both methods perform similarly, with the developed method performing marginally better. For scaled ECG signals and fetal ECG signals, the developed method significantly outperforms the inverse Dower matrix method.

Increased prevalence of prolonged QT interval in males with primary or secondary hypogonadism: A pilot study

Symptoms and signs of male hypogonadism span all organ systems, including the cardiovascular apparatus. The electrocardiographic QT interval reflects cardiac ventricular repolarization and, if prolonged, increases the risk of malignant arrhythmias. QT interval duration is similar in boys and girls during childhood, but shortens in males after puberty and experimental studies suggest that testosterone is a major contributor to shortening of QT interval in men. The aim of the present pilot study was to assess the duration of ventricular repolarization in adult males with primary or secondary hypogonadism. Standard ECG recordings were performed in 26 men (mean age 39.2 +/- 2.17 years) with pituitary or testicular hypogonadism and repeated in 15 patients during testosterone replacement. Twenty-six age-matched control men were also analysed. Measured QT intervals were corrected for heart rate according to Bazzett's formula (QTc = QT/radical RR interval). The prevalence of prolonged QTc was considerably higher in hypogonadal patients (four of 26 men) than in control men (none, p < 0.05) and in the general, healthy population (<2.5%). QTc interval normalized on hormone replacement therapy in the four patients presenting prolonged QTc in the hypogonadal state. Heart rate and left ventricular mass did not differ among the two groups and no known QT-prolonging factor was apparent in patients with abnormal QTc interval. In conclusion, a high number prolonged QT interval measurements was observed in hypogonadal men who may therefore be at increased risk for cardiac arrhythmias. This observation reveals an additional feature of male hypogonadism, which may benefit from testosterone replacement therapy.

Everything Counts in Large Amounts

Although the risk of stroke associated with paroxysmal atrial fibrillation (AF) is comparable to that with persistent (or permanent) AF, the lower representation of patients with paroxysmal AF in clinical trials reduces the confidence of the risk estimate.1 As a group, patients with paroxysmal AF are heterogeneous but typically younger, with less advanced associated cardiovascular disease than those with persistent or permanent AF. Episodes of AF occur daily in some patients but in others are separated by months or even years, and the duration of episodes varies considerably as well. Nevertheless, the threshold burden of paroxysmal AF required to justify chronic anticoagulant therapy has not been clearly defined, and prophylactic therapy is prescribed less consistently for patients with this form of the arrhythmia.2,3 Clinical practice guidelines currently recommend prophylactic antithrombotic therapy based on the axiom that paroxysmal and persistent AF carry similar risks of thromboembolism. The anticoagulation decision is based on clinical features other than the pattern, chronicity, or duration of AF, specifically the presence or absence of associated valvular heart disease, prior thromboembolism, advanced age, hypertension, diabetes, impaired left ventricular function, or heart failure.4 Article see p 474 Even in patients with symptomatic AF, asymptomatic episodes are common.3 In studies of unselected patients based on standard surface ECG recordings, the prevalence of asymptomatic AF ranged from 5% to 20%.5,6 Among the challenges in antithrombotic therapy is identifying patients with asymptomatic paroxysmal AF. Longer-term Holter and event monitoring increases the detection of asymptomatic AF, and in the Prevention of Atrial Fibrillation After Cardioversion (PAFAC) trial, nearly 70% of episodes of paroxysmal AF detected by transtelephonic monitoring were asymptomatic.7 Implanted dual-chamber cardiac arrhythmia devices, including pacemakers, cardioverter-defibrillators, and resynchronization devices (CRTs), are capable of continuously monitoring the rhythm. In a study of patients with paroxysmal …

