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We examined the prognostic impact of eight different intraventricular conduction delays (IVCD) in the standard electrocardiogram (ECG) in a community cohort.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, P0.0001) 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).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.

unster, MGermany Background: We will focus our attention in this article in the ECG changes of classical Prinzmetal angina that occur during occlusive proximal coronary spasm usually in patients with normal or noncritical coronary stenosis. Results: The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve. The most frequent ECG changes associated with ST-segment elevation are: (a) increased height of the R wave, (b) coincident S-wave diminution, (c) upsloping TQ in many cases, and (d) alternans of the elevated ST-segment and negative T wave deepness in 20% of cases. The presence of arrhythmias is very frequent during Prinzmetal angina crises, especially ventricular arrhythmias. The prevalence and importance of ventricular arrhythmias were related to: (a) duration of episodes, (b) degree of ST-segment elevation, (c) presence of ST-T wave alternans, and (d) the presence of >25% increase of the R wave. Conclusions: The incidence of Prinzmetal angina is much lower then 50 years ago for many reasons including treatment with calcium channel blocks to treat hypertension and ischemia heart disease and the decrease of smoking habits. Ann Noninvasive Electrocardiol 2014;19(5):442-453 electrocardiography; Prinzmethal angina; coronary spasm; ST elevation

The electrocardiogram (ECG) findings in acute coronary syndrome should always be interpreted in the context of the clinical findings and symptoms of the patient, when these data are available. It is important to acknowledge the dynamic nature of ECG changes in acute coronary syndrome. The ECG pattern changes over time and may be different if recorded when the patient is symptomatic or after symptoms have resolved. Temporal changes are most striking in cases of ST-elevation myocardial infarction. With the emerging concept of acute reperfusion therapy, the concept STelevation/ non-ST elevation has replaced the traditional division into Q-wave/non-Q wave in the classification of acute coronary syndrome in the acute phase. Keypoints: In acute coronary syndrome, in addition to the traditional electrocardiographic risk markers, such as ST depression, the 12-lead ECG contains additional, important diagnostic and prognostic information. Clinical guidelines need to acknowledge certain high-risk ECG patterns to improve patient care.

Background Possible similarities or differences in the ST- and PR-segment deviations in the electrocardiogram of takotsubo cardiomyopathy (TTC) and acute pericarditis (AP) are not well defined. Methods We compared different parameters of the admission electrocardiogram in eight patients with TTC and eight patients with AP with ST-segment elevation in the acute phase. Results We found significant differences in the maximal magnitude of the T wave in the precordial leads, but not in the ST- and PR-segment deviation patterns between the two patient groups. All the patients in the two groups showed consistent ST-segment depression in lead aVR and absence of ST-segment elevation in lead V1. Conclusions The ST- and PR-segment deviation patterns in TTC are similar to that of AP, namely diffuse ST-segment elevations with reciprocal changes in aVR and V1 and PR-segment elevation in aVR accompanied by PR-segment depression in the inferior leads, possibly indicating that TTC has ECG characteristics of circumferential subepicardial ischemia in the acute phase.

In clinical practice, one occasionally encounters patients with symptoms lasting for relatively long time showing prominent positive T waves combined with minor ST elevation, or ST depression in the precordial leads. This electrocardiographic pattern has been described as Sclarovsky-Birnbaum grade 1 ischemia. We present 3 cases of patients with predominantly grade 1 ischemia, in whom the culprit site was in the left anterior descending coronary artery. The electro/pathophysiologic mechanisms of these electrocardiographic patterns are discussed.

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.We studied the predictive value of a prespecified ECG pattern in patients who underwent urgent or emergent coronary artery bypass grafting (CABG).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.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; P0.001).The global ischemia ECG pattern was strongly associated with angiographic left main coronary artery disease in patients who underwent urgent or emergent CABG.

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

Over half of those who succumb annually to coronary artery disease (CAD) in the US die a sudden cardiac death (SCD) before they are ever diagnosed or treated. The two main causes of these deaths are fatal arrhythmias borne by left ventricular systolic dysfunction (LVSD) associated with viable (hibernating) myocardium, and acute infarctions of silent ischemia. The common denominators of these diagnostic entities are that they are asymptomatic in their pre-clinical phase, and that they have the same therapeutic solution, which is revascularization in a timely manner. In this article we describe: a new ambulatory impedance apparatus, the Non-Invasive Cardiac System – Cardiac Surveyor (NICaS CS), to be used by the family doctor in the community to diagnose these cardiac conditions while still asymptomatic, at a very low cost; the first two case reports that led to the new discovery; and the diagnostic results of a series of tests performed with the NICaS CS on 518 people in a private clinic (at the cost of $50 each).

The electrocardiogram (ECG) remains the most immediately accessible and widely used diagnostic tool for guiding emergency treatment strategies. The ECG recorded during acute myocardial ischemia is of diagnostic, therapeutic, and prognostic significance. In patients with myocardial ischemia as a result of decreased blood supply, the initial 12-lead ECG typically shows (1) predominant ST-segment elevation (STE) as part of STE acute coronary syndrome (STE-ACS), or (2) no predominant STE, that is, non STE ACS (NSTE-ACS). Patients with predominant STE are classified as having either aborted myocardial infarction (MI) or ST-elevation MI (STEMI) based on the absence or presence of biomarkers of myocardial necrosis. The MI may be aborted either by spontaneous or therapeutic reperfusion of the ischemic myocardium before development of myocardial cell necrosis. NSTE-ACS patients are classified as having either unstable angina or NSTE-MI, based also on the absence or presence of biomarkers of mycardial necrosis. The information obtained from the 12-lead ECG at presentation should be complemented by repeated ECGs especially during symptoms indicative of ischemia and, if applicable, by comparing the findings with reference ECGs. Also, continuous ECG recording in a coronary care setting, including the comparison of ECGs with and without pain, adds to the information gained at patient presentation. In this article, mechanisms of ischemic ECG changes and the ECG patterns recorded in both STE-ACS and NSTE-ACS are described. ECG patterns of NSTE-ACS, which include ST depression, negative T wave, and even normal ECG, need to be better defined in future studies to correlate them with the severity and extent of ischemia and to explore to what extent they are explained by acute active ischemia or represent consequences of ischemia. One of the aims of this article is to propose a classification of the ECG patterns encountered in different clinical scenarios of ACS. How these patterns will aid in guiding the diagnostic and therapeutic process is discussed. (c) 2010 Elsevier Inc. All rights reserved.

