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Objectives: ECG left ventricular hypertrophy (ECG-LVH) has been associated with left ventricular dysfunction and adverse prognosis, but little is known about the prevalence and prognostic significance of different levels of QRS duration in the presence of ECG-LVH in a general population., Design: Population-based observational prospective cohort study., Participants: Nationally representative random cluster of Finnish adult population., Methods: We assessed the prevalence and long-term (median 15.9 years) prognostic significance of QRS duration in ECG-LVH, and compared the risk to individuals without ECG-LVH in a predominantly middle-aged random sample of 6033 Finnish subjects aged over 30 years (mean age 52.2, SD 14.6 years), who participated in a health examination including a 12-lead ECG., Main Outcome Measures: Cardiovascular and all-cause mortality, incidence of heart failure (HF)., Results: ECG-LVH was present in 1337 (22.2%) subjects; 403 of these (30.1%) had QRS duration ≥100 ms and 100 (7.5%) had ≥110 ms. The increased risk of mortality in ECG-LVH became evident after a QRS threshold of ≥100 ms. After controlling for known clinical risk factors, QRS 100-109 ms was associated with increased cardiovascular (HR 1.38, 95% CI 1.01 to 1.88, p=0.045) and QRS≥110 ms with cardiovascular (1.74, 95% CI 1.07 to 2.82, p=0.025) and all-cause mortality (1.52, 95% CI 1.02 to 2.25, p=0.039) in ECG-LVH. The risk of new-onset HF was two-fold in subjects with QRS 100-109 ms and threefold in subjects with QRS ≥110 ms, even after adjustment for incident myocardial infarction within the follow-up. When the prognosis was compared with subjects without ECG-LVH, subjects with ECG-LVH but QRS duration <100 ms displayed similar mortality rates with or without ECG-LVH but higher rates of incident HF., Conclusions: In ECG-LVH, the risk of excess mortality and new-onset HF markedly increases with longer QRS duration, but even QRS duration within normal limits in ECG-LVH carried a risk of HF compared with the risk in individuals without ECG-LVH., Competing Interests: Competing interests: None., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Inverted T waves in the electrocardiogram (ECG) have been associated with coronary heart disease (CHD) and mortality. The pathophysiology and prognostic significance of T-wave inversion may differ between different anatomical lead groups, but scientific data related to this issue is scarce., Methods: A representative sample of Finnish subjects (n = 6,354) aged over 30 years underwent a health examination including a 12-lead ECG in the Health 2000 survey. ECGs with T-wave inversions were divided into three anatomical lead groups (anterior, lateral, and inferior) and were compared to ECGs with no pathological T-wave inversions in multivariable-adjusted Fine-Gray and Cox regression hazard models using CHD and mortality as endpoints., Results: The follow-up for both CHD and mortality lasted approximately fifteen years (median value with interquartile ranges between 14.9 and 15.3). In multivariate-adjusted models, anterior and lateral (but not inferior) T-wave inversions associated with increased risk of CHD (HR: 2.37 [95% confidence interval 1.20-4.68] and 1.65 [1.27-2.15], respectively). In multivariable analyses, only lateral T-wave inversions associated with increased risk of mortality in the entire study population (HR 1.51 [1.26-1.81]) as well as among individuals with no CHD at baseline (HR 1.59 [1.29-1.96])., Conclusions: The prognostic information of inverted T waves differs between anatomical lead groups. T-wave inversion in the anterior and lateral lead groups is independently associated with the risk of CHD, and lateral T-wave inversion is also associated with increased risk of mortality. Inverted T wave in the inferior lead group proved to be a benign phenomenon., (© 2020 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)

Background: Previous population studies have presented conflicting results regarding the prognostic impact of intraventricular conduction delays (IVCD)., Methods: We studied long-term prognostic impact and the association with comorbidities of eight IVCDs in a random sample of 6,299 Finnish subjects (2,857 men and 3,442 women, mean age 52.8, SD 14.9 years) aged 30 or over who participated in the health examination including 12-lead ECG. For left bundle branch block (LBBB) and non-specific IVCD (NSIVCD), two different definitions were used., Results: During 16.5 years' follow-up, 1,309 of the 6,299 subjects (20.8%) died and of these 655 (10.4%) were cardiovascular (CV) deaths. After controlling for known clinical risk factors, the hazard ratio for CV death, compared with individuals without IVCD, was 1.55 for the Minnesota definition of LBBB (95% confidence interval 1.04-2.31, p = .032) and 1.27 (95% confidence interval 0.80-2.02, p = .308) for the Strauss' definition of LBBB. Subjects with NSIVCD were associated with twofold to threefold increase in CV mortality depending on the definition. While right bundle branch block, left anterior fascicular block and incomplete bundle branch blocks were associated with seemingly higher mortality, this was no longer the case after adjustment for age and sex. The presence of R-R' pattern was not associated with any adverse outcome., Conclusions: In a population study with long-term follow-up, NSIVCD and Minnesota definition of LBBB were independently associated with CV mortality. Other IVCDs had no significant impact on prognosis. The prognostic impact of LBBB and NSIVCD was affected by the definition of the conduction disorder., (© 2020 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)