Zoledronic acid and atrial fibrillation in cancer patients with bone metastases

e20591 Background: Treatment with a bisphosphonate was linked with a significantly increased risk for atrial fibrillation (AF) in a few studies. Once-yearly infusions of intravenous zoledronic acid (ZA) was also significantly increased serious AF in postmenopausal women with osteoporosis. This study was conducted to determine the frequency of atrial fibrillation among cancer patients receiving the standard treatment of ZA. Methods: One hundred and twenty-four cancer patients who had bone metastasis receiving ZA were included in this study. All patients have been receiving 4 mg ZA at 4-week intervals; with each dose administered over 15 minutes. Patients who presented outpatient clinic for any reason (routine control, chemotherapy, ZA administration) a short survey completed and standard 12-lead ECG recordings were obtained. Results: One hundred and twenty-four cancer patients with documented bone metastases were evaluated. Mean age of the patients was 55 ± 13.0 years, 60% of the patients were female. Forty-one percent of the patients had breast cancer and 17% non-small cell lung cancer and the remainder had other solid tumors. Mean duration of ZA administration was 13.4 ± 15.0 months/patients. Mean total cumulative dose was 54 ± 15.0 mg per patients. 60 (48%) of the patients were treated with antracycline including regimens, and 37 (30%) were treated with mediastinal radiotherapy that might effect the heart. Twenty-three percent of the patients had hypertension, 10% diabetes mellitus, 7% currently smoker and 32% exsmoker, 3.7% myocardial infarction history, 1.9% congestive heart failure, and 1% valvular disease. On ECG evaluation; we observed sinus rhythm in 58%, sinus tachycardia in 15%, sinus bradicardia in 3.2%, ventricular exracystole in 5.7% of the patients. There were no AF. Conclusions: Although most of the patients were also having potentially cardiotoxic treatment, there was no increase in AF frequency in cancer patients who were treated with intravenous ZA. We believe that the risk of AF is small and may increase with age and comorbidity. No significant financial relationships to disclose.

The acute effect of tropisetron on ECG parameters in cancer patients

The 5-hydroxytryptamine 3 receptor antagonists, including tropisetron, ondansetron, granisetron, and dolasetron are agents used effectively for supportive care. They are used for the prevention and treatment of chemotherapy and radiotherapy-induced emesis. Despite their overall excellent safety profile, some electrocardiographic changes related to heart rate and repolarization were reported. Ondansetron, granisetron, and dolasetron were studied on this manner. But to our knowledge, there is no information about the cardiac side effects of tropisetron. In this study, we aimed to determine the acute effects of tropisetron on ECG parameters related to repolarization, heart rate, and systemic blood pressure. Fifty-five cancer patients who received tropisetron for the prevention of acute chemotherapy-induced nausea and vomiting were enrolled into this single center, prospective study. Standard 12-lead ECG recordings were performed at baseline and 30 min after tropisetron (5 mg given over 1 min IV bolus) administration. P wave durations and corrected QT intervals were measured; P wave dispersion and QTc dispersion were calculated. In comparison with baseline, mean heart rate significantly decreased 30 min after administration of tropisetron. Tropisetron did not result in a significant change in P wave duration, corrected QT interval, P dispersion, and QTc dispersion. In this study, tropisetron did not show any ventricular and atrial arrhythmogenic effect because of repolarization abnormalities. Only it may cause a slight decrease in heart rate.

