Search

The incidence of precordial T changes has been described in athletes and in specific populations, while the etiology in a large patient population admitted to the hospital has not previously been reported.All electrocardiograms (ECGs) read by the same physician with new (compared to prior ECGs) or presumed new (no prior ECGs) precordial T wave inversions of1 mm (0.1 mV) in multiple precordial leads were retrospectively reviewed and various ECG, patient-related, and imaging parameters assessed. A total of 226 patients and their ECGs were initially selected for analysis. Of these, 35 were eliminated leaving 191 for the final analysis.Patients and their ECGs were divided into 5 groups based on diagnosis and incidence including Wellens syndrome, takotsubo, type 2 myocardial infarction, other (including multiple diagnoses), and unknown. Although subtle differences including number of T inversion leads, depth of T waves, QTc intervals, and other variables were present between some groups, diagnosis in individual cases required appropriate clinical, laboratory, or imaging studies. For example, although Wellens syndrome was identified in20% of cases, a presenting history of chest discomfort with precordial T changes either on the admission or next-day ECG was highly sensitive and specific for this diagnosis. In some cases, type 2 myocardial infarction can also have a Wellens-like ECG phenotype without significant left anterior descending disease.Precordial T wave changes in hospitalized patients have various etiologies, and in individual cases, the changes on the ECG alone cannot easily distinguish the presumptive diagnosis and additional data are required.

This is the second of two articles exploring assessment and clinical reasoning of conditions relating to the heart and cardiovascular system in the context of emergency care. In the last article, the structure and function of the heart was reviewed, and reference made to many of the conditions that may affect the heart. In addition, the common presenting complaints of cardiac conditions were highlighted, together with important aspects of the history for each symptom. The full cardiac examination was outlined. In this article, some of the common cardiac conditions will be discussed. These will be linked to common findings in the history, examination, and investigations.

Resumen Introducción y objetivos: El trauma cardiaco en países subdesarrollados es de predominio penetrante, con altas tasas de mortalidad extrahospitalaria, pero con mortalidad intrahospitalaria que dependerá en parte de si el paciente se encuentra taponado o no. Las técnicas mínimamente invasivas para practicar la ventana pericárdica y la nueva interpretación del resultado positivo, han hecho variar paradigmas previamente establecido, lo cual ha llevado a realizar un cambio en el abordaje inicial de los pacientes con trauma precordial penetrante estables hemodinámicamente. Por lo cual, queremos mostrar nuestra experiencia en el manejo mínimamente invasivo de pacientes estables hemodinámicamente llevados a ventana pericárdica por trauma precordial. Materiales: En un periodo entre el 2018 y el 2019, se evaluaron 5 pacientes con herida penetrante precordial al servicio de trauma Hospital Universitario del Valle Evaristo García lo cuales fueron manejados por cirugía mínimamente invasiva. Resultados: Pacientes con e-FAST(tomado de las siglas en inglés, Extended Focused Assessment with Sonography in Trauma) positivo subxifoideo; llevados a ventana pericárdica por toracoscopia y laparoscopia, todas positivas con identificación de lesiones en pericardio, aurícula derecha , ventrículo izquierdo y auricula izquierda no sangrante, manejadas con lavado con SSN 500 cc hasta obtener líquido claro, aspiración de coágulos. Drenaje de hemotórax y Toracostomía cerrada para abordaje torácico. 72 horas retiro de tubo de tórax y egresó sin complicaciones documentadas. Conclusiones: La cirugía mínimamente invasiva en trauma resulta ser efectiva y segura para el manejo del trauma penetrante precordial en el paciente estable hemodinámicamente. Evitando toracotomías y esternotomías innecesarias.

Chronic obstructive lung disease (COPD), predominantly emphysema, causes several thoracic anatomical and hemodynamic changes which may cause changes in various electrocardiographic parameters. A 12-lead electrocardiogram (ECG), which is often a part of routine evaluation in most clinical settings, may serve as a useful screening modality for diagnosis of COPD or emphysema. Our current article aims to provide a comprehensive review of the electrocardiographic changes encountered in COPD/emphysema utilizing published PubMed and Medline literature database. Several important ECG changes are present in COPD/emphysema and may serve as a good diagnostic tool. Verticalization of P-vector, changes in QRS duration, pattern recognition of precordial R-wave progression and axial shifts can be considered some of the most valuable markers among other changes. In conclusion, 12-lead surface electrocardiogram can serve as a valuable tool for the diagnosis of COPD and/or emphysema. An appropriate knowledge of these ECG changes can not only help in the diagnosis but can also immensely help in an appropriate clinical management of these patients.

Background Several electrocardiographic (ECG) indices have been proposed to predict the origin of premature ventricular complexes (PVCs) with precordial transition in lead V3. However, the accuracy of these algorithms is limited. Objectives We sought to evaluate a new ECG criterion differentiating the origin of outflow tract with precordial transition in lead V3. Methods We included in our study patients exhibiting outflow tract PVCs with precordial transition in lead V3 referred for ablation. We analyzed a novel new ECG criterion, RV1-V3 transition ratio, for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V3. The RV1-V3 transition ratio was defined as (RV1+RV2+RV3) PVC / (RV1+RV2+RV3) SR (sinus rhythm). Results We included 58 patients in our study. The ratio was lower for right ventricular outflow tract origins than left ventricular outflow tract (LVOT) origins (median [interquartile range], 0.6953 [0.4818–1.0724] vs 1.5219 [1.1582–2.4313], P < .001). Receiver operating characteristic analysis revealed an area under the curve of 0.856 for the ratio, and a cut-off value of ≥0.9 predicting LVOT origin with 94% sensitivity and 73% specificity. This ratio was superior to any previously proposed ECG criterion for differentiating right from left outflow tract PVCs. Conclusion The RV1-V3 transition ratio is a simple and accurate novel ECG criterion for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V3.