Early repolarization (ER), considered a common and benign electrocardiographic pattern on the surface 12-lead electrocardiogram (ECG), was recently found to be prevalent among patients with idiopathic ventricular fibrillation. It is also highly predominant in physically active young males. Reports on sudden cardiac death (SCD) of children and adolescents treated with psychotropic agents have raised concerns regarding the need for cardiovascular monitoring and risk stratification schedules. The rate of ER pattern has not been estimated in children with attention deficit/hyperactivity disorder (ADHD). Thus, in the present retrospective chart review study, we estimated the rate of ER pattern, as well as RR, QT, and QTc intervals, from ECG tracings of physically healthy children with ADHD versus physically and mentally healthy controls.The ECG tracings of 50 children (aged 8.7 +/- 1.4 years; 12 girls, 44 boys) diagnosed as suffering from ADHD were compared to 55 physically and mentally healthy controls (aged 8.25 +/- 2.1 years; 20 girls, 35 boys). ER was defined as an elevation of the QRS-ST junction (J point) of at least 0.1 mV from baseline with slurring or notching of the QRS complex, and assessed separately by two senior cardiologists who were blind to all other data relating to the study participants.The rate of ER pattern was significantly higher in ADHD children compared to normal controls (32% vs. 13%, respectively, P = 0.012; relative risk [RR] = 1.68, 95% confidence interval [CI] 1.16-2.44), irrespective of stimulant treatment or gender. All other standard ECG measures (heart rate, QT and QTc intervals) were within normal range.The rate of ER in children with ADHD is significantly higher than in normal controls. Its clinical significance awaits further research.

Aims The objective of this study is to predict the culprit artery from the electrocardiogram (ECG) by predefined criteria and to compare a new algorithm with a previous one for predicting the culprit artery in inferior ST-elevation myocardial infarction (STEMI). Methods and Results In “all-comers” (n = 187) with acute STEMI, with ECG and angiography from the acute phase, the positive and negative predictive values for the prediction of the left anterior descending coronary artery, left circumflex coronary artery, or right coronary artery as the infarct-related artery were 96% and 96%, 65% and 95%, 92% and 97%, respectively. In inferior STEMI (n = 98), positive and negative predictive values to predict the right coronary artery or the left circumflex coronary artery as the culprit artery were 92% and 75% and 75% and 94%, respectively. Conclusions In “all-comers” with STEMI, the culprit artery could be predicted by ECG criteria with high predictive values. In inferior STEMI, a new algorithm for culprit artery prediction was successfully tested.

Guidelines recommend that patients with suggestive symptoms of myocardial ischemia and ST-segment elevation (STE) inor =2 adjacent electrocardiographic leads should receive immediate reperfusion therapy. Novel strategies aimed to reduce door-to-balloon time, such as prehospital wireless electrocardiographic transmission, may be dependent on the interpretation accuracy of the electrocardiogram (ECG) readers. We assessed the ability of experienced electrocardiographers to differentiate among STE, acute STE myocardial infarction (STEMI), and nonischemic STE (NISTE). A total of 116 consecutive ECGs showing STE were studied. Fifteen experienced cardiologists were asked to decide, based on the ECG and assuming that the patient had compatible symptoms, whether they would send each patient for primary percutaneous coronary intervention (PPCI). If NISTE was chosen, the reader selected 1 or more 12 possible options to explain the choice. Of 116 patients, only 8 had STEMI. The percentage of ECGs for which PPCI was recommended for the patient by the individual readers varied widely (7.8% to 33%). There was no significant difference between the North American and Other Countries readers (p = 0.13). The sensitivity and specificity of the individual readers ranged from 50% to 100% (average 75%) and 73% to 97% (average 85%), respectively. There were broad inconsistencies among the readers in the chosen reasons used to classify NISTE. In conclusion, we found wide variations among experienced electrocardiographers in reading ECGs with STE and differentiating STEMI with need for PPCI from NISTE. There is a need to revise our current electrocardiographic criteria for differentiating STEMI from NISTE.

Udgivelsesdato: 2009-Jan-24 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.

The ECG is the most frequently used tool for evaluating myocardial infarction (MI). The ECG provides an opportunity to describe location and extent of infarction expressed as pathological Q waves or their equivalents. The terminology used for the left ventricular (LV) walls has varied over time,1–7 although the most currently accepted terms by electrocardiographists have been anterior , septal , lateral , and inferior .8–15 However, terminology has been complicated by use of posterior to refer to either the basal lateral or the basal inferior wall (see below). On the basis of correlations with the postmortem anatomic gold standard reported >50 years ago16 and confirmed later,17,18 the presence of abnormal Q waves in leads V1 and V2 was related to septal wall MI; in V3 and V4 to anterior wall MI; in V5 and V6, I, and aVL to lateral wall MI (I, aVL high lateral; V5 and V6, low lateral); and in II, III, and aVF to inferior wall MI. The presence of abnormally increased R waves in V1 and V2 as a mirror image of Q waves in posterior leads was called a posterior wall infarction . Although similar considerations may be applied for ECG location of ST-segment deviation, this report focuses only on ECG localization of the QRS-complex abnormalities indicative of established MI as depicted by cardiac magnetic resonance (CMR) imaging. Although attempts to standardize the terminology applied to the LV walls have been reported,19,20 differences persist among the terms used by anatomists, pathologists, electrocardiographists, cardiac imagers, and clinicians. However, the pathologist’s view of infarcted myocardium lacks insights into the in vivo positioning of the LV walls. CMR imaging with delayed contrast enhancement (CE-CMR) has emerged as a new anatomic …

The prognosis of high-risk patients with non-ST-elevation acute coronary syndrome can be improved by invasive therapy. Taking into account the large number of patients with symptoms suggestive of acute coronary syndrome, the heterogeneity of the population and the increased risk of events shortly after the onset of symptoms, a strategy for initial evaluation and treatment is essential. The electrocardiogram (ECG) is the most accessible and widely used diagnostic tool for patients with symptoms suggestive of acute myocardial ischaemia. The ECG is almost never normal during episodes of rest angina. A specific ECG pattern, transient ST-segment depression and negative T waves maximally in leads V4-5, is associated to left main or severe triple vessel disease, and should alert the treating physician to admit the patient for immediate invasive evaluation. The ECG finding is a result of severe wide-spread subendocardial ischaemia.