Clinical diagnosis of long QT syndrome: back to the caliper

In the last 10 years, the management of cardiac arrhythmias has evolved to an impressive pace, thanks to the development of highly sophisticated technologies for diagnosis and treatment. Mapping of the site of origin of arrhythmias, ablation, and implant of defibrillators have reduced the importance of the traditional approaches based on electrocardiographic reading and prescription of drugs. In this context, inherited arrhythmogenic diseases such as long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia, short QT syndrome, and Brugada syndrome represent the exception in which the ECG has remained the pivotal diagnostic tool. When approaching the diagnosis of one of these diseases, the cardiologist has to leave fancy computer screens and go back to the ‘ruler and caliper’ to measure the duration of an ‘interval’ or the elevation of an electrocardiographic ‘segment’. This apparently simple diagnosis, however, is far from being easy and even ‘experts’ in the field may face substantial diagnostic dilemma. The diagnosis of the LQTS, for example, ‘simply’ requires the measurement of QT interval duration on a standard ECG recording and the correction of the duration for ‘heart rate’ using the Bazett's formula. In real-life, however, the diagnosis is far from being straightforward and it is often more elusive than anticipated for a variety of reasons that encompass the difficulty to define the ‘end’ of the T-wave, the lack of linear behaviour of the Bazett's formula at slower and faster heart rates, and the arbitrary definition of the gender-based diagnostic cut off values that define an abnormally prolonged QTc (QTc >440 for males and QTc >460 for females).1 A large body of literature has been dedicated to the discussion of limitations of manual and automatic QT interval measurement2,3 thus promoting the … *Corresponding author. fax: +39 0382 592059. E-mail address : spriori{at}fsm.it

Effect of Right Bundle Branch Block on Electrocardiographic Amplitudes, Including Combined Voltage Criteria Used for the Detection of Left Ventricular Hypertrophy

Although right bundle branch block (RBBB) delays right ventricular depolarization, its effect on cancellation of right and left ventricular forces within the QRS complex has not been quantified during stable temporal and physiological conditions. Systematic changes in QRS amplitude during transient RBBB bear directly on performance of standard ECG criteria for left ventricular hypertrophy (LVH), and these changes require quantification. We examined the instantaneous effect of RBBB on QRS amplitudes and LVH voltages in 40 patients who had intermittent complete RBBB during a single 10 sec standard 12-lead ECG recording, comprising 0.1% of approximately 400,000 consecutive ECGs in a university teaching hospital setting. Amplitudes were measured by magnifying graticule to the nearest 25 microvolts, averaged for up to 3 normal and 3 RBBB complexes, and compared by paired t test. RBBB was associated with an increase in initial QRS forces (RV1, RV2, and QV6) but significant decreases in mean mid-QRS amplitudes that reflect left ventricular depolarization (RaVL [-75 microvolts], SV1 [-389 microvolts], SV3 [-617 microvolts], RV5 [-100 microvolts], and RV6 [-123 microvolts]). All late QRS forces were increased with RBBB (R'V1, SV5, SI). As a result, combined voltages used for LVH criteria were significantly reduced by RBBB: Sokolow-Lyon voltage decreased from 1520 +/- 739 to 1014 +/- 512 microvolts (p < 0.001), and Cornell voltage decreased from 1438 +/- 683 to 746 +/- 399 microvolts (p < 0.001). RBBB is associated with significant reduction in "left ventricular" QRS amplitudes of the standard ECG, consistent with cancellation, rather than unmasking, of left ventricular mid-QRS forces by altered septal and delayed right ventricular depolarization. Because QRS voltages that are routinely combined for the detection of LVH are reduced in RBBB, standard LVH criteria will perform with lower sensitivity in patients with RBBB.

Impacts of Glycoprotein IIb/IIIa Inhibition on QT Dispersion After Successful Percutaneous Coronary Intervention