Observing modern decompression protocols alone cannot fully prevent diving injuries especially in repetitive diving. Professional audio Doppler bubble measurements are not available to sports scuba divers. If those non-professionals were able to learn audio Doppler self-assessment for bubble grading, such skill could provide significant information on individual decisions with respect to diving safety. We taught audio Doppler self-assessment of subclavian and precordial probe position to 41 divers in a 45-min standardized, didactically optimized training. Assessment before and after air dives within sports diving limits was made through 684 audio Doppler measurements in dive-site conditions by both trained divers and a medical professional, plus additional 2D-echocardiography reference. In all dives (average maximum depth 22 m; dive time 44 min), 33% of all echocardiography measurements revealed bubbles. The specificity of audio bubble detection in combination of both detection sites was 95%, and sensitivity over all grades was 40%, increasing with higher bubble grades. Dive-site audio-Doppler-grading underestimated echo-derived bubble grades. Bubble detection sensitivity of audio Doppler self-assessments, compared to an experienced examiner, was 62% at subclavian and 73% at precordial position. 6 months after the training and 4.5 months after the last measurement, the achieved Doppler skill level remained stable. Audio Doppler self-assessment can be learned by non-professionals in a single teaching intervention. Despite accurate bubble grading is impossible in dive-site conditions, relevant high bubble grades can be detected by non-professionals. This qualitative information can be important in self-evaluating decompression stress and assessing measures for increased diving safety.

Men and women have specific patterns in an electrocardiogram (ECG) differentiated by J-point elevation and ST-segment angle. Although gender-affirming hormone treatment is one of the treatments for gender dysphoria, its influence on an ECG has not been clarified yet.The purpose of this study was to investigate ECG changes induced by gender-affirming hormone treatment.The study population consisted of 29 transgender males and 8 transgender females and 37 age- and sex-matched cisgender females and males. Male pattern was defined as J-point elevation0.1 mV and ST-segment angle20° in precordial leads.In the comparison between 29 transgender males and cisgender females, the prevalence of the male pattern (89.7% vs 6.9%; P.001), prevalence of the early repolarization pattern (51.7% vs 17.2%; P = .01), J-point elevation (leads VGender-affirming hormone treatment for gender dysphoria is accompanied by a change in ECG phenotype toward affirming gender, in which change in androgen level may be involved.

Introduction and objectives The pocket sized KardiaMobile (KM) is a monitoring device for ECG recording through a smartphone-based application. This system is generally aimed as screening tool to detect alterations in cardiac rhythm but its diagnostic potential for detection of ST changes remains largely unknown. This study sought to assess the diagnostic sensitivity of the KM system for detection of ST changes in patients with ST elevated myocardial infarction (STEMI). Methods Patients admitted with diagnosis of STEMI were consecutively included. Recordings with KM were obtained in leads I, II and anterior precordial. KM recordings were obtained as well from healthy individuals. All recordings were submitted for blinded assessment. Results A total of 112 patients with STEMI and 25 healthy individuals were included. Among those showing ST changes, these consisted mostly in depression (75%). Sensitivity was modest for individual leads (57-58%). The combination of 2-leads, when including the precordial, and the combination of 3-leads markedly increased sensitivity (88-98% and 100% respectively) for both inferior and anterior STEMI. Specificity was very high (96-100%) and the Youden's J statistic was excellent for the 2-leads combinations that included the precordial lead (0.84-0.94) and for the 3-leads combination (0.96). Conclusions The Kardia Mobile system with the combination of 2-leads (I + precordial or II + precordial) or 3-leads shows a very high sensitivity for both anterior and inferior STEMI.

A female teenager presented with palpitations. The baseline rhythm on her ECG demonstrates sinus rhythm with normal PR interval of 120 ms, a mild degree of delta wave, RSR′ morphology in V1 with a precordial transition zone between V1 and V2. The frontal axis demonstrates normal QRS axis, in particular a positive lead III and aVF vectors, and negative aVR and aVL vectors, suggesting an overall inferior propagating QRS vector. Intermittently, however, she exhibits a different QRS morphology and a different ventricular activation vector (lead III and aVL), annotated with black arrows in figure 1. Figure 1 ECG of patient illustrating …

BACKGROUND Typically, right coronary artery (RCA) occlusion causes ST-segment elevation in inferior leads. However, it is rarely observed that RCA occlusion causes ST-segment elevation only in precordial leads. In general, an electrocardiogram is considered to be the most important method for determining the infarct-related artery, and recognizing this is helpful for timely discrimination of the culprit artery for reperfusion therapy. In this case, an elderly woman presented with chest pain showing dynamic changes in precordial ST-segment elevation with RCA occlusion. CASE SUMMARY A 96-year-old woman presented with acute chest pain showing precordial ST-segment elevation with dynamic changes. Myocardial injury markers became positive. Coronary angiography indicated acute total occlusion of the proximal nondominant RCA, mild atherosclerosis of left anterior descending artery and 75% stenosis in the left circumflex coronary artery. Percutaneous coronary intervention was conducted for the RCA. Repeated manual thrombus aspiration was performed, and fresh thrombus was aspirated. A 2 mm × 15 mm balloon was used to dilate the RCA with an acceptable angiographic result. The patient’s chest pain was relieved immediately. A postprocedural electrocardiogram showed alleviation of precordial ST-segment elevation. The diagnosis of acute isolated right ventricular infarction caused by proximal nondominant RCA occlusion was confirmed. Echocardiography indicated normal motion of the left ventricular anterior wall and interventricular septum (ejection fraction of 54%), and the right ventricle was slightly dilated. The patient was asymptomatic during the 9-mo follow-up period. CONCLUSION Cardiologists should be conscious that precordial ST-segment elevation may be caused by occlusion of the nondominant RCA.

This article is a concise description of the applied topographical anatomy of the heart, emphasizing those aspects of cardiac functional anatomy that are essential to clinical cardiac examination.

