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Abstract: We searched for special features in patients with complete and incomplete right bundle branch block diagnosed as having arrhythmogenic right ventricular cardiomyopathy/dysplasia. Whether right bundle branch block is a frequent finding in arrhythmogenic right ventricular cardiomyopathy should be studied. The question is whether special features exist such as T-wave inversions, localized right precordial QRS prolongation and r’/s ratio<1. Results: ARVC could be diagnosed according to ISFC/ESC criteria in 374 patients. CRBBB was found in 22 cases (6%) and iCRBBB was present in 47 cases (12.5%). In CRBBB T wave inversions≥V4 was found in 10 cases (n.s.) and r’/s ratio<1 was present in 12 cases (p<0.001). In iCRBBB T wave inversions≥V4 was found in 10 cases (n.s.) and ST segment elevation in right precordial leads was present in 19 cases (p<0.005). In all patients with ARVC localized right precordial QRS prolongation was found. Patients with CRBBB have a bad prognosis: 17 of 22 patients developed biventricular heart failure requiring heart transplantation and diuretic therapy. Conclusions: CRBBB and iCRBBB are infrequent findings in arrhythmogenic right ventricular cardiomyopathy. Complete right bundle branch block is characterized by r’/s ratio<1. There are no significant T wave inversions≥V4. Incomplete right bundle branch block is characterized by ST segment elevation in right precordial leads but not by T wave inversions≥V4. [Copyright &y& Elsevier]

Background: The influence of periprocedural ischaemia on coronary artery bifurcation stenting (percutaneous coronary intervention [PCI]) remains uncertain., Aim: To determine the differences in rates of end procedural ischaemia after bifurcation lesion PCI detected with intracoronary electrocardiography (icECG)., Methods: Unipolar icECGs were recorded before, during, and after stent placement and at the end of procedure in side branch (SB) and main branch (MB). Coronary wire was placed in all distal vessels with diameter > 1.5 mm to "map" the distal zones of ischaemia. The patient population consisted of patients with stable/unstable angina with troponin I evaluated before and after PCI., Results: We studied 147 patients (68% males) with mean age of 64 ± 9 years. One hundred and forty-two patients had icECG recordings at the end of PCI from all locations of the treated region; 36% of patients had MB ST segment elevation (STE) and 31% had icECG STE in the SB region (p = 0.378). The icECG had sensitivity of 82% and specificity of 81% to detect troponin I elevation, with positive predictive value of 81% and negative predictive value of 83%. The independent predictors of troponin increase (> 5 × N) were: sex (for female gender, OR = 0.130, CI 0.017-0.995, p = 0.049), previous myocardial infarction (OR = 33.23, CI 2.802-394.1, p = 0.005), and icECG STE in MB or SB or occlusion of secondary SB (OR = 7.877, CI 2.474-25.07, p < 0.001) and for any troponin elevation were double product - SBPxHR (OR = 0.999, CI 0.999-1.00, p = 0.022) and icECG STE in MB or SB or occlusion of secondary SB (OR = 9.762, CI 3.273-29.12, p < 0.001)., Conclusions: Intracoronary electrocardiography is a highly sensitive and specific method for determination of ischaemic regions and prediction of elevated troponin I.

Secondary cardiac cancer most frequently originates from primary lung cancer and most commonly occurs in the pericardium. On electrocardiographic examination, patients with secondary cardiac cancer occasionally show ST segment elevation that mimics acute coronary syndrome, despite the absence of coronary artery occlusion. We herein describe a rare case of secondary cardiac cancer that presented with ST segment elevation and review the literature regarding ST segment elevation caused by secondary cardiac cancer. A 73-year-old Japanese woman was admitted to the hospital with chest pain. Electrocardiography showed abnormal ST segment elevation in the precordial and lateral leads, suggestive of ST-elevation myocardial infarction. Emergency coronary angiography showed occlusion of the distal left anterior descending coronary artery (LAD), and plain old balloon angioplasty of the LAD was performed. The ST segment elevation initially resolved after angioplasty, but recurred after 7 days. Contrast-enhanced chest computed tomography showed primary lung cancer in the left lower lobe, pericardial metastasis, and myocardial metastasis in the intraventricular septum and posterolateral wall of the left ventricle. Histopathological examination of the lung cancer was not performed. Patients with ST segment elevation due to secondary cardiac cancer may have symptoms and electrocardiographic changes mimicking anteroseptal or lateral infarction without the development of abnormal Q waves. These findings are frequently associated with posterolateral or anteroseptal invasion by primary lung cancer and may indicate a poor prognosis. In conclusion, physicians should be aware that secondary cardiac cancer may present with symptoms and ST segment elevation mimicking acute coronary syndrome, indicating a poor prognosis.