Coronary ischemia augments inhomogeneity in ventricular repolarization. Decrease in the QT dispersion (QTd) following restoration of coronary blood flow to the ischemic myocardium by successful percutaneous coronary intervention (PCI) is an expected outcome. The purpose of the study was to seek whether glycoprotein IIb/IIIa (GP IIb/IIIa) inhibition has additional beneficial effects on QT dispersion after angiographically successful PCI. The study involved 111 consecutive patients scheduled for elective coronary balloon angioplasty with or without stent implantation. Sixty patients (mean age 58 +/-9) were randomized to receive standard therapy including preprocedural aspirin, ticlopidine, and IV heparin, and 51 patients (mean age 54 +/-10) were randomized to receive additional IV tirofiban infusion before the lesion was crossed with the guidewire. Standard 12-lead simultaneous ECG recordings for the measurement of QTd and corrected QTd (QTcd) (calculated by using Bazett's formula) were obtained before and immediately after the procedure, and at the 6th, and 24th hours. Blood samples for detection of postprocedural myocardial damage (CK-MB and cTn-I) were taken before and immediately after the procedure, at the 6th, 12th, and 24th hours. In total, 128 stenoses were treated with PCI. Seventy of these lesions were in the standard therapy group and 58 in the tirofiban group. QTd and QTcd were not statistically different between the 2 groups before and immediately after the procedure and at the 6th hours, but at the 24th hour QTd and QTcd were significantly longer in the standard therapy group (p=0.047 and p=0.001, respectively). Postprocedural troponin-I elevation (B=0.692, p=0.037), maximum inflation pressure (B=0.182, p=0.001), and previous myocardial infarction (MI) (B=0.885, p=0.004) were defined as the predictors of the final QT dispersion at the 24th hour. QT dispersion significantly decreased after successful percutaneous coronary intervention. GP IIb/IIIa inhibition therapy was not superior by means of recovery of increased QT dispersion during the early hours of the intervention, but it prevented minor myocardial necrosis and provided more long-lasting recovery in QT dispersion as compared with heparin therapy. This impact of GP IIb/IIIa receptor inhibition on QTd may be a possible mechanism by which these drugs reduce cardiovascular events after PCI.

Can heart rate variation rule out sleep-disordered breathing in heart failure?

In patients with obstructive sleep apnoea (OSA), the very low frequency power spectral density index (VLFI) derived from analysis of heart rate correlates with the severity of obstructive apnoeas. VLFI is also associated with Cheyne-Stokes respiration/central sleep apnoea (CSR/CSA) in congestive heart failure (CHF). The present authors have tested the hypothesis that per cent VLFI, derived from a standard Holter ECG recording, can be used to detect the presence of OSA and CSR/CSA in patients with mild-to-moderate CHF. In total, 60 CHF patients underwent polysomnography with monitoring of heart rate. Data from 33 patients were analysed for per cent VLFI. Of the 60 patients, 27 were excluded due to atrial fibrillation, extensive pacing or frequent ventricular extra systoles. Receiver operator characteristic curves were constructed to establish the per cent VLFI that would optimally identify the presence or absence of sleep-disordered breathing. Using an apnoea-hypopnoea index>20 events.h-1 and setting the per cent VLFI at 2.23% yielded a sensitivity of 85%, specificity of 65%, positive predictive value of 61% and a negative predictive value of 87%. The latter increased to 100% when using an apnoea-hypopnoea cut-off of 30 events.h-1. In conclusion, these results suggest that spectral analysis of heart rate may be useful as a "rule-out test" for sleep-disordered breathing in patients with mild-to-moderate congestive heart failure.

Relationship between Antidiabetic Treatment with QT Dispersion During Acute Coronary Syndromes in Type 2 Diabetes: Comparison between Patients Receiving Sulfonylureas and Insulin

Patients with acute coronary syndromes (ACS) show prolongation of QT interval duration and its dispersion (QTd). Prolongation of QTd has been associated with inhomogeneity of ventricular recovery times and high arrhythmyogenic potential. Previous studies have shown that preservation of the ischaemic preconditioning is associated with shorter QTd. Sulfonylureas may inhibit cardiac ischaemic preconditioning. The effect, however, of the previous treatment with sulfonylureas on QTd in patients with ACS has not been studied so far. This cross-sectional study examined the effect of the previous antidiabetic treatment on QTd in patients with type 2 diabetes during ACS. A total of 150 patients with ACS (myocardial infarction: n = 120; unstable angina: n = 30) admitted to the coronary care unit of our hospital were studied. Three groups of patients were examined: patients without diabetes (n = 60); patients with type 2 diabetes treated with sulfonylureas alone or in combination with metformin (n = 50); and patients treated with insulin alone or in combination with metformin (n = 40). Standard 12-lead ECG recordings at admission to the coronary care unit were obtained. QT interval duration and QTd were measured using ECG analysis software. At admission, QTd was not different between diabetic and non-diabetic patients (72.1 +/- 21.7 vs. 78.4 +/- 21.3 msec, p = 0.13, respectively). Similarly, the values of the above interval were also not different between patients with type 2 diabetes treated with sulfonylureas and insulin (73.8 +/- 23.9 vs. 70.1 +/- 18.5 msec, p = 0.55, respectively). It is concluded that the previous treatment with either sulfonylureas or insulin does not affect QTd in patients with type 2 diabetes and ACS.