The earlier the detection and diagnosis of congenital heart diseases (CHD), the greater the clinical benefit; however, early fetal cardiac examination can be a challenge. The aim of our study is to demonstrate that the fetal cardiac examination at 13+0–13+6 weeks can be as adequately assessed as the examination performed at 16 weeks in patients with low and high body mass index (BMI). The study was a prospective observational cohort study. One hundred pregnant women at low risk of congenital heart anomalies were divided into two groups: 49 women with low BMI (

We present the case of a 16-year-old male patient with a history of anxiety disorder who presented with a cardiopulmonary arrest at his home. The first cardiac rhythm (+0) was remarkable for irregular and very wide, aberrated QRS complexes (320 ms) without identifiable atrial activity. Cardiopulmonary resuscitation manoeuvres were initiated. He was intubated and transferred to the acute cardiac care unit. In the immediate ECG (+2 hours) irregular, very wide (320 ms), aberrated and right-bundle-branch-like morphology QRS complexes persisted, but after several hours of treatment (+15 hours) a sinusal activity started, QRS complexes shortened (160 ms) and a specific ECG pattern was noted on right precordial …

Introduction A drug provocation test (DPT) is important for the diagnosis of Brugada syndrome (BrS). The link, however, between dynamic changes of ECG features after DPT and unstable ventricular arrhythmia (VA) in BrS remains unknown. Methods Between 2014 and 2019, we assessed 27 patients with BrS (median age: 37.0 [interquartile range, IQR: 22.0-51.0] years; 25 men], including 9 (33.3%) with a history of unstable VA and 18 (66.7%) without. All patients in the study presented with Brugada-like ECG features before DPT. The ECG parameters and dynamic changes (∆) in 12-lead ECGs recorded from the 2nd , 3rd , and 4th intercostal spaces (ICS) before and at 1, 6, 12, 18, 24 hours after DPT (oral flecainide 400 mg) were analyzed. Results The total amplitude of V1 at the 3rd ICS 18 and 24 hours after DPT was significantly lower in patients with history of unstable VA than in those without. Patients with BrS and unstable VAs had a significantly larger ∆ amplitude of V1 at the 2nd ICS 12 hours after DPT than in those without unstable VAs (0.28[0.18-0.41] mV vs. 0.08[0.01-0.15] mV, p=0.01). A multivariate analysis revealed that the amplitude of V1 at the 3rd ICS 18 and 24 hours after DPT and the ∆ amplitude of V1 at the 2nd ICS 12 hours after DPT were associated with history of unstable VA. Conclusion Nonuniform changes and spatiotemporal differences in precordial ECG features after DPT were observed in patients with BrS and these may be surrogate markers for risk stratification. This article is protected by copyright. All rights reserved.

Visualizing the vascular territories of coronary arteries during echocardiography or electrocardiography (ECG) requires trainees to mentally relate and overlay 2D sonographic images or cardiac lead projections with 3D anatomical representations of the ventricular walls and their respective blood supply. To facilitate the acquisition of these competencies, this study focuses on the feasibility of developing low-cost, open-sourced 3D printed heart models with standard ultrasound views or ECG lead projections illustrating the myocardial perfusion territories. A 3D digital heart model was cut to reflect the typical cardiac ultrasound views. The 4-chamber view model was further punctured for the paths of the precordial and limb leads of an ECG. Painting coronary arteries on the surface and internal views of the 3D prints illustrated vessel territories. Students, residents, and staff were surveyed during bedside ultrasound simulation sessions and ECG teaching half-days. Results demonstrated clear appreciation of 3D printed models, which suggests such models can easily be implemented by other institutions to augment trainees’ experience during skill acquisition.

Background While early precordial electrocardiographic (ECG) characteristics are useful to differentiate left-sided from the right-sided outflow tract ventricular arrhythmia (OTVA), few patterns predict an origin from the septal margin of the left ventricular (LV) summit. Objective The purpose of this study was to report mapping and ablation characteristics of a new ECG pattern with left bundle branch morphology and an abrupt R-wave transition in lead V3 (ATV3). Methods Over a 3-year period, 78 consecutive patients (mean age 57±15 years; 35% female) with OTVA were referred for mapping and ablation. Twenty patients (26%) exhibited an ATV3 pattern, of whom 65% failed prior ablation. Results Ninety-two percent of patients with ATV3 that underwent simultaneous epicardial and endocardial mapping demonstrated an intramural or epicardial site of origin. Eighty percent of OTVA with ATV3 was eliminated by ablation from the vantage point of the interleaflet triangle below the right-left coronary junction. The ATV3 pattern showed higher sensitivity, specificity, predictive value, and accuracy than validated ECG criteria (notch or "w" pattern in lead V1, qrS pattern in leads V1 through V3, and pattern break V2) for predicting successful ablation in the region of the anterior LV ostium. At 12±11 months, freedom from ventricular arrhythmia recurrence was 89% and 82% in the ATV3 and control groups, respectively. Conclusion ATV3 is a simple and distinct ECG pattern indicative of a site of origin from the septal margin of the LV summit. The right-left aortic interleaflet triangle vantage point was effective to eliminate OTVA with ATV3 that overwhelmingly exhibited the earliest activation from the epicardium or mid-myocardium. Test characteristics for ATV3 were superior to ECG patterns validated for the anterior LV ostium.

Background The initial depolarization vector of outflow tract (OT) ventricular arrhythmia (VA) varies in different origins, which may help to predict OT-VA origin more accurately. Objective The purpose of this study was to develop a more accurate electrocardiographic (ECG) criterion for differentiating between left and right OT-VA origins. Methods We studied 275 patients with successful ablation in the right ventricular outflow tract (RVOT) (n = 207) or left ventricular outflow tract (LVOT) (n = 68) in the development cohort. Amplitude of the QRS complex within initial 40 ms (QRSi40) in precordial leads was measured. A novel criterion for identifying OT-VA origin was developed based on the development cohort. Predictive performance of novel criterion was further validated by comparing with previous ECG criteria (V2S/V3R index, V2 transition ratio, and transition zone index) in the validation cohort with 107 patients (RVOT 75; LVOT 32). Results QRSi40 of identical precordial leads were significantly greater in the LVOT group than the RVOT group (P Conclusion V2QRSi40 is a novel and accurate ECG criterion to predict OT-VA origin that outperforms previous criteria.