Takotsubo cardiomyopathy (TTC) is characterized by acute and reversible ventricular dysfunction in the absence of significant coronary artery disease, typically triggered by acute emotional or physical stress. In the acute phase of TTC, the electrocardiogram (ECG) shows ST-segment elevation, which rapidly evolves into negative T waves and QT prolongation. However, different types of ventricular dysfunction may be associated with different patterns of ECG presentation. In this paper, we discuss the correlation between ECG presentation and cardiovascular magnetic resonance imaging in TTC.

Treatment of acute myocardial infarction has changed considerably during the last few years with the introduction of primary coronary angioplasty. In the acute phase risk stratification is largely based on simple clinical parameters, laboratory markers of myocardial injury and 12-lead electrocardiography. The electrocardiogram is of crucial importance especially during the first few hours after initiation of chest pain when important therapeutic decisions are made. Biochemical markers of myocardial injury are usually not elevated at that time point. Cases with inferior ST-elevation myocardial infarction from our hospital are presented to show how anatomical interpretation of ECG recorded during chest pain helps to risk stratify patients.

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 V 4 - 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 V 4 - 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.

Estrogen has been reported to have both short- and long-term effects on the cardiovascular system. However, it remains to be examined how short-term transdermal estrogen therapy (TET) affects insulin sensitivity (SI) in patients with cardiac syndrome X (CSX), who are characterized by elevated insulin resistance. SI was assessed in a randomized, double-blind, placebo-controlled crossover study by minimal model analysis in seven postmenopausal women with CSX treated by TET. SI decreased by 32 ± 8.3%, from 5.94 ± 1.14 at baseline to 3.61 ± 0.40 [(10–4 × min–1)/(µU/ml)] during TET (p = 0.03). Time to the onset of symptoms increased from 414.2 ± 51.0 s at baseline to 450.0 ± 53.2 s (p = 0.04). We conclude that TET increases SI in postmenopausal women with CSX. This effect is unrelated to the beneficial anti-ischemic effects on exercise duration.

BACKGROUND Patients with inferior-wall acute myocardial infarction (AMI) who have ST-segment depression in the left precordial leads (LSTD+) on the initial electrocardiogram were reported to have more diffuse coronary artery disease (CAD) than had those without this finding (LSTD-). This suggests that LSTD+ patients may need extensive revascularization interventions more often than do LSTD- patients. However, this has not yet been confirmed. OBJECTIVE To compare the coronary angiographic findings and treatment strategies for patients with inferior-wall AMI according to the LSTD pattern. METHODS The clinical outcomes and the angiographic findings for 238 consecutive patients aged < or = 75 years who had been admitted to our hospital between 1 February 1995 and 1 February 1997 with inferior-wall AMI were retrospectively analyzed. The patients were divided into two groups according to the pattern of precordial ST-segment depression: LSTD+, ST-segment depression in leads V4-V6; and LSTD-, absence of this finding. All patients were treated according to current practice guidelines including with thrombolysis and revascularization interventions. RESULTS The final study population included 217 patients; 83 were LSTD+ and 134 were LSTD-. All underwent coronary angiography within 30 days of the infarction. Compared with LSTD- patients, LSTD+ patients tended to be older (mean age 62.7 +/- 11.7 versus 58.3 +/- 9.6 years, P = 0.004), and had higher incidences of hypertension (39.8 versus 24.6%, P = 0.019) previous myocardial infarction (45.8 versus 20.1%, P = 0.0001) and congestive heart failure (21.7 versus 3.7%, P = 0.00008). Three-vessel CAD was much more common, and single-vessel CAD much less common, in the LSTD+ than in LSTD- group (62.7 versus 13.4% and 8.4 versus 50.7%, P < 0.00001 for both). Coronary-artery-bypass surgery and multivessel percutaneous coronary interventions (PCI) were used in treating 65.1% of the LSTD+ versus only 6.0% of the LSTD- patients (P < 0.00001), whereas single-vessel PCI was used in treating 71.6% of the LSTD- patients versus only 24.1% of the LSTD+ patients (P < 0.00001). Thus, the LSTD- pattern predicted single-vessel disease and single-vessel PCI only, whereas the LSTD+ pattern was predictive of multivessel CAD and of use of coronary-artery-bypass surgery or multivessel PCI (predictive values of 94.0 and 65.1%, respectively). CONCLUSIONS Among patients with inferior-wall AMI, left precordial ST-segment depression predicts a very high prevalence of multivessel CAD and use of extensive revascularization interventions. The absence of this finding predicts nondiffuse CAD and lack of a need for extensive revascularization.

Background Heart rate variability (HRV) and QT dispersion are new and promising noninvasive indices for postinfarction risk stratification. The relationship between measures in patients with acute myocardial infarction (AMI) is unknown. Methods We analyzed short-term HRV and standard electrocardiogram recordings for QT dispersion in 56 patients with first Q-wave anterior wall AMI. Results All frequency domain measures of HRV correlated inversely with the magnitude of QT dispersion. The correlations were relatively stronger for rate-corrected (−0.46 to −0.59) than for original values (−0.37 to −0.5) of QT dispersion. Similarly, the average normal cardiac cycle length (average NN) computed from HRV recordings correlated weakly and inversely with the magnitude of noncorrected QT dispersion (r =−0.29). Conclusions The inverse relationships between QT dispersion and both NN interval and HRV found in the present study suggest impaired adaptation of ventricular repolarization to changes in heart rate in AMI patients. Abnormal autonomic modulation of ventricular repolarization may thus result in increased QT dispersion. This finding may provide some insight into the mechanism underlying increased risk of sudden death after AMI. A.N.E. 1999; 4(2):152–157