24-Hour Electrocardiogram before and during Cisapride Treatment in Neonates and Infants

We studied prospectively the effects of cisapride on heart rate and rhythm using standard ECG and 24-hour ECG recordings in term and preterm neonates and infants. We studied subjects with gastroesophageal reflux disease (apparent life-threatening events, apneas, bradycardias) before and 3 days after starting cisapride (0.8 mg/kg/day in 4 doses). We performed standard ECGs for determination of corrected Q-T interval (QTc) and Q-T dispersion (QTd) and 24-hour ECG recordings for analysis of heart rate, heart rate variability, and heart rhythm. Fourteen term and 17 preterm subjects (gestational age range 28–36 weeks) were studied at a median chronological age of 29 (range 3–132) days. Cisapride significantly increased the QTc in preterm infants (before vs. after: 408 ± 7 vs. 433 ± 7 ms, p = 0.001). Two preterm and 1 term infant had a QTc >450 ms before cisapride. Four preterm (4/15 = 27%) and 2 term (2/13 = 15%) subjects had a QTc >450 ms on cisapride. After cisapride the QTd remained normal, and no relevant arrhythmias were documented on Holter recordings. Cisapride significantly decreased peak and mean heart rates of all study subjects without affecting the heart rate variability, while it increased the minimal heart rate of preterm infants only (before vs. after: 66 ± 5 vs. 78 ± 5 bpm, p = 0.02). The maximally measured R-R intervals (pauses) decreased after cisapride in preterm infants (before vs. after: 1.33 ± 0.2 s vs. 1.05 ± 0.2 s, p = 0.04). Although cisapride did cause a significant prolongation of the ventricular action potential duration in preterm infants, the QTd remained unaffected, and no clinically relevant arrhythmias were documented in this small sample. On the other hand, cisapride had a direct lowering effect on the maximal and mean heart rates of both term and preterm infants, while the drug increased the minimal heart rate and reduced the severity of bradycardia episodes in preterm infants.

Gender differences in stability of the instantaneous patterns of body surface potentials during ventricular repolarisation.

Women have a higher risk of developing torsade de pointes under OT-prolonging conditions. The electrophysiological differences between the sexes that could account for this are largely unknown. The objective of the work was to evaluate gender differences in repolarisation potentials using a method that is independent of the specific electrical properties of the thorax. 1410 normal recordings from the Glasgow 12-lead ECG database and 52 normal ECG maps obtained separately in Milan were analysed. The average difference between 1 and the correlation coefficient of the instantaneous pattern at the peak of T with that at every other instant is called the early repolarisation deviation index (ERDI) for J-T peak and the late repolarisation deviation index (LRDI) for T peak-T end. In standard ECG recordings, the ERDI was 0.42 +/- 0.22 in females compared with 0.19 +/- 0.16 in males (p < 10(-6)). The LRDI was higher in males under the age of 50. In body surface maps, the ERDI was 0.32 +/- 0.21 in females against 0.16 +/- 0.17 in males (p < 0.01), and the LRDI was non-significantly higher in males. The pattern of instantaneous body surface potentials showed gender differences during repolarisation with a method that is independent of the electrical properties of the thorax.