Background: Even minor ST depression in the electrocardiogram (ECG) is associated with cardiovascular disease and increased mortality. There is limited data on the prognostic significance of ST-level changes in the general population., Subjects and Methods: A random sample of Finnish subjects (n = 6354) aged over 30 years (56.1% women) underwent a health examination including a 12‑lead ECG in the Health 2000 survey. The effects of relative ST level as a continuous variable and ST slope (upsloping, horizontal, downsloping) in three different lead groups were analyzed using a multi-adjusted Cox proportional hazard model separately for men and women with total mortality as endpoint., Results: The follow-up lasted for 13.7 (SD 3.3) years for men and 13.9 (SD 3.1) years for women. Lower lateral ST levels were associated with all-cause mortality in multi-adjusted models in both genders (at J + 80 ms hazard ratio [HR] 0.64 for a change of 1.0 mm [95% confidence interval 0.49-0.84, p = 0.002] for men and HR 0.61 [0.48-0.78, p < 0.001] for women). Associated coronary heart disease had no major influence on the results. Exclusion of subjects with ECG signs of left ventricular hypertrophy from the analyses increased the mortality risk of lower lateral ST levels in men but decreased it in women. For the anterior and inferior lead groups, no statistically significant difference was seen after multivariate adjustment. ST slope was not an independent predictor of mortality after multivariate adjustment., Conclusion: Lower ST level in the lateral ECG leads is an independent prognostic factor to predict all-cause mortality in the general population., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Both Q waves and T-wave inversion (TWI) in the presenting ECG are associated with a progressed stage of myocardial infarction, possibly with less potential for myocardial salvage with reperfusion therapy. Combining the diagnostic information from the Q- and T-wave analyses could improve the prognostic work-up in ST-elevation myocardial infarction (STEMI) patients., Methods: We sought to determine the prognostic impact of Q waves and TWI in the admission ECG on patient outcome in STEMI. We formed four groups according to the presence of Q waves and/or TWI (Q+TWI+; Q-TWI+; Q+TWI-; Q-TWI-). We studied 627 all-comers with STEMI derived from two patient cohorts., Results: The patients with Q+TWI+ had the highest and those with Q-TWI- the lowest 30-day and one-year mortality. One-year mortality was similar between Q-TWI+ and Q+TWI-. The survival analysis showed higher early mortality in Q+TWI- but the higher late mortality in Q-TWI+ compensated for the difference at 1 year. The highest peak troponin level was found in the patients with Q+TWI-., Conclusion: Q waves and TWI predict adverse outcome, especially if both ECG features are present. Q waves and TWI predict similar one-year mortality. Extending the ECG analysis in STEMI patients to include both Q waves and TWI improves risk stratification., (© 2018 Wiley Periodicals, Inc.)