We assessed the prognostic significance of negative T waves on admission in leads with ST elevation in 2,853 patients with acute myocardial infarction treated with thrombolysis. Patients were classified into 2 groups based on the presence of negative (T–) or positive (T+) T waves in the leads with ST elevation on admission. T+ and T– waves on admission were detected in 2,601 (91%) and 252 (9%) patients, respectively. T– waves were observed in 6.7 and 9.6% of patients admitted ≤2 and 2–6 h after onset of infarction, respectively. There was a difference in prognosis between patients admitted ≤2 and >2 h after symptom onset. T– patients admitted ≤2 h after onset had no hospital mortality (0/52 patients), as compared to a 5.0% mortality rate in T+ patients (36/726 patients; p = 0.19). T– patients treated >2 h after onset suffered higher mortality (20/196 patients; 10.2%) than T+ patients (100/1,836 patients; 5.4%; p = 0.01). Multivariate analysis of the data on patients treated >2 h after onset demonstrated T– waves to be associated with mortality (OR 1.86; 95% CI 1.07–3.25; p = 0.017). T– waves in leads with ST elevation upon admission are associated with adverse prognosis in patients presenting >2 h after symptom onset, whereas in patients presenting ≤2 h after first symptoms, T– waves may be associated with better prognosis.

Background QT dispersion has been proposed as a simple, noninvasive measure for identifying patients at risk of postinfarction arrhythmia. It is assumed to reflect nonuniform ventricular repolarization, which, in turn, may result from regional differences in repolarization time as well as from localized activation delay. The aim of this study was to examine the relation between QT dispersion and intraventricular conduction abnormalities in patients with acute anterior wall myocardial infarction. Methods and Results Standard 12-lead electrocardiographic and 12-lead signal-averaged electrocardiographic recordings were performed in 25 patients with a first Q-wave anterior wall myocardial infarction. Measures calculated by using the 6 precordial (V 1 through V 6 ) leads for QT dispersion were (1) difference between maximum and minimum QT and QTc intervals and (2) standard deviation of QT and QTc intervals. Measures calculated from the signal-averaged electrocardiogram were (1) maximum filtered QRS duration; (2) mean; and (3) standard deviation of filtered QRS duration. No relation was found between any measure of filtered QRS duration and that of QT dispersion by using linear correlation analysis. Similarly, no significant association was demonstrated between the filtered QRS duration and corresponding QT interval measurements (total 131 leads). Conclusions The lack of correlation between signal-averaged electrocardiogram indexes of slow intraventricular conduction and electrocardiogram variables of QT dispersion suggests an independent predictive value for the 2 methods in identifying patients at risk of postinfarction arrhythmia. This suggestion is further supported by the finding that altered activation sequence is an unlikely mechanism of QT dispersion in patients with acute myocardial infarction, as indicated by the lack of association between the filtered QRS duration and corresponding QT interval measurements. (Am Heart J 1999;137:104-8.)

Background and Aims: Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied. Methods: Oral isosorbide-5-mononitrate (ISMN) (50 mg once daily) or placebo was administered to 136 patients (NYHA Class 2–3) treated for heart failure, all receiving captopril and most also furosemide. Endpoints were treadmill exercise time at 12 weeks by modified Naughton protocol (primary), with an additional 12-week follow-up period. Secondary endpoints included left ventricular dimensions, ejection fraction, cardiothoracic ratio, functional class, quality of life, hospitalizations and plasma norepinephrine and atrial natriuretic peptide in a four-center substudy. Results: Intention-to-treat analysis showed that mean change in treadmill exercise duration tended to be greater in patients receiving ISMN than placebo (treatment difference +42 s, 95% CI –5, +90 s at 12 weeks and +21 s, 95% CI –25, +74 s after 24 weeks) (NS). Treatment difference was greater in the prespecified subgroup with ejection fraction 31–40% (+55 s, 95% CI –11, +136 s at 12 weeks and +65 s, 95% CI +3, +147 s) (p = 0.035) at 24 weeks. No deleterious effects (i.e. hypotension) were observed with ISMN, although headache was reported in 19% of the active treatment group (p = 0.0001). Conclusions: ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant.

This study assessed whether differences in the underlying mechanisms for various patterns of precordial ST-segment depression with inferior acute myocardial infarction (AMI) are associated with poorer prognoses. We studied 1,155 patients with inferior AMI who underwent thrombolysis in the Global Utilization of Streptokinase and TPA for Occluded arteries (GUSTO-I) angiographic substudy: those without precordial ST depression (n = 412; 35.7%), those with maximum ST depression in leads V1 to V3 (n = 547; 47.4%), and those with maximum ST depression in leads V4 to V6 (n = 196; 17.0%) on admission electrocardiogram. We compared the infarct-related artery, presence of left anterior descending or multivessel coronary artery disease, and left ventricular function among groups. Patients with maximum ST depression in leads V4 to V6 more often had 3-vessel disease (26.0%) than those without precordial ST depression (13.5%) or those with ST depression in leads V1 to V3 (15.7%; p = 0.002), and they had a lower ejection fraction (median 54% vs 60% and 55%, respectively; p

patients with coronary artery disease, those with chest pain and ST-segment depression during atrial pacing had an increase in the left ventricular end-diastolic pressure (LVEDP), whereas those without ischemia showed no increase. This indicates that ST-segment depression was caused by an increase in LVEDP. Extensive supply ischemia, for example, caused by sudden obstruction of the left main coronary artery, impairs the relaxatio n of the left ventr icle. 3 The resultin g increase in LVEDP induces severe subendocardial ischemia. In animals, a constriction of the left main coronary artery, causing global left ventricular ischemia, resulted in a significant decrease in the endocardial-to-epicardial flow ratio and a significant incre ase of end-diasto lic left ventricul ar trans mura l press ure. 4 Nikus et al have shown that the ECG pattern of STsegment depression and inverted T waves, maximally in leads V4 to V5, was strongly associated with left main or severe 3-vess el disea se ( Fig. 2). 5 ST-segment elevation in

Saphenous vein graft stenting without predilation may potentially decrease procedural complications such as distal embolization and no-reflow phenomenon. In this report the authors describe the deployment of stents (three Wallstents, one Palmaz-Schatz, one Multilink, and one NIR) without predilation in five patients with unstable angina pectoris due to high-grade stenosis in old saphenous vein grafts. Stent deployment was successful in all patients without procedure-related complications. Stenting without predilation appears to be feasible in old bypass grafts with significant stenosis. The potential of this new stenting technique to reduce the risk of stenting complications should be tested by a randomized trial.