Quantification of cumulated physical fatigue at the workplace.

Quantification of physical fatigue remains a challenge. We hypothesized that its effects on central autonomic nervous system activity could be explored for such a quantification. To test this relationship, we prospectively measured central autonomic nervous activity through nocturnal heart rate variability (HRV) in six French garbage collectors, aged 32.1+/-4.3 years, twice a week during 3 consecutive weeks of work, and during the following week of rest. Eight healthy sedentary males formed a control group. HRV indices were calculated by applying standard temporal domain and wavelet transform analyses to standard ECG recordings. During the 3 consecutive weeks of work, there was a significantly progressive decrease in HRV indices, particularly pNN50 (-34.2%, P<0.05), as well as the high (-33.3%, P<0.05) and low (-22.2%, P<0.01) frequency components of wavelet transform, while there was an increase, although non-significant, of the ratio of low to high frequencies (9.1%). During the resting period, there was a significant recovery of HRV indices, notably of its high (50.0%, P<0.05) and low (28.6%, P<0.05) frequency components. No such changes occurred in the control group. A central signature of cumulated physical fatigue can thus be detected and quantified through nocturnal autonomic nervous system activity. Its characteristics are those of a progressive parasympathetic withdrawal.

Akumulasi Kalkulus Gigi yang Berlebihan pada Penderita Diabetes Tipe 2: Gejala Klnis Kemungkinan Menderita Penyakit Jantung Koroner

The relaive risk for Coronary Heart Disease (CHD) death in type 2 diabetics was 1.9-3.3 times higher, when compared to non-diabetics. Pathological studies have demonstrated a strong correlation between the presence of coronary calcium and CHD. Previous studies reported that the accumulation of dental plaque and dental calculus, and the severity of periodontal disease in type 2 diabetics were widely varied. A cross-sectional study on periodontal and CHD status of 36 non smoker type 2 diabetics was performed. The periodontal status was determined using Plaque Index of Sillness and Loe, Calculus Index of lingual anterior teeth, Papillary bleeding Index of Muleman, Periodontal Index of Russell, and dental panoramic rontgenogram. The CHD was determined by using standard ECG recording. Statistical analysis was using Fisher's exact test with the significant level of p 2) was not found in positive CHD diabetics, but found in 925 (36%) of negative CHD diabetics; a slight to moderate dental plaque accumulation was found in 11/11 (100%) of positive CHD diabetics, and 16/25 (64%) of negative CHD diabetics (p=.03). A heavy lingual calculus accumulaiton (score>2) was found in 11/11 (100%) of positive CHD diabetics and 10/25 (40%) of negative CHD diabetics (p=0.006). A severe generalized gingival bleeding (score>2) was not found in positive CHD diabetics, but found in 8/25 (32%) of negative CHD diabetics; a mild to moderate gingival bleeding was found in 11/11 (100%) of positive CHD diabetics and 17/25 (68%) of negative CHD diabetics (p=0.7). A severe generalized periodontal disease (score>5) was not found in positive CHD diabetics, but found in 9/25 (36%) of positive CHD diabetics; a mild to moderate periodontal disease (score<5) was found in 11/11 (100%) of positive CHD diabetics and 16/25 (64%) of negative CHD diabetics (p=.03). In conclusion, our data suggest that in type 2 diabetics, the presence of CHD is significantly correlated with the presence of a slight to moderate dental plaque accumulation, a heavy lingual calculus accumulation of anterior teeth, and a mild to moderate periodontal disease status. Although all the positive CHD diabetics have a mild to moderate gingival bleeding, the CHD status is not significantly correlated with the gingival bleeding status.

The CB-12L: a new device for transtelephonic transmission of a 12-lead electrocardiogram.