Objectives: The sensitivity and specificity of the conventional 12-lead ECG to identify carriers of hypertrophic cardiomyopathy (HCM) - causing mutations without left ventricular hypertrophy (LVH) has been limited. We assessed the ability of novel electrocardiographic parameters to improve the detection of HCM mutation carriers., Methods: We studied 140 carriers (G+) of the TPM1-Asp175Asn or MYBPC3-Gln1061X pathogenic variants for HCM: The G+/LVH+ group (n = 98) consisted of mutation carriers with LVH and the G+/LVH- group (n = 42) without LVH. The control group consisted of 30 subjects. The standard 12-lead ECG was comprehensively analyzed and two novel ECG variables were introduced: RV1RV3 and septal remodeling. A subset of 65 individuals underwent cardiac magnetic resonance imaging and 2D strain echocardiography., Results: Conventional major ECG criteria were sensitive (90%) and specific (97%) in identifying G+/LVH+ subjects. RV1RV3 and septal remodeling were more prevalent in the G+/LVH- subjects compared to the control group (33% vs 3%, p = 0.005 and 45% vs 3%, p < 0.001, respectively). The combination of RV1RV3 and Q waves and repolarization abnormalities (QR) differentiated between the G+/LVH- subjects and the control group with a sensitivity of 52% and specificity of 97%. The combination of septal remodeling and QR differentiated between G+/LVH- subjects and the control group with a sensitivity of 64% and specificity of 97%., Conclusions: The novel ECG-parameters RV1RV3 and septal remodeling were effective in identifying G+/LVH- subjects and could be useful in the diagnostics of new suspected HCM patients and in the screening and follow-up of HCM families., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Grade 3 ischemia (G3I) in the 12‑lead electrocardiogram (ECG) predicts poor outcome in patients with ST-elevation myocardial infarction (STEMI). The outcome of G3I in "real-life" patient cohorts is unclear., Methods: The aim of the study was to establish the prognostic significance of grade 2 ischemia (G2I), G3I and the STEMI patients excluded from ischemia grading (No grade of ischemia, NG) in a real-life patient population. We assessed in-hospital, 30-day and 1-year mortality as well as other endpoints., Results: The NG patients had more comorbidities and longer treatment delays than the two other groups. Short-term and 1-year mortality were highest in patients with NG and lowest in patients with G2I. Maximum troponin level was highest in G3I, followed by NG and G2I. In logistic regression multivariable analysis, NG was independently associated with 1-year mortality., Conclusions: NG predicted poor outcome in STEMI patients. G2I predicted relatively favorable outcome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Early electrocardiogram (ECG) changes after breast cancer radiotherapy (RT) have been reported, but their characteristics and associated factors are largely unknown. This study aimed to explore early RT-induced ECG changes and to compare them with echocardiography changes., Materials and Methods: Sixty eligible patients with chemotherapy-naïve left-sided and 20 with right-sided breast cancer were evaluated with echocardiography, blood samples and ECG before and after RT., Results: RT-induced ECG changes in the anterior leads. T-Wave changes were most frequent. T-Wave decline was associated independently with patient age (β=-0.245, p=0.005), mean heart radiation dose (β=1.252, p=0.001) and global systolic strain rate change (β=7.943, p=0.002). T-Wave inversion was associated independently with mean heart radiation dose (β=0.143, p<0.001), global longitudinal strain change (β=0.053, p=0.017) and posterior calibrated integrated backscatter (β=-0.022, p=0.049)., Conclusion: RT-induced ECG changes were prevalent and associated with functional and structural changes in echocardiography. ECG could be used for post-RT cardiac screening., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: ST segment depression (STD) and T wave inversion (TWI) are typical electrocardiographic (ECG) findings in non-ST elevation myocardial infarction (NSTEMI). In ST elevation myocardial infarction, ST changes represent transmural ischemia. The pathophysiological mechanisms of the ECG changes in NSTEMI are unclear., Purpose: We studied the associations between ECG and the echocardiographic findings in NSTEMI patients., Methods: Twenty patients with acute NSTEMI were recruited during their hospital stay. A comprehensive echocardiography study was performed. The findings were compared with blinded ECG analyses., Results: Nine (45%) patients had STD, and 16 (85%) patients had TWI. In multivariable analysis, STD was independently associated with a lower global early diastolic strain rate (β=-5.061, p=0.033). TWI was independently associated with lower circumferential strain (β=0.132, p=0.032)., Conclusions: The typical ECG changes in NSTEMI patients were associated with subtle echocardiographic changes. STD was related to changes in diastolic function, and TWI was associated with systolic deterioration., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Acute left circumflex coronary artery (LCx) occlusion is not easily detected by the standard 12-lead electrocardiogram (ECG)., Methods: In 16 patients continuous ECG recording was performed during balloon occlusion. The treated lesions were divided into proximal and distal based on the location of the ischemic segments with respect to the left obtuse margin of the heart., Results: Mean ΔST (=ST amplitude during inflation - pre-inflation ST) ≥0.5mm in both leads I and aVL predicted a proximal occlusion site with sensitivity of 62.5% (95% confidence interval [CI] 24.9-91.5%), specificity 100% (95% CI 63.1-100%), positive predictive value 100% (95% CI 47.8-100%), and negative predictive value 72.7% (95% CI 39-94%). In lead III, mean ΔST was +0.3mm in the distal and -0.2mm in the proximal group, respectively (p=0.036)., Conclusions: ST elevation in leads I and aVL is associated with myocardial ischemia at or proximal to the left obtuse margin., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Time from symptom onset may not be the best indicator for choosing reperfusion therapy for patients presenting with acute ST-elevation myocardial infarction (STEMI); consequently ECG-based methods have been developed., Methods: This study evaluated the inter-observer agreement between experienced cardiologists and junior doctors in identifying the ECG findings of the pre-infarction syndrome (PIS) and evolving myocardial infarction (EMI). The ECGs of 353 STEMI patients were independently analyzed by two cardiologists, one fellow in cardiology, one fellow in internal medicine and a medical student. The last two were given a half-hour introduction of the PIS/EMI-algorithm., Results: The inter-observer reliability between all the investigators was found to be good according to kappa statistics (κ 0.632-0.790) for the whole study population. When divided into different subgroups, the inter-observer agreements were from good to very good between the cardiologists and the fellow in cardiology (κ 0.652 -0.813) and from moderate to good (κ 0.464-0.784) between the fellow in internal medicine, medical student and the others., Conclusions: The PIS and EMI ECG patterns are reliably identified by experienced cardiologists and can be easily adopted by junior doctors., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Patients with acute ST-elevation myocardial infarction (STEMI) benefit substantially from emergent coronary reperfusion. The principal mechanism is to open the occluded coronary artery to minimize myocardial injury. Thus the size of the area at risk is a critical determinant of the patient outcome, although other factors, such as reperfusion injury, have major impact on the final infarct size. Acute coronary occlusion almost immediately induces metabolic changes within the myocardium, which can be assessed with both the electrocardiogram (ECG) and cardiac magnetic resonance (CMR) imaging., Methods: The 12-lead ECG is the principal diagnostic method to detect and risk-stratify acute STEMI. However, to achieve a correct diagnosis, it is paramount to compare different ECG parameters with golden standards in imaging, such as CMR. In this review, we discuss aspects of ECG and CMR in the assessment of acute regional ischemic changes in the myocardium using the 17 segment model of the left ventricle presented by American Heart Association (AHA), and their relation to coronary artery anatomy., Results: Using the 17 segment model of AHA, the segments 12 and 16 remain controversial. There is an important overlap in myocardial blood supply at the antero-lateral region between LAD and LCx territories concerning these two segments., Conclusion: No all-encompassing correlation can be found between ECG and CMR findings in acute ischemia with respect to coronary anatomy., (© 2014 Wiley Periodicals, Inc.)