Background Published algorithms for accessory pathway localization in Wolff-Parkinson-White (WPW) syndrome are inaccurate in pediatric patients, especially for septal pathways. Objective We aimed to develop a new algorithm that is sensitive for septal pathways and more applicable in pediatric patients. Methods In 120 patients (mean age: 11.7 ± 3.9 years) who underwent catheter ablation for WPW syndrome, the candidate criteria for new algorithm were searched by comparing electrocardiography parameters and accessory pathway locations. A new algorithm was designed to increase the sensitivity for septal pathways. For validation, 142 patients (mean age: 15.8 ± 3.7 years) were additionally evaluated. New and published algorithms were applied to electrocardiography of 262 patients and the results were compared. Results The new algorithm achieved its best discrimination by combining several parameters together in each step: (1) QRS polarity in V1 and QRS shape in lead I for left/right discrimination, and (2) delta wave polarity in V1, QRS transition in precordial leads, and delta wave polarity in lead III for septal pathway screening. The new algorithm showed higher sensitivity for septal pathways (95.7%) than 7 published algorithms (average: 62.1%), with satisfactory positive predictive value (77.9%). Delta wave polarity in V1 among septal pathways and QRS axis among right anteroseptal pathway showed age-related trend; this could be the reason for the lower accuracy in localizing septal pathways in children. Conclusion The inaccuracy of published algorithms in pediatric patients is due to the age-related trend in the electrocardiography of septal pathways. The new algorithm was superior for localizing septal pathways in pediatric patients.

A 57-year-old man presented with palpitations and dizziness for one day. He reported a history of similar short-lasting, self-limiting episodes in the past. Evaluation showed a hemodynamically stable, ongoing monomorphic ventricular tachycardia (VT) with positive concordance in the precordial leads and inferior axis. A structurally normal heart was seen on echocardiography. The VT was cardioverted to normal sinus rhythm with a biphasic 100-J direct-conversion shock under mild sedation, only to spontaneously start over again. In view of the patient’s structurally normal heart, a previous history of similar complaints in the past, and no obvious trigger including ischemia for VT, he subsequently underwent an electrophysiology study (EPS).

Particularities of African descent patient's electrocardiogram have been described for many years. Variations such as higher QRS voltage, early repolarization pattern, precordial T-wave inversion and anterior ST segment elevation associated with T-wave inversion are more frequently observed. Ignorance of these variations can lead to misdiagnosis or therapeutic negligence. We present the electrocardiographic particularities attributed to the patient of African origin.

This study evaluated if modifying electrocardiographic (ECG) precordial leads to a higher intercostal position improved the accuracy of outflow tract ventricular arrhythmia (OTVA) localization.Precordial ECG prediction algorithms that use a standard lead configuration localize OTVA with variable accuracy.Patients who underwent OTVA ablation were prospectively enrolled to have a standard and modified (high) precordial ECG. R- and S-wave amplitudes and intervals were measured to develop an algorithm that differentiated the right ventricular outflow tract (RVOT) and the left ventricular outflow tract (LVOT) with high accuracy-the modified lead R-wave deflection interval (RWDI). This interval was defined from the earliest QRS onset (using all modified leads) to the lead with longest R-wave deflection. The RWDI was compared with all other ECG algorithms.A total of 50 patients (38 women; mean age 51 ± 17 years) had successful catheter ablation for OTVA (RVOT 60%, LVOT 40%). The modified lead RWDI was significantly shorter in the RVOT group (18.5 ms, interquartile range 25th to 75th percentile [IQRThe modified lead RWDI is a simple, easily interpretable algorithm that can potentially differentiate a right- or left-sided origin of OTVA with high accuracy.

The aim of this study is to estimate the possibility of using the differences of negative T waves in the right precordial leads for the differential diagnosis of the pulmonary thromboembolism (pulmonary embolism) and Wellens syndrome. We studied the first ECGs with T -wave inversion in leads V 1 –V 3 in 70 patients (38 patients with pulmonary embolism and 32 patients with Wellens syndrome). The ratio of the magnitude of negative T wave in the lead V 1 to the magnitude of negative T wave in the lead V 3 (T V1 /T V3 ) was more than 0.5 in all patients with pulmonary embolism and in only one (4.5%) patient with Wellens syndrome. So, this criterion T V1 /T V3 >0.5 may by useful for the differential diagnosis of these diseases.

High altitude syndromes are illnesses attributed directly to hypobaric hypoxia. Hypobaric Hypoxic pressure changes in the right side of the heart with ECG changes in right precordial leads are seen in cases like High Altitude Pulmonary Edema (HAPE), Pulmonary Thormboembolism (PTE) and thrombotic cause in acute coronary syndrome (ACS). Cases of these mimics with T wave inversion in precordial chest leads are seen in low landers on induction into high altitude without any high altitude illness, ACS or PTE. These findings may reflect asymptomatic pressure changes in the heart and pulmonary vasculature due to hypobaric hypoxia of high altitude to the point where they are not manifested. High altitude environment is itself being a procoagulant state compounded with hypobaric hypoxia, if these changes are not addressed in time and not treated with oxygen supplementation, these individuals may present at a later stage with HAPE or SAMS. We hypothesized that oxygen supplementation can reverse these changes. Intervention study with oxygen supplementation @ 6/min intermittently over 12 hr/day was given in all those individuals who have T wave inversion in precordial ECG meeting inclusion criteria over a week. The study was conducted at peripheral hospital 11000ft in Himalayan ranges over a period of 06 months. 100 % of cases had shown normalization of T waves in response to oxygen supplementation. However 02 individuals had recurrence of ECG changes and they were deinducted to plains. None of them developed high altitude illness over next 06 months of followup.