BACKGROUND In patients with acute myocardial infarction, distortion of the terminal portion of the QRS complex on the electrocardiogram (ECG) at the time of their admission to hospital is associated with larger final infarct size and greater mortality. This study assessed the results of emergency coronary angioplasty in patients with anterior acute myocardial infarction with and without distortion of the terminal portion of the QRS complex on the admission ECG. METHODS We assessed the Thrombolysis in Myocardial Infarction (TIMI) trial flow grade, resolution of ischemic ECG changes, and clinical outcome after emergency angioplasty for acute anterior wall myocardial infarction in patients with (n = 21) and without (n = 21) distortion of the terminal portion of the QRS complex on the admission ECG. RESULTS Compared with patients without distortion of the terminal portion of the QRS complex on the admission ECG, those with distortion had a significantly lower incidence of TIMI flow grade 3 (52% compared with 84%, P < 0.05), lower rate of resolution of the ischemic ECG changes (33% compared with 84%, P < 0.005), and greater rate of mortality during their stay in hospital despite successful balloon angioplasty (19% compared with 0%, P < 0.05). CONCLUSIONS In patients with anterior wall acute myocardial infarction, distortion of the terminal portion of the QRS complex on the admission ECG predicts a greater mortality rate and a greater incidence of reflow impairment after emergency angioplasty.

This study assessed the ability of simple clinical and electrocardiographic variables routinely obtained on admission to identify patients who are at high risk of developing high-degree atrioventricular (AV) block during hospitalization in 1,336 patients with inferior wall acute myocardial infarction (AMI). Patients were classified into 2 initial electrocardiographic patterns based on the J-point to R-wave amplitude ratio: pattern 1: those with J point/R wave0.5 and pattern 2: patients with J point/R waveor =0.5 inor =2 leads of the inferior leads II, III, and aVF. High-degree AV block was found in 6.7% of patients (41 of 615) with pattern 1 versus 11.8% of the patients (85 of 721) with pattern 2 on admission electrocardiogram (p = 0.0008). Multivariate logistic regression analysis revealed that the only variables found to be independently associated with high-degree AV block were female gender (odds ratio [OR] 1.48; 95% confidence interval [CI] 0.98 to 2.23; p = 0.06); Killip class on admissionor =2 (OR 2.24; CI 1.43 to 3.51; p = 0.0004); initial electrocardiographic pattern 2 versus pattern 1 (OR 1.82; CI 1.22 to 2.21; p = 0.003); and absence of abnormal Q waves on admission (OR yes vs no 0.68; CI 0.44 to 1.05; p = 0.08). A simple electrocardiographic sign (J point/R waveor =0.5 inor =2 leads) is a reliable predictor of the development of advanced AV block among patients receiving thrombolytic therapy for inferior wall AMI.

Aims The aim of this study was to assess the value of the electrocardiogram in predicting the patency of the left anterior descending artery and left ventricular ejection fraction in patients with a first acute anterior wall myocardial infarction at discharge from the coronary care unit. Methods We included 116 consecutive patients with an acute anterior myocardial infarction who had undergone coronary angiography and left ventriculography before discharge from the coronary care unit (7th to 10th day). The ST segment, either elevated or isoelectric (< 1 mm), and the T wave (positive or negative) in precordial leads V2−V4 were analysed and compared to the TIMI flow from each patient. Results Out of 69 patients with negative T waves, 38 (55%) had TIMI flow 3 compared with 20 (29%) and 11 (16%) with TIMI flow 2 and 0–1, respectively; and out of 47 patients with positive T waves seven (15%) had TIMI flow 3, 17 (36%) TIMI flow 2 and 23 (49%) TIMI flow 0–1 ( p

Objectives. This study assessed prospectively the correlation between the conal branch of the right coronary artery and the pattern of ST segment elevation in leads V1and V3R during anterior wall acute myocardial infarction (AMI).Background. The traditional electrocardiographic (ECG) definition of anteroseptal AMI—ST segment elevation in leads V1to V3—has recently been challenged. The significance of ST segment elevation in lead V1during anterior wall AMI is unclear.Methods. The admission 12-lead ECG with additional lead V3R and the coronary angiograms performed within 10 days of hospital admission were evaluated in 28 consecutive patients (mean age ± SD 62 ± 9 years) admitted to the coronary care unit with anterior wall AMI. Patients were classified into two groups according to the magnitude of ST segment elevation in lead V1: group A (elevation ≥1.5 mm, n = 12) and group B (elevation

In acute myocardial ischemic syndrome the electrocardiogram is capable of providing sophisticated information on coronary artery anatomy (the culprit artery, the level of obstruction, the arterial dimension), along with the hemodynamics, molecular biological characteristics and ionic changes that occur in the involved and uninvolved ischemic musculature. In acute myocardial ischemia, during a sudden obstruction of a distal co-dominant right coronary artery the ECG may be able to discriminate between physiological and pathological remodeling, providing predictive information to differentiate low from high risk cases during acute inferior wall infarction.