Aims: The prevalence of eight different ventricular conduction blocks and their association with risk factors and major cardiovascular diseases were studied in a major Finnish population study., Methods: Data, including 12-lead electrocardiograms, were collected from 6315 subjects. The prevalence of left bundle branch block (LBBB), right bundle branch block (RBBB), non-specific ventricular block, incomplete LBBB, incomplete RBBB, R-R'-pattern, left anterior hemiblock (LAHB), and left posterior hemiblock (LPHB) was calculated for both genders in three age groups. Their association with risk factors and cardiovascular diseases was studied., Results: R-R'-pattern was the most common ventricular conduction block in all age groups (3.9%, p<0.001 for comparison between groups), but it showed no association with cardiovascular diseases. Males had more RBBB (1.5% vs. 0.7%, p<0.001), incomplete LBBB (1.8 vs. 0.4, p<0.001) and non-specific ventricular block (1.1% vs. 0.1%, p<0.001). With increasing age (<45 years vs. >55 years) LBBB, RBBB and LAHB (0 vs. 2.2%, 0.3 vs. 2.2%, 0.2 vs. 1.9% respectively, p-values<0.001) became more prevalent. LBBB, RBBB and non-specific ventricular conduction block were associated with coronary heart disease (angina pectoris in 28.3, 20.3 and 22.9%, respectively) and heart failure (25.0, 10.1 and 11.4%, respectively). LBBB and RBBB were also associated with peripheral vascular disease (8.8%)., Conclusions: Ventricular conduction blocks differ in prevalence between sexes and age groups. They also show disparate association with cardiovascular diseases. These differences need to be taken into consideration in everyday clinical practice., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Despite its potential prognostic value concurrent atrial ischemia is often overlooked in patients with acute myocardial infarction (AMI). There is no study concerning the relationship between atrial coronary circulation and dynamic PR-segment changes in patients with AMI. We evaluated dynamic PR-segment changes in 37 patients with AMI. The flow in the principal atrial coronary branches was diminished in 14 (38%) patients. Dynamic changes in the PR-segment level [median 47 (inter quartile range 19-55) μV vs. 23 (18-30) μV, P=0.005] and PR-segment area [3.15 (1.75-3.69) nVs vs. 1.62 (1.18-2.04) nVs, P=0.005] were significantly greater in patients with compromised than in those with normal flow in the atrial coronary branches. Our findings support the concept that atrial ischemia produces similar changes in the PR-segment as ventricular ischemia in the ST-segment. Given the possible deleterious consequences of atrial ischemia these data may have important clinical implications in evaluation of patient with AMI., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Global ischemia (GI) electrocardiogram (ECG), wide-spread ST depression with inverted T waves maximally in leads V(4-5), and lead aVR ST elevation (STE), is a marker of an adverse outcome in patients with non-ST elevation acute coronary syndromes (ACS), perhaps because this pattern is indicative of left main stenosis. The prognostic value of this ECG pattern has not been established., Aims: The distribution of ECG changes and the prognostic value of the GI ECG were studied., Methods: ECGs of consecutive patients admitted with suspected ACS (n = 1,188) were classified into seven ECG categories: STE, Q waves without STE, left bundle branch block, left ventricular hypertrophy, GI ECG, other ST depression and/or T wave inversion, and other findings., Results: The GI ECG pattern predicted a high rate (48%) of composite end-points (mortality, re-infarction, unstable angina, resuscitation, or stroke) at 10-month follow-up compared to the other ECG categories (36%) (HR 1.78; CI 95% 1.31-2.41; P < 0.001). In multivariate analysis, the GI ECG pattern was associated with a higher rate of composite end-points (HR 1.40; CI 95% 1.02-1.91; P = 0.035). The multivariate analysis furthermore identified age, creatinine level, and diabetes as independent predictors of prognosis., Conclusions: The GI ECG pattern predicted an unfavorable outcome, when compared to other ECG patterns in patients with ACS.

Background: Right and left circumflex coronary artery occlusions cause inferior myocardial infarction. To improve the targeting of diagnostic and therapeutic measures individually, factors interfering with identification of the culprit artery by the electrocardiogram (ECG) were explored., Methods: Patients with inferior preinfarction syndrome (n = 266) were included to the Danish Trial in Acute Myocardial Infarction-2 substudy. The culprit vessel was predicted by the ECG, and findings were correlated with angiography. Factors associated with false identification of the culprit artery by the ECG were examined., Results: Electrocardiogram criteria for right coronary artery occlusion to predict coronary angiography findings had sensitivity, specificity, and positive and negative predictive values of 95%, 52%, 84%, and 81%. For left circumflex coronary artery occlusion, the corresponding values were 51%, 93%, 70%, and 85%, respectively. False ECG identification of the culprit artery was independently associated with left coronary dominance (P < .001; odds ratio [OR], 22.0; 95% confidence interval [CI], 7.2-67.0), multivessel disease (P = .035; OR, 2.2; 95% CI, 1.1-4.7), and absence of proximal occlusion pattern in the ECG (P = .003; OR, 4.0; 95% CI, 1.6-9.8)., Conclusions: Left coronary artery dominance, multivessel disease, and absence of ECG signs of proximal culprit lesion are associated with failure to predict the culprit artery of inferior myocardial infarction by the 12-lead ECG., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Widespread ST-segment depression with inverted T waves maximally in leads V4-V5 (ie, the global ischemia electrocardiogram [ECG] pattern) is a marker of adverse outcome in patients with non-ST-segment elevation acute coronary syndrome (ACS), perhaps because this pattern is indicative of left main stem stenosis. However, the prognostic value of this ECG pattern has not yet been established., Objective: We studied the predictive value of a prespecified ECG pattern in patients who underwent urgent or emergent coronary artery bypass grafting (CABG)., Methods: We studied the sensitivity, specificity, and predictive values for the global ischemia ECG to predict angiographic left main coronary artery disease. Patients with a 12-lead ECG recorded during anginal symptoms before CABG were included., Results: The global ischemia ECG pattern was found in 61 (76%) of 80 patients with and 12 (19%) of 65 patients without left main disease. The sensitivity, specificity, and positive and negative predictive values for left main coronary artery disease in patients with the global ischemia ECG pattern were 76%, 81%, 84%, and 74%, respectively. In multivariate analysis, the global ischemia ECG pattern was strongly associated with angiographic left main coronary artery disease after adjusting for age, gender, diabetes, hypertension, and smoking (hazard ratio, 16.0; 95% confidence interval, 6.5-39.5; P < 0.001)., Conclusion: The global ischemia ECG pattern was strongly associated with angiographic left main coronary artery disease in patients who underwent urgent or emergent CABG.