Pulmonary arterio-venous fistula is an uncommon cause of cyanosis and should be suspected when normal cardiac examination is associated without evidence of intra-cardiac shunt. Diagnosis of extra-cardiac shunt can be suspected by contrast echocardiography using agitated saline and confirmation of pulmonary arterio-venous fistula can be made by computed tomography pulmonary angiography with information regarding the size feeding vessels necessary for the planning of intervention. With the advancement of trans-catheter devices, fistula can be occluded successfully by embolotherapy. Coils, duct occluders, and vascular plugs are some of the commonly used trans-catheter devices among the armamentarium. Each device has its own inherent advantages and limitations. However, operators’ familiarity and expertise is an important parameter to choose the device to be employed in closure of fistula. The experience of Amplatzer family of devices in closure of pulmonary arterio-venous fistula is limited in the literature. We report a case of large pulmonary arterio-venous fistula successfully closed with a 20 mm Amplatzer septal occluder device in a 16-year-old cyanotic boy. Post-procedure contrast echocardiography confirmed absence of right to left shunt and computed tomography pulmonary angiography confirmed the device in situ closing the feeding vessel. Over a follow-up of six months reversal of clubbing and cyanosis was noted.

BACKGROUND Diagnosing long QT syndrome (LQTS) remains challenging because of a considerable overlap in QT interval between patients with LQTS and healthy subjects. Characterizing T-wave morphology might improve LQTS diagnosis.OBJECTIVE The purpose of this study was to improve LQTS diagnosis by combining new polynomial-based T-wave morphology parameters with the corrected QT interval (QTc), age, and sex in a model.METHODS A retrospective cohort consisting of 333 patients with LQTS and 345 genotype-negative family members was used in this study. For each patient, a linear combination of the first 2 Hermite-Gauss (HG) polynomials was fitted to the STT segments of an average complex of all precordial leads and limb leads I and II. The weight coefficients as well as the error of the best fit were used to characterize T-wave morphology. Subjects were classified as patients with LQTS or controls by clinical QTc cutoffs and 3 support vector machine models fed with different features. An external cohort consisting of 72 patients and 45 controls was finally used to check the robustness of the models.RESULTS Baseline QTc cutoffs were specific but had low sensitivity in diagnosing LQTS. The model with T-wave morphology features, QTc, age, and sex had the best overall accuracy (84%), followed by a model with QTc, age, and sex (79%). The model with T-wave morphology features especially performed better in LQTS type 3 patients (69%).CONCLUSION T-wave morphologies can be characterized by fitting a linear combination of the first 2 Hermite-Gauss polynomials. Adding T-wave morphology characterization to age, sex, and QTc in a support vector machine model improves LQTS diagnosis.

Introduction: Corrected QT interval (QTc) >460 ms in the right precordial leads has been described as a predictor of malignant ventricular arrhythmias (MVA) in patients with Brugada syndrome (BrS). Objective: To assess the presence of QTc>460 ms in multiple electrocardiograms (ECGs) during follow-up as a predictor of recurrence of MVA in patients with BrS. Methods: The study group included 43 patients with BrS and an implantable cardioverter-defibrillator. ECGs were performed serially between June 2000 and January 2017. QT interval was measured and QTc was obtained by Bazett's formula. The sample was divided into three groups: Group 1 (patients with no ECGs with QTc>460 ms); Group 2 (patients with only one ECG with QTc>460 ms); and Group 3 (patients with two or more ECGs with QTc>460 ms). Results: The following variables were more frequently observed in Group 3: family history of sudden death (p=0.023), previous history of cardiorespiratory arrest (p=0.032), syncope (p=0.039), documented MVA (p=0.002), and proportion of ECGs with coved-type ST interval during follow-up (p=0.002). In Group 3, 67% of BrS patients had events during follow-up, as opposed to only 22% of Group 1 and 14% of Group 2 (Group 1 vs. Group 2, p=0.33015; Group 1 vs. Group 3, p=0.04295; and Group 2 vs. Group 3, p=0.04155). Conclusions: QTc>460 ms in more than one ECG during follow-up increases the risk of MVA events in patients with BrS. Resumo: Introdução: Um intervalo QTc>460 ms nas derivações precordiais direitas foi descrito como um fator preditivo de arritmias ventriculares malignas em doentes com síndrome de Brugada (SB). Objetivo: Avaliar se a presença de QTc>460 ms em eletrocardiogramas (ECGs) seriados durante o seguimento é um fator preditivo de recidiva de arrtimias ventriculares malignas em doentes com SB. Métodos: O grupo de estudo incluiu 43 doentes com SB e com cardioversor-desfibrilhador implantável; os ECGs seriados foram efetuados entre junho de 2000 e janeiro de 2017. Foi medido o intervalo QT, tendo sido o QTc obtido através da fórmula de Bazzet. Os doentes foram divididos em três grupos: Grupo 1 (doentes sem ECGs com QTc>460 ms); Grupo 2 (doentes com apenas um ECG com QTc>460 ms) e Grupo 3 (doentes com dois ou mais ECGs com QTc>460 ms). Resultados: As seguintes variáveis foram observadas com mais frequência no Grupo 3: história familiar de morte súbita (p=0,023), história prévia de paragem cardiorrespiratória (p=0,032), síncope (p=0,039), arritmias ventriculares malignas documentadas (p=0,002) e percentagem de ECGs convexos durante o seguimento (p=0,002). No Grupo 3, 67% dos doentes com SB apresentaram eventos durante o seguimento. Por outro lado, no caso dos doentes com SB apenas 22% do Grupo 1 e 14% do Grupo 2 apresentaram eventos durante o seguimento (Grupo 1 versus Grupo 2, p=0,33015; Grupo 1 versus Grupo 3, p=0,04295 e Grupo 2 versus Grupo 3, p=0,04155). Conclusões: O QTc>460 ms em mais do que um ECG durante o seguimento aumenta o risco de eventos de arrtimias ventriculares malignas.

Background Concentrations of cardiac troponin I (cTnI) and T (cTnT) are associated with clinical cardiac outcomes, but do not correlate closely in subjects recruited from the general population. Accordingly, we hypothesized that cTnI and cTnT concentrations would be influenced by different cardiovascular (CV) and non-CV risk factors and reflect different CV phenotypes. Methods We measured cTnI and cTnT with last generation assays in 1236 women and 1157 men with no known CV disease participating in the prospective observational Akershus Cardiac Examination 1950 Study. All study participants underwent extensive CV phenotyping at baseline, including detailed echocardiography. Results Concentrations of cTnI were measurable in 60.3% and cTnT in 72.5% of study participants (P Conclusions In a large community-based cohort examined with extensive echocardiography, concentrations of cTnI and cTnT are associated with subclinical LV hypertrophy and dysfunction. Concentrations of cTnI appear superior to cTnT in predicting subclinical LV hypertrophy.

