1
|
Na SJ, Ko RE, Chung CR, Yang JH, Oh DK, Lee SY, Park MH, Lee H, Lim CM, Suh GY. Early detection of low QRS voltage and its association with mortality in patients with sepsis. Sci Rep 2024; 14:16066. [PMID: 38992092 PMCID: PMC11239899 DOI: 10.1038/s41598-024-66612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024] Open
Abstract
Various electrocardiographic changes occur during sepsis, but data on the clinical importance of a low QRS voltage in sepsis are still limited. We aimed to evaluate the association between low QRS voltage identified early in sepsis and mortality in patients with sepsis. Between September 2019 and December 2020, all consecutive adult patients diagnosed with sepsis in the emergency room or general ward at Samsung Medical Center were enrolled. Patients without a 12-lead electrocardiogram recorded within 48 h of recognition of sepsis were excluded. In 432 eligible patients, 12-lead electrocardiogram was recorded within the median of 24 min from the first recognition of sepsis, and low QRS voltage was identified in 115 (26.6%) patients. The low QRS group showed more severe organ dysfunction and had higher levels of N-terminal pro-brain natriuretic peptide. The hospital mortality was significantly higher in the low QRS voltage group than in the normal QRS voltage group (49.6% vs. 28.1%, p < 0.001). Similarly, among the 160 patients who required intensive care unit admission, significantly more patients in the low QRS group died in the intensive care unit (35.9% vs. 18.2%, p = 0.021). Low QRS voltage was associated with increased hospital mortality in patients with sepsis.
Collapse
Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Kyu Oh
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su Yeon Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Hyeon Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Haein Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Zena LA, Ekström AT, Morgenroth D, McArley T, Axelsson M, Sundh H, Palmquist A, Johansen IB, Gräns A, Sandblom E. Beating the heart failure odds: long-term survival after myocardial ischemia in juvenile rainbow trout. Am J Physiol Regul Integr Comp Physiol 2024; 326:R484-R498. [PMID: 38406842 DOI: 10.1152/ajpregu.00005.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 02/27/2024]
Abstract
Salmonid fish include some of the most valued cultured fish species worldwide. Unlike most other fish, the hearts of salmonids, including Atlantic salmon and rainbow trout, have a well-developed coronary circulation. Consequently, their hearts' reliance on oxygenation through coronary arteries leaves them prone to coronary lesions, believed to precipitate myocardial ischemia. Here, we mimicked such coronary lesions by subjecting groups of juvenile rainbow trout to coronary ligation, assessing histomorphological myocardial changes associated with ischemia and scarring in the context of cardiac arrhythmias using electrocardiography (ECG). Notable ECG changes resembling myocardial ischemia-like ECG in humans, such as atrioventricular blocks and abnormal ventricular depolarization (prolonged and fragmented QRS complex), as well as repolarization (long QT interval) patterns, were observed during the acute phase of myocardial ischemia. A remarkable 100% survival rate was observed among juvenile trout subjected to coronary ligation after 24 wk. Recovery from coronary ligation occurred through adaptive ventricular remodeling, coupled with a fast cardiac revascularization response. These findings carry significant implications for understanding the mechanisms governing cardiac health in salmonid fish, a family particularly susceptible to cardiac diseases. Furthermore, our results provide valuable insights into comparative studies on the evolution, pathophysiology, and ontogeny of vertebrate cardiac repair and restoration.NEW & NOTEWORTHY Juvenile rainbow trout exhibit a remarkable capacity to recover from cardiac injury caused by myocardial ischemia. Recovery from cardiac damage occurs through adaptive ventricular remodeling, coupled with a rapid cardiac revascularization response. These findings carry significant implications for understanding the mechanisms governing cardiac health within salmonid fishes, which are particularly susceptible to cardiac diseases.