Background: Acute anterior myocardial infarction (MI) caused by proximal occlusion of the left anterior descending coronary artery (LAD), is associated with unfavourable outcome and should be recognized by simple noninvasive methods like the 12-lead electrocardiogram (ECG)., Methods: In a prospective post-hoc DANAMI-2 substudy we compared two pre-specified ECG patterns to determine the level of LAD occlusion. The ECG findings were correlated to coronary angiography from the acute phase. The impact on clinical outcome of ECG and angiographic signs of proximal versus distal LAD occlusion was studied., Results: In 146 patients without confounding factors on the ECG, either ST-elevation>or=0.5 mm in lead aVL or any ST-elevation in lead aVR in association with precordial ST-segment elevation in at least two contiguous leads (including V2, V3 or V4) had a sensitivity of 94%, specificity of 49%, positive predictive value of 85% and negative predictive value of 71% to predict a proximal LAD lesion. Surprisingly, ECG or angiographic signs of lesion proximality were not associated with worse outcome at 30 day or 2.7 year follow-up., Conclusions: The site of occlusion in the LAD could be reliably predicted by 12-lead ECG in patients with acute anterior MI. The prognostic significance of the level of occlusion in the LAD in the modern era of acute ST-elevation MI treatment should be reassessed.

Aims: The aim of the study was to assess two distinct 12-lead electrocardiogram (ECG) patterns and their prognostic value with respect to reperfusion strategy., Methods and Results: In a DANAMI-2 substudy (n = 1522), we defined the pre-infarction syndrome (PIS) as ST-elevation accompanied by positive T waves and evolving myocardial infarction (EMI) as pathological Q waves and/or negative T wave. We used a composite of death, clinical re-infarction, or disabling stroke at median 2.7 year follow-up. A higher overall event rate was observed in the EMI group compared with the PIS group [11.4 (9.4-13.9) and 6.9 (6.0-8.0) per 100 person-years, respectively, ratio of the rate (RR) 1.6, P < 0.001]. The EMI pattern was independently predictive of adverse outcome in multivariable analysis (hazard ratio 1.52, confidence interval 1.01-2.30, P = 0.04). The PIS pattern (n = 952) was associated with lower overall event rate in patients treated with primary percutaneous coronary intervention (PCI) compared with fibrinolytic therapy (FT) [5.5 (4.4-6.9) and 8.5 (7.0-10.4) per 100 person-years, respectively, RR = 0.6, P = 0.004]. No significant difference in the outcome between treatment strategies was observed in the EMI group as a whole. However, in patients with anterior EMI without ECG signs of reperfusion, superiority of primary PCI was driven by a 51% reduction in the relative risk of composite endpoint (P = 0.008)., Conclusion: More detailed ECG analysis, involving also Q- and T-wave morphology, is useful for rapid identification of high-risk patients in whom every effort should be made to transfer for primary PCI, or vice versa, for identifying low-risk patients in whom FT might be an alternative option.

Aims: As a part of the Finnish Cardiovascular Study, we tested the hypothesis that T-wave alternans (TWA) predicts mortality in a general population of patients referred for a clinical exercise test., Methods and Results: A total of 1037 consecutive patients (mean age+/-SD of 58+/-13 years, 673 men and 364 women) with a clinically indicated exercise test and with technically successful electrocardiographic (ECG) data during a bicycle ergometer test were included in the study. Digital ECGs were recorded and TWA was analysed continuously with the time-domain modified moving average method. The maximum TWA value at heart rate (HR)<125 b.p.m. was derived and its capacity to stratify risk for all-cause death, cardiovascular death, and sudden cardiac death (SCD) was tested. During a follow-up of 44+/-7 months (mean+/-SD), 59 patients died; 34 were due to cardiovascular causes and 20 were due to SCD. In multivariate analysis after adjustment for age, sex, use of beta-blockers, functional class, maximal HR during exercise, previous myocardial infarction, and other common coronary risk factors, the relative risk of TWA>or=65 microV for SCD was 7.4 (95% CI, 2.8-19.4; P<0.001), for cardiovascular mortality 6.0 (95% CI, 2.8-12.8; P<0.001), and for all-cause mortality 3.3 (95% CI, 1.8-6.3; P=0.001)., Conclusion: Time-domain TWA analysis powerfully predicts mortality in a general population undergoing a clinical exercise test.

Background: Rapid identification of a proximal occlusion site of a major coronary artery is of paramount importance in the care of myocardial infarction (MI). It is increasingly recognized that routine electrocardiogram (ECG) can be used for that purpose, provided that expert interpretation is available. Computer-based signal analysis has potential to enhance early ECG interpretation but its performance must be validated against manual algorithms. We therefore set out to develop a computer-assisted model to detect proximal occlusion of the left anterior descending coronary artery (LAD) in patients with suspected acute coronary syndrome (ACS)., Methods: Based on manual anatomical interpretation of the ECG, obtained from 216 consecutive patients who were admitted due to suspected ACS, an automatic computerized ECG model to detect LAD occlusion was constructed. Agreement between manual evaluation of the ECG by two cardiologists and a computerized ECG algorithm to detect occlusion of the LAD and the site of occlusion was determined., Results: Using an expert electrocardiographer's anatomical interpretation as the gold standard, the computer model recognized patients fulfilling ECG criteria for any occlusion of the LAD with a specificity of 99% and a sensitivity of 67% (kappa= 0.71). However, proximal LAD occlusion was detected with 100% specificity and 86% sensitivity (kappa= 0.72). The computer program detected a distal occlusion in the LAD with a specificity of 99% and a sensitivity of 40% (kappa= 0.72)., Conclusions: Computerized anatomical interpretation of the ECG is feasible and allows detection of a proximal LAD occlusion with excellent accuracy.