Hypothesis: The presence of late potentials on the signalaveraged electrocardiogram (SAECG) identifies patients at high risk for development of ventricular tachyarrhythmias after myocardial infarction (MI). Methods: The electrocardiogram and left ventricular function in 65 patients recovering from a first acute anterior wall MI were analyzed. We compared the pattern of the ST segment (isoelectric or elevated) and of the T wave (positive or negative) with the SAECG using an orthogonal bipolar lead configuration (X, Y, Z) with bidirectional Butterworth filtering (Simson's method). Results: Abnormal SAECG was found in 17 (26%) patients; 11 of 18 patients with ST elevation had abnormal SAECG, and only 6 of 47 patients with isoelectric ST segment developed abnormal SAECG (p

Previous studies have shown an association between distortion of the terminal portion of the QRS (QRS[+] pattern: emergence of the J point ≥50% of the R wave in leads with qR configuration, or disappearance of the S wave in leads with an Rs configuration) on admission and in-hospital mortality in acute myocardial infarction (AMI). However, the mechanism for this association is not known. We assessed the relation between QRS(+) pattern and coronary angiographic findings, infarct size, and long-term prognosis in the Thrombolysis In Myocardial Infarction 4 trial. Patients were allocated into 2 groups based on the presence (QRS[+], n = 85) or absence (QRS[−], n = 293) of QRS distortion. The QRS(+) patients were older (mean ± SD: 61.1 ± 10.6 vs 57.5 ± 10.6 years, p = 0.004), had more anterior AMI (49% vs 37%, p = 0.04), and less previous angina (42% vs 54%, p = 0.05). QRS(+) patients had larger infarct size as assessed by creatine kinase release over 24 hours (209 ± 147 vs 155 ± 129, p = 0.003), and predischarge sestamibi (MIBI) defect (17.9 ± 15.9% vs 11.2 ± 13.4%, p

Objectives. This study assessed retrospectively the correlation between the pattern of precordial ST segment depression on the admission electrocardiogram (ECG) and hospital mortality in patients with an inferior myocardial infarction treated with intravenous thrombolytic therapy. Background. Previous studies have shown that in acute inferior myocardial infarction, ST segment depression in the precordial leads is associated with increased hospital mortality. However, the significance of the different patterns of precordial ST segment depression has been evaluated in only two previous studies. Methods. The study included 1,321 patients (1,020 men) who enrolled in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial in Israel and received intravenous thrombolytic therapy. Patients with an ST segment elevation ≥0.1 mV in at least two of the inferior leads were included. Patients were classified into four groups on the basis of their admission ECG: group I = patients with no precordial ST segment depression (n = 346); group II = those for whom the sum of ST segment depression in leads V1 to V3 was greater than that in leads V4 to V6 (n = 700); group III = those for whom the sum of ST depression in leads V1 to V3 was equal to that in leads V4 to V6 (n = 162); group IV = those with maximal ST depression in leads V4 to V6 (n = 113). Results. The overall hospital mortality rate was 3.6% (48 patients): for groups I, II, III and IV it was 2.9%, 2.8%, 4.3% and 9.7%, respectively. Multivariable logistic regression analysis confirmed that hospital mortality was independently associated with the pattern of precordial ST segment depression. The odd ratios in group IV relative to group I was 2.78 (95% confidence interval 1.26 to 6.13, p = 0.007). Conclusions. The risk of mortality is higher in patients with an inferior myocardial infarction and maximal ST segment depression in precordial leads V4 to V6 versus precordial leads V1 to V3 on the admission ECG.

It is well-known that many patients with coronary artery disease have reduced left ventricular diastolic distensibility with normal systolic function. However, researchers have to date focused on the diastolic rapid filling phase of the radionuclide volume curve in ischemic patients, paying less attention to the ensuing left ventricular filling associated with passive filling (‘diastasis') and atrial contraction (‘A' wave). We analyzed the radionuclide volume curves of 27 consecutive patients suspected ischemic heart disease, who manifested normal systolic function at rest and during exercise, as assessed by multigated equilibrium technetium-99m radionuclide cineangiography. For all patients, the amplitute of the maximal ‘A' deflection relative to the peak of the diastolic curve (presented as percentage units) was calculated manually from the radionuclide left ventricular volume curves obtained at rest and during exercise. Twenty patients (Group I) had transient perfusion defects on thallium scintigraphy (treadmill), and 7 (Group II) did not. Patients in Group I manifested prominent ‘A'-deflections during exercise, with a rise of 120 ± 43% (mean ± S.D.) from rest to exercise, whereas the patients in Group 11 had only 34 ± 11% (mean ± S.D.) rise in ‘A' wave amplitude during exercise ( P = 0.0001). We conclude that the appearance of a prominent ‘A' deflection in the radionuclide left ventricular volume curve during exercise might be a sensitive marker of myocardial ischemia.

OBJECTIVE: To assess serum interleukin-1 beta (IL-1 beta) concentrations in patients with ischaemic heart disease, to characterise subgroups of patients with raised IL-1 beta concentrations, and to examine whether serum IL-1 beta concentrations correlate with non-specific indices of inflammation. DESIGN: Survey study of patients with ischaemic heart disease. SETTING: Cardiac catheterisation laboratory of a tertiary medical centre. PATIENTS: Consecutive patients with angina pectoris and patients recovering from uncomplicated acute myocardial infarction and undergoing elective coronary angiography. RESULTS: Mean(SD) serum IL-1 beta concentrations were higher (P < 0.001) in patients with angina and < 50% coronary artery stenosis (n = 11; 18.8(19.9) pg/ml), patients with angina > or = 50% stenosis (n = 23; 10.2(11.4) pg/ml), and patients 8(0.8) days post-infarction (n = 13; 4.4(5.8) pg/ml) than in 15 healthy, age-matched controls (0.3(0.5) pg/ml). Serum IL-1 beta concentrations did not correlate with total blood leucocyte counts (r = -0.07, P = NS), blood lymphocyte counts (r = -0.24, P = NS), and blood monocyte counts (r = -0.29, P = NS), or with fibrinogen (r = -0.16, P = NS) and C-reactive protein concentrations (9(10.5) mg/dl v 14.1(19) mg/dl for patients with undetectable and detectable concentrations, respectively, P = NS). CONCLUSION: Serum IL-1 beta concentrations are raised in patients with ischaemic heart disease, in particular in those with minimal coronary artery disease and angina. The precise role of IL-1 beta in coronary artery disease remains to be determined.