Abstract: We present the case of a patient with Tako-Tsubo cardiomyopathy whose initial diagnosis, based on the location of shoulder and chest pain and electrocardiographic (ECG) changes, suggested that she was suffering from pericarditis. However, 24 h after admission, evolutionary changes of ECG and the echocardiogram performed suggested a Tako-Tsubo cardiomyopathy. In this context, we review the literature to discuss the clinical presentation and evolutionary ECG changes associated with Tako-Tsubo cardiomyopathy. [Copyright &y& Elsevier]

Abstract: We describe a case of isolated right ventricular myocardial infarction as the cause of anterior precordial lead ST segment elevation. This case illustrates that anterior ST segment elevation may occur with occlusion of the right coronary artery. It is important to recognize this scenario as the treatment of right ventricular myocardial infarction differs from that of left ventricular myocardial infarction. [Copyright &y& Elsevier]

Abstract: Rarely, hypertrophic cardiomyopathy can be associated with ST elevation on electrocardiogram. We report a rare case of anterior hypertrophic cardiomyopathy mimicking an acute myocardial infarction where the diagnosis of myocardial hypertrophy was made by cardiac magnetic resonance. The method was able to identify the myocardial hypertrophy located in basal segments of anterior wall respect to echocardiography. [Copyright &y& Elsevier]

The benefits of early perfusion in ST elevation myocardial infarctions (STEMI) are established; however, early perfusion of non-ST elevation myocardial infarctions has not been shown to be beneficial. In addition, ST elevation (STE) caused by conditions other than acute ischemia is common. Non-ischemic STE may be confused as STEMI, but can also mask STEMI on electrocardiogram (ECG). As a result, activating the primary percutaneous coronary intervention (pPCI) protocol often depends on determining which ST elevation patterns reflect transmural infarction due to acute coronary artery thrombosis. Coordination of interpreting the ECG in its clinical context and appropriately activating the pPCI protocol has proved a difficult task in borderline cases. But its importance cannot be ignored, as reflected in the 2013 American College of Cardiology Foundation/American Heart Association guidelines concerning the treatment of ST elevation myocardial infarction. Multiples strategies have been tested and studied, and are currently being further perfected. No matter the strategy, at the heart of delivering the best care lies rapid and accurate interpretation of the ECG. Here, we present the different patterns of non-ischemic STE and methods of distinguishing between them. In writing this paper, we hope for quicker and better stratification of patients with STE on ECG, which will lead to be better outcomes.

Guidelines report that the optimal treatment for ST-elevation myocardial infarction (STEMI) is a primary percutaneous coronary intervention (PPCI) when performed timely by trained operators. Yet, the reopening of the infarct-related artery (IRA) is not always followed by myocardial reperfusion. This phenomenon is most commonly called "no-reflow", is caused by microvascular obstruction (MVO) and is associated to a worse outcome. Electrocardiogram (ECG) is crucial for the diagnosis of STEMI, but is also useful for the assessment of MVO. In this review we summarize ECG-derived parameters associated to MVO and their prognostic relevance., (© 2013.)

A 57-year-old male was admitted with suspected acute coronary syndrome. He reported experiencing moderate chest pain when walking during the day prior to admission, but had very prominent ST segment elevations in the precordial electrocardiography (EKG) leads. A physical examination revealed remarkable severe kyphoscoliosis with chest deformity. The patient's cardiac troponin levels remained normal, while cardiac ultrasound and magnetic resonance imaging of the chest confirmed hypertrophic cardiomyopathy (HCM) with severe thickening of the interventricular septum. Ischemic heart disease was ruled out by myocardial perfusion imaging with (99m)Tc-MIBI during rest and dipyridamole-induced stress without showing irreversible or reversible myocardial ischemia. Our diagnosis was that the chest pain was noncardiac in origin and that the pronounced ST segment elevations in the precordial EKG leads reflected the severely hypertrophic interventricular septum through the normally thick left ventricular free wall. The patient's chest wall deformity brought his septum and the ventricular free wall nearly parallel to the left side of the chest wall, allowing for complete expression of the reciprocal EKG pattern of septal hypertrophy. We suggest that EKG findings should always be interpreted with the chest wall shape being kept in mind.