Background: ST-segment elevation in the right-sided chest lead V(4)R in inferior wall myocardial infarction is recognized as a sign of proximal occlusion of the right coronary artery with evolving right ventricular myocardial infarction. Our objective is to study how often lead V(4)R is recorded in clinical practice and how this might be associated with use of reperfusion therapy and outcome of patients., Methods: Recording of lead V(4)R in 814 consecutive patients with acute myocardial infarction, administration of therapy, and outcome of the patients during a median follow-up of 285 days (174-313 days) were studied., Results: V(4)R was recorded in 52% of patients with inferior ST-elevation myocardial infarction. Patients with V(4)R recorded were more likely to receive fibrinolytic therapy compared with patients without recording (65% vs 51%; P = .035). In multivariate analysis, recording of lead V(4)R (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.2; P = .006), along with age (P < .001), previous myocardial infarction (OR 2.2, 95% CI 1.3-3.5; P = .002), and diabetes (OR 3.9, 95% CI 1.1-2.4; P = .03) correlated to the use of reperfusion therapy. Patients with lead V(4)R recorded had less (P = .055) reinfarction, unstable angina, stroke, and/or death during follow-up., Conclusions: Lead V(4)R was recorded in only half of patients with inferior ST-elevation myocardial infarction. Patients with V(4)R recorded were more likely to receive thrombolytic therapy than those without recording of the additional chest lead.

Accurate and rapid electrocardiographic interpretation is of crucial importance in acute coronary syndrome (ACS). Computerized electrocardiographic algorithms are often used in out-of-hospital settings. Their accuracy should be carefully validated in ACS, particularly in ST-elevation myocardial infarction. This study evaluated the comparative accuracy of lead-specific computer-based versus manual measurements of the J-point, ST-segment, and T-wave deviations in standard 12-lead electrocardiograms (ECGs) (excluding lead aVR). Sixty-nine consecutive patients with suspected ACS were included. The interobserver reliability in the determination of ST-segment deviation>or=0.2 mV in leads V2 and V3 was very good (kappa=0.94 and 0.93, respectively). Agreement between a cardiologist and the computer regarding ST elevation>or=0.2 mV in lead V2 was moderate (kappa=0.72) and in V3 was very good (kappa=0.85). For ST depression or elevation>or=0.05 mV in lead LIII, agreement was good and moderate (kappa=0.79 and 0.51, respectively). Bland-Altman analysis demonstrated clinically acceptable limits of agreement comparing measurements of the J point and the T wave, but clinically inadequate limits of agreement with respect to ST-segment deviation, between the electrocardiographer and the computer. The optimal cut-off points were 0.115 mV (sensitivity 89%, specificity 98%) for the computer program to detect ST elevation>or=0.2 mV and 0.045 mV (sensitivity 74%, specificity 99%) for revealing ST elevation>or=0.1 mV. It was found that automatically measured ST-segment deviations were smaller than those manually measured. In conclusion, a correction should be performed to obtain optimal results in the automated analysis of ECGs, because the results have important implications for clinical decision making.

Background: The significance of ST-segment depression in acute coronary syndrome has been the subject of debate for many decades. Studies indicate that different manifestations of ST/T changes may have significantly different prognostic implications., Methods and Results: We studied the correlation of ST/T changes in 12-lead electrocardiography recorded during pain, to clinical and angiographic findings and in-hospital prognosis, in patients with non-ST-elevation acute coronary syndrome and elevated troponin levels. Fifty consecutive patients could be differentiated into two groups: (1) 25 patients with ST-segment depression and a negative T wave maximally in leads V4-5, (2) 25 patients with ST-segment depression and a positive T wave in the precordial lead with maximal ST-segment depression. Patients in group I had significantly more often left main or left main equivalent coronary artery disease; 76% versus 8% (P < 0.001), heart failure; 40% versus 4% (P = 0.005), and higher in-hospital mortality; 24% versus 0% (P = 0.02), than patients in group II. The troponin levels did not differ significantly between the groups., Conclusions: In patients with non-ST-elevation acute coronary syndrome and elevated troponin levels two subgroups could be identified. Transient ST-segment depression and a negative T wave maximally in leads V4-5 during anginal pain predicts left main, left main equivalent, or severe three-vessel coronary artery disease with high sensitivity and specificity. In patients with ST-segment depression and a positive T wave, there is a high probability of one-vessel disease.