Collapse
Affiliation(s)
- Lucas A Zena
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Applied Animal Science and Welfare, Swedish University of Agricultural Sciences, Gothenburg, Sweden
| | - Andreas T Ekström
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Morgenroth
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Tristan McArley
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Michael Axelsson
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Sundh
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Anders Palmquist
- Department of Biomaterials, University of Gothenburg, Gothenburg, Sweden
| | - Ida B Johansen
- Department of Preclinical Sciences and Pathology, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - Albin Gräns
- Department of Applied Animal Science and Welfare, Swedish University of Agricultural Sciences, Gothenburg, Sweden
| | - Erik Sandblom
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
3
|
Martini N, Sinigiani G, De Michieli L, Mussinelli R, Perazzolo Marra M, Iliceto S, Zorzi A, Perlini S, Corrado D, Cipriani A. Electrocardiographic features and rhythm disorders in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:257-264. [PMID: 36841466 DOI: 10.1016/j.tcm.2023.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by extracellular deposition of amyloid fibrils, mainly derived from transthyretin, either wild-type or hereditary variants, or immunoglobulin light chains misfolding. It is characterized by an increased left ventricular (LV) mass and diastolic dysfunction, which can lead to heart failure with preserved ejection fraction and/or conduction disturbances. The diagnosis is based on invasive pathology demonstration of amyloid deposits, or non-invasive criteria using advanced cardiovascular imaging techniques. Nevertheless, 12-lead electrocardiogram (ECG) remains of crucial importance in the assessment of patients with CA, since they can manifest peculiar features such as low QRS voltages, in discordance with the LV hypertrophy, but also pseudo-infarction patterns, sinus node dysfunction, atrioventricular blocks, premature supraventricular and ventricular beats, which support the presence of a myocardial disease. Great awareness of these common ECG characteristics of CA is needed to increase diagnostic performance and improve patient's outcome. In the present review, we discuss the current role of the ECG in the diagnosis and management of CA, focusing on the most common ECG abnormalities and rhythm disorders.
Collapse
Affiliation(s)
- Nicolò Martini
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Giulio Sinigiani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Laura De Michieli
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Sabino Iliceto
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alessandro Zorzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Stefano Perlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy; Emergency Medicine, Vascular and Metabolic Disease Unit, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy.
| |
Collapse
|
4
|
Tso JV, Montalvo S, Christle J, Hadley D, Froelicher V. Should ECG criteria for Low QRS voltage (LQRSV) be specific for Sex? Am Heart J 2024; 270:117-124. [PMID: 38342392 DOI: 10.1016/j.ahj.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/03/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Low QRS peak-to-nadir voltage (LQRSV) is associated with arrhythmogenic right ventricular cardiomyopathy (ARVC) and other cardiomyopathies. Recent studies have proposed criteria for LQRSV when screening athletes for cardiovascular disease. These criteria have not yet been evaluated in a large population of healthy young athletes. METHODS The target population was 10,728 (42.5% female, 57.5% male, mean age 18.1 ± 4.3 years) athletes who participated in mass ECG screenings between 2014 and 2021 at multiple sites across the United States including grade schools (11%), high schools (32%), colleges (50%), and professional athletic teams (6%) with digitally recorded ECGs and a standardized protocol. Since by design, complete follow up for outcomes and the results of testing were not available. Including only ECGs from initial evaluation among athletes 14-35 years of age and excluding those with right bundle branch block, left bundle branch block, Wolf-Parkinson-White pattern, reversed leads and 3 clinically diagnosed cardiomyopathies at Stanford, 8,679 (58% males, 42% females) remained eligible for analysis. QRS voltage was analyzed for each ECG lead and LQRSV criteria were applied and stratified by sex. RESULTS QRS voltage was lower in all leads in female athletes compared to male athletes. Using traditional limb lead criteria or precordial lead criteria, the prevalence of LQRSV was significantly lower in males than females (P < .001). Strikingly, LQRSV using the Sokolow-Lyon Index was present in 1.9% of males and 9.8% of females (P < .001). Applying first percentile for LQRS amplitude criteria provided possible values for screening young athletes for LQRSV. CONCLUSIONS LQRSV is more common among female athletes than male athletes using established criteria. Using first percentile sex-specific cut points should be considered in future analyses. Proposed novel LQRSV criteria in young athletes should be specific for males and females.
Collapse
Affiliation(s)
- Jason V Tso
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Samuel Montalvo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Jeffrey Christle
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA
| | | | - Victor Froelicher
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA; Cardiac Insight Inc, Seattle, WA.