Apical hypertrophic cardiomyopathy (ApHCM) is characterized by apical wall thickness ≥15 mm by transthoracic echocardiography or cardiovascular magnetic resonance (CMR), lack of apical tapering, and presence of precordial T wave inversion on electrocardiogram (ECG). Three subphenotypic variants

Phonocardiogram based auscultation is the most suitable cardiac examination technique for primary health care since heart sound can be captured and analyzed using a smart-phone and a digital stethoscope. The phonocardiogram signal provides, among others, valuable information about valve functioning of the heart. It is well known that many heart problems are associated with valve dysfunctions. Notably, the time differences between valves closure are very critical to diagnose some pathologies. Hence, the need of the correct detection of these instants. Up to now, this research problem represents a serious challenge. This Study takes place in this area of concern and targets to propose a greedy-based two-stage strategy to detect the instants of the heart valves closure. The first stage concerns the dictionary construction from the estimation of the impulse response functions associated to each heart valve. In the second stage, the instants of valves closures are identified by applying the Orthogonal Matching Pursuit algorithm alongside the constructed dictionaries. Simulations on both synthetic and real-life phonocardiogram signals are performed to validate the performance of the proposed two-stage approach in detecting the closure instants of the heart valves.

We report anesthetic management in a patient with Brugada syndrome, an inherited syndrome characterized by normal QT interval, typical ST-segment–elevation in the right precordial leads, and increased risk of sudden cardiac death in the absence of myocardial ischemia or structural heart disease. A 69-year-old man scheduled for glaucoma filtering surgery underwent local peribulbar anesthesia using 5 mL of lidocaine 20 mg/mL solution that was slowly injected into two different sites approximately 10 min prior to the surgical procedure. The surgery proceeded uneventful and data of patient’s blood pressure, heart rate, oxygen saturation were collected. Continuous electrocardiography monitoring before, during, and up to 6 h after surgery did not reveal any arrhythmia or tachycardia. A certain number of drugs should be avoided in patients with Brugada syndrome because of their potential risk to trigger an arrhythmia. Among them there are some anesthetics and in particular those that are sodium channel blockers. Ropivacaine and bupivacaine, commonly used for peribulbar block, have been associated with onset of severe arrhythmias. Contrarily, the use of class IB drugs mexiletine and lidocaine is generally considered safe. Local anesthetic agent should be carefully chosen, and anesthesia should be obtained using the minimal necessary drug dose.

One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a? VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.

Background: Reusable suction-cup electrodes are used for recording a 12-lead electrocardiogram (ECG) in resource-limited settings. These electrodes may easily detach if those are attached on a hirsute chest. Additionally, the suction pressure may cause erythema and pain. Aim: The aim of this study was to develop a low-cost strap for holding the suction-cup-based precordial electrodes and to test its applicability to the recording of ECG. Materials and Methods: A scrap rubber tube was cut in size so that it can cover all the precordial electrode positions. Slit openings (electrodes can be inserted through these opening) were made on this rubber strap. A cloth and a hook-and-loop fastener were used to make an adjustable fastener. ECG was recorded first on 16 non-hairy males with electrodes placed on the chest with the strap and then with electrodes attached by suction. After that, ECG was recorded on 16 males with hirsute chest first with the electrodes placed with the help of the strap and then with suction (without strap) on the shaved chest. Results: The outcome of this study is a low-cost ECG chest strap for a hirsute chest. Both the negative and positive QRS voltages in six precordial leads recorded with electrodes placed with the strap were similar to that of suction-attached electrodes in both non-hairy and hirsute chest. Conclusion: Developed rubber chest strap can be made with minimal cost and expertise in any resource-limited settings. This would help in recording the ECG of a patient with a hirsute chest. This prototype strap has scope for further improvement.

Background Unlike T‐wave alternans (TWA), the relation between QRS alternans (QRSA) and ventricular arrhythmia (VA) risk has not been evaluated in hypertrophic cardiomyopathy (HCM). We assessed microvolt QRSA/TWA in relation to HCM risk factors and late VA outcomes in HCM. Methods and Results Prospectively enrolled patients with HCM (n=130) with prophylactic implantable cardioverter‐defibrillators underwent digital 12‐lead ECG recordings during ventricular pacing (100–120 beats/min). QRSA/TWA was quantified using the spectral method. Patients were categorized as QRSA+ and/or TWA+ if sustained alternans was present in ≥2 precordial leads. The VA end point was appropriate implantable cardioverter‐defibrillator therapy over 5 years of follow‐up. QRSA+ and TWA+ occurred together in 28% of patients and alone in 7% and 7% of patients, respectively. QRSA magnitude increased with pacing rate (1.9±0.6 versus 6.2±2.0 µV; P =0.006). Left ventricular thickness was greater in QRSA+ than in QRSA− patients (22±7 versus 20±6 mm; P =0.035). Over 5 years follow‐up, 17% of patients had VA. The annual VA rate was greater in QRSA+ versus QRSA− patients (5.8% versus 2.0%; P =0.006), with the QRSA+/TWA− subgroup having the greatest rate (13.3% versus 2.6%; P P =0.001). Separate Cox models revealed QRSA+ (hazard ratio [HR], 2.9 [95% CI, 1.2–7.0]; P =0.019) and QRSA+/TWA− (HR, 7.9 [95% CI, 2.9–21.7]; P Conclusions In HCM, microvolt QRSA is a novel, rate‐dependent phenomenon that can exist without TWA and is associated with greater left ventricular thickness. QRSA increases VA risk 3‐fold in all patients, whereas the absence of QRSA confers low VA risk in patients with Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02560844.