Introduction: Atrial fibrillation (AF) is a frequent finding in acute coronary syndrome (ACS), but there is conflicting scientific evidence regarding its long-term impact on patient outcome. The aim of this study was to survey and compare the ≥10-year mortality of ACS patients with sinus rhythm (SR) and AF. Methods: Patients were divided into 2 groups based on rhythm in their 12-lead ECGs: (1) SR (n = 788) at hospital admission and discharge (including sinus bradycardia, physiological sinus arrhythmia, and sinus tachycardia) and (2) AF/atrial flutter (n = 245) at both hospital admission and discharge, or SR and AF combination. Patients who failed to match the inclusion criteria were excluded from the final analysis. The main outcome surveyed was long-term all-cause mortality between AF and SR groups during the whole follow-up time. Results: Consecutive ACS patients (n = 1,188, median age 73 years, male/female 58/42%) were included and followed up for ≥10 years. AF patients were older (median age 77 vs. 71 years, p < 0.001) and more often female than SR patients. AF patients more often presented with non-ST-elevation myocardial infarction (69.8 vs. 50.4%, p < 0.001), had a higher rate of diabetes (31.0 vs. 22.8%, p = 0.009), and were more often using warfarin (32.2 vs. 5.1%, p < 0.001) or diuretic medication (55.1 vs. 25.8%, p < 0.001) on admission than patients with SR. The use of warfarin at discharge was also more frequent in the AF group (55.5 vs. 14.8%, p < 0.001). The rates of all-cause and cardiovascular mortality were higher in the AF group (80.9 vs. 50.3%, p < 0.001, and 73.8 vs. 69.6%, p = 0.285, respectively). In multivariable analysis, AF was independently associated with higher mortality when compared to SR (adjusted HR 1.662; 95% CI: 1.387–1.992, p < 0.001). Conclusion: AF/atrial flutter at admission and/or discharge independently predicted poorer long-term outcome in ACS patients, with 66% higher mortality within the ≥10-year follow-up time when compared to patients with SR. [ABSTRACT FROM AUTHOR]

Background Increased cardiovascular morbidity and mortality are major late complications after radiotherapy ( RT) in the thoracic region. Ultrasound tissue characterization ( UTC) is a noninvasive method for the identification of myocardial changes. The aim of this prospective clinical trial was to assess whether the analysis of cyclic variation of integrated backscatter ( CVIBS) can detect early RT-induced myocardial alterations. Methods Seventy-three eligible patients with early-stage breast cancer were evaluated before and immediately after adjuvant RT. Twenty and 53 patients had right-sided and left-sided breast cancer, respectively. None of the patients received chemotherapy. Comprehensive echocardiographic examination included three-dimensional (3D) measurements and UTC analysis of the left ventricular ( LV) septum and posterior wall. Results RT reduced CVIBS in a dose-dependent manner. The mean heart radiation dose over two gray (Gy) reduced the septal CVIBS from 12.0±3.4 to 9.6±2.5 dB ( P<.001) and the posterior wall CVIBS from 12.8±2.7 to 11.3±2.4 dB ( P=.007). The CVIBS remained unchanged when the mean heart RT dose was below 2 Gy. Multivariate analysis showed an independent association with a change in septal CVIBS and the use of aromatase inhibitor (β=2.986, P=.001) and body mass index (β=−0.241, P=.014). The posterior values were worse with higher mean lung dose (β=-.485, P=.018) and with nonsmoking status (β=−2.411, P=.009). Echocardiography parameters showed increased myocardial mass but conventional measurements of the LV systolic function remained unchanged. Conclusions Cyclic variation of integrated backscatter analysis seems to be a sensitive method to detect early RT-induced myocardial changes. Hence, it may be useful in screening of patients needing closer follow-up. [ABSTRACT FROM AUTHOR]

Aims. We examined the prognostic impact of eight different intraventricular conduction delays (IVCD) in the standard electrocardiogram (ECG) in a community cohort. Methods and results. Data were collected from 6299 Finnish individuals. During a mean 8.2 years (interquartile range 8.1 to 8.3) of follow-up 640 subjects died (10.2%); 277 (4.4%) were cardiovascular deaths. For both sexes, all-cause and cardiovascular mortality was higher in subjects with IVCD than in those without. In Cox regression analysis after adjustment for age and gender, the hazard ratio for cardiovascular mortality for non-specific IVCD was 4.25 (95% confidence interval [CI] 1.95-9.26, P < 0.0001) and for left bundle branch block (LBBB) 2.11 (95% CI 1.31-3.41, P = 0.002). Right bundle branch block (RBBB) was not related to additional mortality, while incomplete RBBB (IRBBB) presented a hazard ratio of 2.24 (95% CI 1.064-4.77, P = 0.036). Conclusions. In the general population, non-specific IVCD, LBBB, and IRBBB were associated with increased relative risk for all-cause and cardiovascular mortality. RBBB did not have an impact on cardiovascular mortality either in subjects with or without previous heart disease. [ABSTRACT FROM AUTHOR]

This study was conducted to determine the frequency, severity and outcome of cardiac findings in patients with acute Puumala hantavirus-induced nephropathia epidemica (NE). 70 consecutive, hospital-treated patients with serologically confirmed NE were prospectively examined using serial electrocardiograms (ECG), plasma troponin I, tumour necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and echocardiography (ECHO). Examinations were repeated after 3 and 12 months. ECG changes were observed in 57% of patients. Plasma troponin I levels remained normal in all. In six patients, ECHO showed left ventricular contraction abnormalities, and 1 patient had mild pericardial effusion. There were no differences in clinical or standard laboratory findings or in plasma TNF-α and IL-6 concentrations between patients with and without ECG or ECHO changes. During the follow-up, all acute-phase changes in ECG and ECHO reverted to normal, which probably reflects their benign nature. We conclude that abnormal cardiac findings are surprisingly common during NE. [ABSTRACT FROM AUTHOR]