Acute myocardial infarction with ST elevation in lead aVL may represent involvement of the first diagonal or the first obtuse marginal branch. This study assesses the correlation among different electrocardiographic patterns of acute myocardial infarction with ST elevation in aVL and the site of the infarct-related artery occlusion. Patients who underwent coronary angiography within 14 days of infarction with an unequivocal culprit lesion were included. Fifty-seven patients were evaluated. The culprit lesion was in the left anterior descending coronary artery proximal to the first diagonal, first diagonal, and first obtuse marginal branches, in 38, 8, and 11 patients, respectively. ST elevation in aVL and V2 through V5 signifies left anterior descending artery occlusion proximal to the first diagonal branch (positive predictive value [PPV] and negative predictive value [NPV] of 95% and 94%, respectively). ST elevation in aVL and V2, not accompanied by ST elevation in V3 through V5, favors occlusion of the first diagonal branch (PPV, 89%; NPV, 100%). ST elevation in aVL accompanied by ST depression in V2 predicts obstruction of the first obtuse marginal branch (PPV, 100%; NPV, 98%).

We examined whether the pattern of ST segment depression in lateral leads (I, aVL, V5, V6) in the initial electrocardiogram of patients (n = 88) with inferior wall acute myocardial infarction (ST segment elevation of > or = mm in > or = 2 inferior leads) correlates with the site of obstruction, as determined angiographically during acute hospitalization. Of the 62 patients in which the culprit artery could be determined unequivocally, in 46 the culprit artery was the right coronary artery (20 proximal to the first right ventricular branch and 26 distal), and in 16 the left circumflex coronary artery (seven proximal to the first marginal branch or involving a high first marginal branch, and nine with distal obstruction). Significant ST segment depression (ST < or = 1 mm) in leads I and aVL was more common in right coronary artery obstruction (P < 0.05 and P < 0.0001, respectively). The absence of significant ST segment depression in lead aVL was most common in proximal circumflex obstruction (P < 0.0001), with a similar trend for lead I (P < 0.11). ST segment depression patterns in leads V5 and V6 were not indicative of the infarct-related artery or the site of obstruction. Thus, significant ST segment depression in leads I and aVL indicates right coronary artery-associated inferior wall acute myocardial infarction with a sensitivity of 70% and 100%, and a specificity of 63% and 38%, respectively, whereas the lack of ST segment depression in these leads indicates proximal circumflex obstruction with a sensitivity of 71% and 86%, and a specificity of 65% and 100%, respectively.

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.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.R-R'-pattern was the most common ventricular conduction block in all age groups (3.9%, p0.001 for comparison between groups), but it showed no association with cardiovascular diseases. Males had more RBBB (1.5% vs. 0.7%, p0.001), incomplete LBBB (1.8 vs. 0.4, p0.001) and non-specific ventricular block (1.1% vs. 0.1%, p0.001). 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-values0.001) 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%).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.

We describe eight patients with a distinct electrocardiographic pattern of anterior wall myocardial infarction characterized by three main features: (1) a pattern of ‘transmural ischemia' (ST-elevation with positive T-wave) in nonconsecutive leads: aVL and V 2 , and two different types of ST-depression; (2) a pattern of ‘true reciprocal changes' (ST-depression and negative T-wave) in III and aVF; (3) a pattern of ‘sub-endocardial ischemia' (ST-depression with positive T-wave) in V 4–5 , while ST in V 3 was either isoelectric or depressed. We characterize the electrocardiographic features and correlate them with the echocardiographic, radionuclide, and angiographic data. All patients admitted to the coronary care unit from January 1990 to April 1992 with evolving acute myocardial infarction were evaluated prospectively. Patients whose admission electrocardiogram met the description above were included. The electrocardiographic evolution, echocardiographic, Technetium MIBI tomography, and coronary angiography are described. Of 471 patients with acute anterior wall myocardial infarction, admitted to the coronary care unit during the study period, eight patients met the inclusion criteria (1.7% of acute anterior wall myocardial infarction). Echocardiographyic studies revealed mid-anterior hypokinesis in two patients, anterior and apical hypokinesis in one, and no wall motion abnormality in four patients. Technetium MIBI tomography, done in five patients, was consistent with mid-anterior or mid-anterolateral infarction without involvement of the septum or apex. Coronary angiography, performed in seven patients, demonstrated significant obstruction of the first diagonal branch in all of the patients. In four patients, the diagonal occlusion was the only significant coronary lesion in the left coronary artery. Conclusion : Most of the anterior myocardial infarctions also involve the septal and apical regions. Anterior wall myocardial infarctions limited to the mid-anterior or mid-anterolateral wall, without apical or septal wall involvement are relatively rare. This study describes a special electrocardiographic form of anterior wall acute myocardial infarction. This distinct electrocardiographic pattern represents true mid-anterior wall myocardial infarction, caused by occlusion of a first diagonal branch of the left anterior descending coronary artery. The septal and apical regions are not involved because the blood supply via the left anterior descending artery is not interrupted.