This article aims to increase knowledge of cardiac assessment. Anatomy and physiology of the heart are briefly reviewed and reference is made to pathology that can cause cardiac dysfunction. The main features to look for when taking a cardiac history are discussed, with suggestions for questions to elicit this information, and the signs to look for when undertaking a cardiac examination. There is also an introduction to the main investigations to aid differential diagnosis and clinical reasoning. A follow-up article will look in more detail at some common cardiac conditions presenting to emergency care, with an emphasis on critical thinking and diagnostic reasoning. These articles are written from an emergency care perspective, and therefore do not focus in great detail on invasive investigation of cardiology conditions, but more so on picking up these possibilities in undifferentiated patients presenting to emergency care.

Background Ablation of idiopathic ventricular arrhythmias (VAs) in the cardiac crux region is one of the challenging procedures due to the complex anatomical structure where the four chambers of the heart are offset. Although this region is complex, the contiguous cardiac structures allow for the ablation of arrhythmias from adjacent sites. Case presentation We present different anatomical approaches in radiofrequency ablation and the ECG characteristics from a case series of VAs originated from the basal inferior ventricular septum, the corresponding endocardial aspect of the basal cardiac crux region. Conclusions Ablation of VAs originated from the basal cardiac crux region requires detailed mapping in the proximal coronary venous system and the adjacent structures including the RV, RA, and LV. In addition to the characteristic ECG of basal crux VAs, our three cases present an abrupt precordial transition in V2 with R wave amplitude greater than in V1 and V3.

Background: Use of lung ultrasonography (LUS) to diagnose neonatal pneumothorax (PTX) has been well documented. This study aimed to emphasize the value of precordial heart image (PHI) disappearance as an ultrasound sign to diagnose neonatal PTX and to perform thoracentesis at the precardiac area in patients with PTX.Methods: From March 2017 to May 2021,a total of 288 infants were included in this retrospective study, including 48 patients with PTX,48 patients with respiratory distress syndrome,48 patients with transient tachypnea,48 patients with meconium aspiration syndrome,48 patients with pneumonia,and 48 patients with normal lung tissue.LUS was performed routinely,and thoracentesis was performed under LUS guidance.Results: Eight of 48 patients with PTX (16.7%) presented with PHI disappearance on LUS,which exhibited a sensitivity of 16.7% and a specificity of 100% for diagnosing neonatal PTX.Needle aspiration was performed on 42 patients with PTX (87.5%),8 of whom underwent puncture at the precardiac area. Satisfying results were obtained in 40 patients (95.2%) without any complications.Conclusion: PHI disappearance is an uncommon ultrasound sign on LUS that can be used to diagnose neonatal PTX.Selection of the precardiac area as the puncture site is safe for the treatment of neonatal PTX in patients with PHI disappearance.

BACKGROUND It is known that nasal septal deviation (NSD) has negative effects on the cardiovascular system, but the possible pathophysiological mechanisms of these effects still need to be explained. The aim of this study was to investigate the endothelial dysfunction (ED) caused by NSD and the effects of septoplasty on it. METHODS The study included 40 patients between the ages of 18 to 50 years with a marked NSD indication for septoplasty and 40 healthy age-and gender-matched individuals. Nasal obstruction symptom evaluation scale was used to evaluate the severity of nasal obstruction and the effectiveness of septoplasty. All participants underwent detailed cardiac examination and ultrasonographic measurement of flow-mediated dilatation (FMD). The same cardiac evaluations and nasal obstruction symptom evaluation scale assessments were repeated in the patient group at the postoperative 3rd month. RESULTS The mean FMD value in the control group was significantly higher than preoperative FMD in the patient group (9.1 ± 2.9 versus 7.6 ± 2.4, P = 0.024). In the patient group, preoperative and postoperative FMD values were measured as 7.6 ± 2.4 and 9.0 ± 2.7, respectively, and there was a significant difference between them (P = 0.032). There was no significant difference in FMD values between the control group and postoperative patient group (P = 0.925). CONCLUSIONS This study shows that NSD can cause ED, which is a precursor of atherosclerosis, and that successful septoplasty can improve ED.

Background and objective: The aim of this study was to investigate the influence of pre-hydration levels on circulating bubble formation for scuba divers and to evaluate the appropriate volume of water intake for reducing the risk of decompression sickness (DCS). Materials and Methods: Twenty scuba divers were classified into four groups according to the volume of water taken in before scuba diving as follows: no-water-intake group (NWIG), 30%-water-intake group (30WIG), 50%-water intake group (50WIG), and 100%-water-intake group (100WIG). We measured the circulating bubbles using movement status by Doppler on the right and left subclavian veins and precordial regions at pre-dive, post-dive, and 30 min after diving to a depth of 30 m for a duration of 25 min at the bottom. Results: Participants belonging to the 30WIG showed the lowest frequency, percentage, and amplitude of bubbles and consequently the lowest bubble grade in the left and right subclavian veins and precordial region at post-time and 30 min after diving. Conclusions: It can be inferred that pre-hydration with 30% of the recommended daily water intake before scuba diving effectively suppressed the formation of bubbles after diving and decreased the risk of DCS.

Hand held ECG recorders are transforming the way we detect and diagnose heart rhythm disorders. The Kardia 6 L was launched in 2019 to detect and diagnose heart rhythm disorders recording a six lead (limb lead) ECG. Recording and analysis of precordial leads are currently not supported by the Kardia 6 L. In this study we aim to assess if reliable chest lead data can be obtained using a simple modification to the recording system.

Atrial fibrillation (Af) with acute myocardial infarction (AMI) is a life-threatening disease, and electrocardiogram is indispensable for the initial diagnosis of high-risk patterns in the emergency department. Here we report a case of a 63-year-old male of Af with AMI, presented with isolated elevation of the precordial V2 lead ST-segment, mostly arising from major occlusion of the left main coronary artery and right coronary artery.