Background: The significance of ST-segment depression in acute coronary syndrome has been the subject of debate for many decades. Studies indicate that different manifestations of ST/T changes may have significantly different prognostic implications.Methods and Results: We studied the correlation of ST/T changes in 12-lead electrocardiography recorded during pain, to clinical and angiographic findings and in-hospital prognosis, in patients with non-ST-elevation acute coronary syndrome and elevated troponin levels. Fifty consecutive patients could be differentiated into two groups: (1) 25 patients with ST-segment depression and anegativeT wave maximally in leads V4–5, (2) 25 patients with ST-segment depression and apositiveT wave in the precordial lead with maximal ST-segment depression. Patients in group I had significantly more often left main or left main equivalent coronary artery disease; 76% versus 8% (P<0.001), heart failure; 40% versus 4% (P= 0.005), and higher in-hospital mortality; 24% versus 0% (P= 0.02), than patients in group II. The troponin levels did not differ significantly between the groups.Conclusions: In patients with non-ST-elevation acute coronary syndrome and elevated troponin levels two subgroups could be identified. Transient ST-segment depression and anegativeT wave maximally in leads V4–5 during anginal pain predicts left main, left main equivalent, or severe three-vessel coronary artery disease with high sensitivity and specificity. In patients with ST-segment depression and apositiveT wave, there is a high probability of one-vessel disease. [ABSTRACT FROM AUTHOR]

Objective. Hypoestrogenemia in postmenopausal female has important effects on the heart with possible arrhythmic consequences. We studied the prevalence of atrial arrhythmias in 12-lead Holter in patients with normal baseline ECGs. We used morphologic ECG data to define the origin of the arrhythmias. Methods. Twelve lead Holter recordings in 172 consecutive patients in the community were analyzed. The prevalence of ectopic and reentry nonsustained atrial tachycardia (NSAT), atrial fibrillation, atrial flutter, and right and left premature atrial complexes, was studied in men and women. Patients aged ⩾50 years and <50 years were analyzed separately. Results. Premature atrial complexes were frequent in all the four groups. In women aged ⩾50 years, the prevalence of ectopic NSAT was 57%. Women aged ⩾50 years, who showed episodes of atrial fibrillation or flutter, had a prevalence of concomitant ectopic NSAT of 67 %. All the NSAT episodes were repetitive (⩾10 episodes/24h). There was a striking gender difference, as the corresponding number for men in the same age group was only 17 %. Conclusions. Ectopic NSAT is frequently associated with atrial fibrillation or flutter in women aged ⩾50 years. We propose a hypothesis related to hormone metabolism and collagen expression in the heart to explain this phenomenon. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was to investigate the impact of obstructive sleep apnea (OSA) on the QT interval variability and duration in patients during different sleep stages.Methods: Polysomnographic recordings of 28 (13 male, 15 female) patients with OSA and 30 (15 male, 15 female) patients without OSA were analyzed. The QT interval variability index (QTVI) and the corrected QT interval (QTc) analyses were performed using two awake, 3-4 non-rapid eye movement (NREM) and three rapid eye movement (REM) sleep episodes (each 300 s). The Bazett formula, linear, and parabolic heart rate correction formulas with two separate α values were used.Results: QTVI was statistically higher in OSA than in non-OSA patients for males while awake (awake -0.7 ± 0.3 vs -1.2 ± 0.2, p = 0.001; NREM ‒0.9 ± 0.4 vs -1.1 ± 0.3, p = 0.110; REM ‒1.1 ± 0.3 vs -1.3 ± 0.2, p = 0.667) and for females in all wake-sleep stages (awake -0.3 ± 0.7 vs -0.9 ± 0.5, p = 0.001; NREM ‒0.3 ± 0.5 vs -0.8 ± 0.4, p = 0.002; REM -0.3 ± 0.5 vs -1.0 ± 0.4, p < 0.001). QTVI was significantly higher during awake compared to sleep stages in OSA males (p < 0.05); no difference between wake-sleep stages was found in females (p > 0.05). Significant gender differences in QTVI existed in OSA patients during sleep (p < 0.05) but not while awake. No significant differences in QTc between patients groups were observed.Conclusions: OSA is associated with increased QT variability. REM sleep per se does not increase QTVI. In OSA patients, QTVI might be a more useful measure to detect ventricular repolarization abnormality than measures of QTc. [ABSTRACT FROM AUTHOR]

: PurposeTo determine the incidence of and risk factors for electrocardiographic (ECG) abnormalities in adults with diphtheria.: MethodsA prospective study was conducted involving 122 adult patients with respiratory tract diphtheria. Diphtheria was confirmed by isolation of a toxin-producing strain of Corynebacterium diphtheriae. Patients had serial clinical evaluations and ECGs for a minimum of 21 days.: ResultsCardiac involvement was detected in 25 (28%) of 88 evaluable patients, with a median time from symptom onset to an abnormal ECG of 9 days (range, 4 to 24 days). In a logistic regression analysis, age (odds ratio [OR] = 4.1; 95% confidence interval [CI]: 1.6 to 11.0), shared accommodation (OR = 2.9; 95% CI: 1.0 to 8.6), fever (OR = 4.2; 95% CI: 1.1 to 16.6), and extensive respiratory tract infection with subcutaneous edema (OR = 7.0; 95% CI: 1.2 to 42.2) were independent risk factors for cardiac involvement.: ConclusionCardiac involvement is a common complication of respiratory tract infection with C. diphtheriae, and occurs more often among older patients, those with lower socioeconomic status, and those with severe respiratory tract involvement. [Copyright &y& Elsevier]