This study assesses the significance of inferior ST-segment depression during anterior acute myocardial infarction (AMI) by investigating the relationship between inferior ST-segment depression and (1) the site of the left anterior descending (LAD) coronary artery lesion and (2) ST-segment deviation in the various anterior and lateral leads. We studied 126 patients with anterior AMI who underwent coronary angiography within 21 days of hospitalization. The admission 12-lead electrocardiograms were evaluated for ST-segment amplitude in each lead at 0.08 second after the J-point. Coronary angiography was evaluated for the site and severity of luminal narrowing of the coronary arteries. The site of the culprit lesion in the LAD artery, relative to the origin of the first septal and diagonal branches, was determined. In four patients no lesion was identified in the LAD artery. Of the remaining 122 patients, 40 and 53 patients had a LAD artery lesion proximal to the first septal and first diagonal branches, respectively. Additional luminal narrowing (≥70% of diameter) was found in the circumflex and the right coronary arteries in 27 and 37 patients, respectively. ST-segment depression of >1 mm in leads II, III, and aVF was noted in 24, 29, and 24 patients, respectively. The prevalence of a LAD artery preseptal and prediagonal lesion was higher in patients with inferior ST-segment depression. The positive predictive values of ST-segment depression >1 mm in leads II, III, and aVF for a lesion proximal to the first septal branch were 58.3%, 65.5%, and 75%, respectively, and those for a prediagonal lesion were 70.8%, 79.3%, and 87.5%. The corresponding specificities were 88%, 88%, and 93% for a preseptal lesion, and 90%, 91%, and 96% for a prediagonal lesion. No differences were observed between the groups with interior ST-segment depression in the distribution of single-vessel or three-vessel disease or significant right or circumflex coronary artery narrowing. Univariate linear regression models revealed that the magnitude of the ST amplitude in leads III and aVF is mainly affected by the ST amplitude in leads I and aVL (coefficient of the regression −0.75 and −0.80, R 2 = 43% and 68%, for lead III, respectively; coefficient of the regression −0.57, and −0.66, R 2 = 32% and 58%, for lead aVF, respectively). The magnitude of the ST deviation in the precordial leads has only a minor impact on the inferior ST-segment deviation. Multivariate regression models confirmed that the ST deviation in leads III and aVF is mainly influenced by the ST levels in aVL. It is concluded that ST-segment depression in the inferior leads during anterior AMI represents reciprocal changes to the high anterolateral region, shown by ST-segment elevation in leads I and aVL. ST depression in the inferior leads predicts a culprit lesion proximal to the origin of the first diagonal branch. No relationship was found between the magnitude of ST-segment depression in leads II, III, and aVF and the occurrence of right coronary or left circumflex artery narrowing or three-vessel disease.

T-lymphocyte levels may adversely affect the clinical course and outcome of patients with acute myocardial infarction (AMI). To characterize the T-lymphocyte profile during AMI and to explore whether these cells play a detrimental role in the extent of myocardial insult, levels of T-lymphocyte subpopulations, free soluble interleukin-2 receptor (sIL-2R), and interleukin-1 beta (IL-1 beta), were measured during the first week of AMI. Results were correlated with left ventricular ejection fraction (LVEF), age, sex, survival rate, thrombolytic therapy, and the occurrence of reinfarction. Thirty-nine patients, 20 men and 19 women aged 30 to 80 years, with first AMI were included. Patients were divided into two groups. Group A (13 patients) experienced reinfarction; group B (26 patients) did not. T-helper and-suppressor cells were measured by the indirect immunofluorescence method and sIL-2R and IL-1 serum levels by enzyme-linked immunosorbent assay (ELISA) methods on days 1, 4, and 7 after AMI. A low count of T-helper cells (CD4) was found on the first day after AMI in both AMI groups; however, the count returned to normal in group B but not in group A. A significant correlation (r = 0.63) was found between T-helper cell count on day 4 of AMI and LVEF assessed by radionuclide ventriculography, and between the CD4/CD8 ratio on day 1 and the creatine phosphokinase level (r = -0.6950). High sIL-2R levels were found in groups A and B of the AMI patients as compared with the control group (p < or = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Electrocardiography (ECG), introduced in 1902 by Einthoven, is the most commonly used procedure for the diagnosis of heart disease. It is a frequently performed procedure by internists and family practitioners as well as by emergency department physicians and cardiologists. As a record of electrical activity of the heart, it is a technology that provides information not readily obtained by other methods. The 12-lead ECG has numerous potential clinical uses. It serves as the criterion standard for noninvasive diagnosis of arrhythmias and conduction disturbances, and occasionally it is the only marker for the presence of heart disease. Prior studies have shown that misinterpretation of the ECG can lead to inappropriate diagnoses and clinical decisions. Telecardiology is one of the oldest applications in telemedicine, and has been largely applied during the last 10-20 years. Telecardiology encompasses a wide variety of applications and is one of the fastest-growing fields in telemedicine. Telecardiology in some fields such as emergency and chronic care undoubtedly improves the quality of health care and helps to contain rising costs. ECG consultations between general practitioners and specialists encompass a wider spectrum of clinical entities, including non-urgent patient care. An internet-based telecardiology centre for ECG consultations was established in 2008. The centre provides physicians with comprehensive ECG consultations, including description of the ECG findings, case urgency, need for further examinations, and recommendations for therapeutic strategy, like changes in medication or need for hospital admission. The service was initially provided by a separate enterprise, which in 2010 was incorporated into the Tampere University Hospital Heart Centre, a tertiary cardiologic referral centre. In this chapter, the patient material from the consultation service is presented, including age, sex, and estimated case urgency. The ECG findings are classified into clinical categories, like suspected acute coronary syndrome, and arrhythmias. Consultation response delays and technical aspects are reported, as well as recommendations provided by the cardiology experts. The potential benefit of an ECG consultation service, which provides clinical recommendations, is discussed. There are quite a few challenges with the introduction of a new consultation model. Many physicians are unaware of their limitations and believe that

The availability of potent, but potentially dangerous, types of reperfusion therapy for acute myocardial infarction (AMI) has forced us to refine our tools for early and accurate diagnosis and for early risk stratification of patients with evolving AMI. The estimation of risk has to be made shortly after admission, when only the history, physical examination, and the ECG are available. This study was undertaken to compare in-hospital mortality with different patterns of the ECG obtained at admission in 147 consecutive patients with an evolving first AMI of the anterior wall. By using a new classification of the admission ECG, it was possible to divide the patients into 3 groups: (1) group A contained 12 patients with tall peaked T waves in the involved leads, without ST segment elevation; (2) group B comprised 77 patients with abnormal T waves and ST elevation, but without major changes in the terminal portion of the QRS complex; and (3) group C comprised 58 patients with abnormal T waves, ST elevation, and distortion of the terminal portion of the QRS. The mortality was 0, 3 percent, and 29 percent in groups A, B, and C, respectively (χ 2 = 22.91; p 3=0). By using a logistic regression model, it was found that the initial ECG pattern alone is a strong predictor of in-hospital mortality in patients with an evolving anterior wall AMI. The predicted probabilities of death in groups A, B, and C are 0.0016, 0.025, and 0.29, respectively. This simple classification of the initial ECG pattern in patients with a first AMI of the anterior wall may enable the differentiation of patients with low in-hospital mortality (groups A and B) and of those with an in-hospital mortality of almost 30 percent (group C). (Chest 1993; 103:1681-87)