Introduction The interval from the peak to the end of the electrocardiographic T wave (Tp-Te) may correspond to malignant ventricular arrhythmias. In this study we aimed to assess Tp-Te variability and investigate the transmural dispersion of repolarisation in pulmonary sarcoidosis disease without proofed cardiac involvement. Material and methods This was a retrospective case-control study that included patients who had a pathologic and radiologic diagnosis of sarcoidosis. All data of the patients' demographic features and electrocardiographs were analysed. Results We enrolled 78 patients with sarcoidosis and 54 healthy volunteers as controls in our study. Men comprised 36% of the sarcoidosis group and 27% of controls. The mean age in the sarcoidosis and control group was 45.4 ±8.7 years (range: 23-58 years) and 44.6 ±11.9 years (range: 21-73 years), respectively. There was no significant difference between the groups for age or sex (p = 0.654, p = 0.246, respectively). There was a significant increase in Tp-Te results in all precordial leads in the sarcoidosis group compared with the control group (p < 0.05). Conclusions Pulmonary sarcoidosis is suspected to have cardiac involvement; therefore, we need to develop new approaches. We present strong evidence that Tp-Te intervals were increased in patients with pulmonary sarcoidosis, which suggests that there may be a link between sarcoidosis and ventricular arrhythmias without proofed cardiac involvement.

INTRODUCTION The electrocardiograms (ECG) criteria to anchor the lead to the right ventricular septum have not been established. This study aimed to identify ECG criteria of pacing at the right ventricular mid septum (RVMS) and investigate whether the paced QRS duration (pQRSd) from the RVMS was narrow. METHODS AND RESULTS In 42 patients, ECG pacing at the basal anterior wall (BA), mid-anterior wall (MA), apex (AP), and mid septum (MS) was recorded. The pacing sites were validated by using right ventriculography and computed tomography. We estimated the ECG parameters and compared them among the four pacing sites. The combination of simple four paced-ECG parameters could reliably confirm the pacing at the RVMS. The area under the receiver-operating characteristics curve for the number of positive findings among the following: (a) positive QRS in lead aVL, (b) QRS notching in lead I, (c) precordial leads transition at less than V5, and (d) presence of isoelectric QRS in the inferior leads was 0.95 (95% confidence interval, 0.91-0.98) and the number of positive findings (≥3) had a sensitivity of 83.3% and a specificity of 93.7% for discriminating MS from the other sites. The pQRSd with three or more positive findings was significantly narrower than that with less than three positive findings (≥3: 137.4 ± 9.2 ms

The aim of this study was to develop a new electrocardiographic criterion for differentiating the origin of outflow tract ventricular arrhythmias (OT-VAs) with precordial transition in lead V3. A total of 147 consecutive patients with OT-VAs displaying precordial transition in lead V3 who underwent successful catheter ablation in the right ventricular outflow tract (RVOT) (n = 118) or left ventricular outflow tract (LVOT) (n = 29) were included in this study. The V1–V3 transition index was defined as the sum of S-wave amplitude in lead V1 and V2 during premature ventricular contractions (PVCs) divided by the S-wave amplitude during sinus rhythm (SR), respectively, minus the sum of R-wave amplitude in lead V1, V2, and V3 during PVCs divided by the R-wave amplitude during SR, respectively, i.e., [(SPVC/SSR)V1 + (SPVC/SSR)V2] − [(RPVC/RSR) V1 + (RPVC/RSR)V2 + (RPVC/RSR)V3]. The V1–V3 transition index was significantly higher for RVOT origins than for LVOT origins (1.25 ± 2.48 vs. − 3.94 ± 3.11; P − 1.60 predicted a RVOT origin with a 93% sensitivity and 86% specificity. With respect to AUC and accuracy, the V1–V3 transition index was superior to any previously proposed ECG indices for differentiating left from right OT-VAs. In 37 prospective cases, the new index was able to predict the site of a RVOT origin with 95% accuracy (35 of 37 cases). The V1–V3 transition index is a useful novel ECG criterion for distinguishing left from right OT-VAs with precordial transition in lead V3.

espanolEl neumomediastino espontaneo idiopatico es la presencia de aire en el mediastino, sin ninguna causa aparente, siendo descrito en 1939 por el Dr. Hamman. Se atribuye a una fuga dinamica de aire desde los alveolos a traves del intersticio de personas jovenes (efecto Macklin). La clinica no es especifica, pero el dolor toracico agudo retroesternal y la tos, son los sintomas mas orientativos; los signos mas especificos son los crepitos precordiales (signo de Hamman) y el enfisema subcutaneo. La radiografia de torax es suficiente para el diagnostico,aunque otras tecnicas de imagen sirven para evaluar causas secundarias. El tratamiento es reposo, analgesicos y, opcionalmente, oxigeno suplementario. Se presenta el caso de un nino en edad escolar con neumomediastino espontaneo sin ningun desencadenante identificable, siendo el primer caso pediatrico colombiano reportado de esta variante. MED.UIS.2019;32(2):47-52 EnglishIdiopathic spontaneous pneumomediastinum is the presence of air in the mediastinum, without any apparent cause, it was described in 1939 by Dr. Hamman. It is attributed to a dynamic escape of air from the alveoli through the pulmonary interstice of young people (Macklin effect). The clinical symptoms are not specific, but acute retrosternal chest pain and cough are the most indicative symptoms; the most specific signs are precordial crepitus (Hamman’s sign) and subcutaneous emphysema. The chest X-ray is enough for the diagnosis; however, other imaging techniques are used to evaluate secondary causes. The treatment is rest, analgesics and, optionally, supplemental oxygen. There is presented the case of a school-age child with spontaneous pneumomediastinum without any identifiable trigger, being the first reported Colombian pediatric case of this variant. MED.UIS.2019;32(2):47-52

Electrocardiography can provide useful prognostic information in acute pulmonary embolism (APE). Several abnormal QRS changes in lead V1, including notched or fragmented QRS, incomplete or complete right bundle branch block (IRBBB or CRBBB) and the QR sign, which are associated with APE, are of prognostic significance. To illustrate this, we describe lead V1 QRS changes in combination with the clinical state of six APE patients. The dynamic ECG changes suggest that a change from a diminution of the S wave amplitude to notched S wave, next to RBBB and then to the QR sign indicate worsening of the patients' condition, and vice versa. Also, a diminution of the S wave amplitude in lead V1 associated with a final R' wave in the right precordial accessory leads indicates the possibility of hidden RBBB. Understanding dynamic QRS changes in APE may aid in risk stratification.