The value of transtelephonic transmission of ECG information is well established, and technological advances have continuously provided improved state-of-the-art equipment. Shahal Medical Services provides professional care to subscribers who call the medical center and describe their symptoms, whereupon therapeutic measures are decided upon. A new 12-lead patient controlled device for telephonically transmitting an ECG (GB-12L) has become available; the aim of this study was to evaluate its accuracy and practicability. Forty tracings (20 standard ECG tracings obtained under medical supervision in the physician's office and 20 by the patient in his home using the new CB-12L ECG device and transmitted by telephone to the center) from 20 subjects with various electrocardiographic pathologies were reviewed by 19 experienced physicians who were asked to interpret the results and identify the recording device. In 82% of the possibilities, the interpretation of the tracings was identical for both those recorded by the standard ECG recorder and the CB-12L ECG. An equal number of physicians could not identify the means by which device the tracings were taken. Proper placement of the electrodes did not prove to be a problem for the patient. Thus, the CB-12L ECG was found to be an easily operable and reliable tool which may be of value for early and prompt diagnosis of threatening cardiac situations in the prehospital setting.

Cerebellar Infarctions and ‘Vestibular Neuritis’

Consecutive subjects 50 to 75 years of age with sudden onset of vertigo but without cochlear or neurological symptoms were investigated with neuro-imaging techniques. Doppler sonography of the vertebral and carotid arteries and recording of voluntary saccades and pursuit eye movements, caloric, spontaneous, gaze and optokinetic nystagmus. Among those studied, 6 out of 24 subjects could be demonstrated to have cerebellar infarctions, another 2 subjects had occlusion of one vertebral artery. Caloric tests could not identify subjects with a cerebellar infarction whereas prominently reduced pursuit eye movements could. Subjects with cerebellar infarction either had a vertebral artery occlusion or prominent cardio-embolic risk factors. It is suggested that subjects with symptoms as vestibular neuritis should be investigated with pursuit eye movements and with at least standard ECG recordings.

Late potentials and arrhythmogenesis.

There are three current prognostic indicators of ventricular electrical instability: categorization and stratification of spontaneous ventricular arrhythmias from standard ECG recordings; programmed electrical stimulation; direct recording of delayed depolarization potentials, usually referred to as late potentials. Of the three, the latter offers a new and promising approach. Late potentials represent delayed activation potentials of diseased myocardial zones and may prove to be a strong independent marker of the propensity to develop reentrant ventricular arrhythmias and sudden cardiac electrical death. The problem in identifying late potentials on the body surface is that the signal is smaller than the electrical noise produced by various sources. Two different techniques have been utilized to improve the signal-to-noise ratio: first, signal averaging, which is applicable to regular repetitive electrocardiographic signals but cannot detect moment-to-moment dynamic changes in the signal; second, low-noise or high-resolution electrocardiography that utilizes spatial averaging techniques as well as other noise-reducing measures to record the late potentials on a beat-to-beat basis. This technique has the potential of directly identifying malignant "reentrant" versus benign "focal" ventricular rhythms. The present report discusses the electrophysiologic basis of late potentials and the clinical results of both signal-averaged and low-noise recordings for evaluation of ventricular electrical instability, particularly in patients with ischemic heart disease.

Esophageal ECG recording--a valuable diagnostic tool in dual chamber pacing.

The interpretation of the ECG of a dual chamber pacemaker necessitates the identification of atrial activity. This is a prerequisite for the evaluation of pacemaker function and for the correct adjustment of programmable pulse generators. The assessment of atrial capture in standard 12-lead ECGs is, however, sometimes rather difficult. Esophageal ECG recording by means of a reusable unipolar electrode, inserted transnasally, and connected to a standard ECG recorder, is a simple, rapid and inexpensive method for the reliable identification of P-waves. Clinical examples are presented to illustrate the value of this technique in determining atrial capture and as a tool for the differential diagnosis of pacemaker-involved tachycardias. The use of esophageal ECG recording in the clinical follow-up of patients with dual chamber pacemakers is recommended.