| |
Collapse
|
5
|
Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Card Electrophysiol Clin 2024; 16:35-49. [PMID: 38280813 PMCID: PMC11207195 DOI: 10.1016/j.ccep.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
Collapse
Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
6
|
Pelliccia A, Drezner JA, Zorzi A, Corrado D. Prevalence and clinical significance of low QRS voltages in healthy individuals, athletes and patients with cardiomyopathy: implications for sports preparticipation cardiovascular screening. Eur J Prev Cardiol 2024:zwae027. [PMID: 38243782 DOI: 10.1093/eurjpc/zwae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 01/21/2024]
Abstract
Low QRS voltages (LQRSV), defined as a QRS amplitude from peak to nadir <0.5 mV in all limb leads, are an emerging diagnostic finding on the electrocardiogram (ECG). In healthy individuals and athletes, LQRSV are rare (2.2-4% of elite athletes, 0.5% of recreational athletes and 0.3% of sedentary individuals). LQRSV athletes commonly show ventricular arrhythmias (VAs) on exercise, and up to 40% of those with LQRSV and VAs have late gadolinium (LGE) on cardiac magnetic resonance (CMR). The prevalence of LQRSV in arrhythmogenic cardiomyopathy (ACM) ranges 17-40%, predicts left ventricular (LV) involvement, and is correlated with more extensive LGE replacement on CMR. In hypertrophic cardiomyopathy (HCM), LQRSV ranges 0.7% to 11%. LQRSV-HCM patients have more segments with LGE, despite relatively smaller LV mass, suggesting a more advanced clinical stage and a worse prognosis. In dilated cardiomyopathy (DCM), LQRSV range 6%-7%, but may be higher (36%) in certain genetic forms of DCM. On a follow-up, LQRSV are independently associated with incident cardiac events, such as sudden death, sustained ventricular arrhythmia, or appropriate internal cardioverter defibrillator discharge. In cardiac amyloid (CA), LQRSV range from 34% to 66% and demonstrate a negative prognostic value, with worse clinical outcomes regardless of underlying biologic, genetic, and clinical variables. In conclusion, LQRSV deserve careful consideration for exclusion of arrhythmogenic substrates in healthy individuals, athletes, and patients. While additional research is needed, it is reasonable that LQRSV should trigger clinical investigation to exclude underlying diseases at risk of life-threatening arrhythmias.
Collapse
Affiliation(s)
| | - Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| |
Collapse
|
7
|
de Magalhães EFS, da Fonseca AJ, Jensen NT, Moreira AMRF, Cardoso AF. An unusual presentation of low QRS voltage in a patient with aortic aneurysm. J Electrocardiol 2024; 82:86-88. [PMID: 38081098 DOI: 10.1016/j.jelectrocard.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/18/2023] [Accepted: 11/29/2023] [Indexed: 01/17/2024]
Abstract
There are many causes of low QRS voltage on the electrocardiogram (ECG). Although uncommon, there is evidence that an enlarged aorta can cause diminished QRS amplitude on ECG. In this case report, we describe an unusual presentation of low QRS voltage confined to the first three precordial leads (V1-V3) in a 77-year-old female with ascending aortic aneurysm. Analysis of the patient's medical history, echocardiogram and contrast-enhanced computed tomography indicates that the ECG pattern was caused by interposition of the aortic aneurysm between the heart and the skin electrodes (V1-V3), revealing a possible indirect sign for large aortic aneurysm on ECG.
Collapse
Affiliation(s)
- Eduardo Faria Soares de Magalhães
- Department of Internal Medicine from Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Alfredo José da Fonseca
- Electrocardiology Service, Medical Department from Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Nicole Turin Jensen
- Department of Internal Medicine from Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | - Acácio Fernandes Cardoso
- Electrocardiology Service, Medical Department from Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| |
Collapse
|
8
|
Pelliccia A, Tatangelo M, Borrazzo C, Zampaglione D, Mango F, Fedele E, Lanzillo C, Martino A, Crescenzi C, Maestrini V, Zorzi A, Corrado D, Calò L. Low QRS voltages and left ventricular hypertrophy: a risky association. Eur J Prev Cardiol 2023; 30:1132-1138. [PMID: 36779916 DOI: 10.1093/eurjpc/zwad035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 02/14/2023]
Abstract
AIMS Low QRS voltages (LQRSV) are an unexpected finding in left ventricular hypertrophy, i.e. hypertrophic cardiomyopathy (HCM) or athlete's heart. METHODS AND RESULTS Prevalence and clinical correlates of LQRSV were investigated in 197 consecutive HCM patients, aged 58 ± 13 years and comparatively in 771 Olympic athletes, aged 23 ± 4. Clinical characterization included family/personal history, symptoms, New York Heart Association (NYHA) functional class, electrocardiographic pattern, ventricular arrhythmias, and cardiac magnetic resonance (CMR). Twenty-two (11%) of HCM and 18 (2.3%) of athletes presented LQRSV. At initial evaluation, in HCM, LQRSV showed no differences vs. non-LQRSV for functional class (90% vs. 91%, in Classes I and II; P = 0.983), symptoms (27% vs. 18%; P = 0.478), and ventricular arrhythmias (40% vs. 39%; P = 857) but showed larger extent of late gadolinium enhancement (LGE) at CMR (4.1 ± 1.5 vs. 1.5 ± 0.7 affected segments; P < 0.001). In athletes, LQRSV was associated with larger prevalence of inverted T-waves (22% vs. 9%; P < 0.001) and ventricular arrhythmias (28% vs. 8%; P = 0.005). In one LQRSV athlete, arrhythmogenic cardiomyopathy was identified. Over 4.5 ± 2.6-year follow-up, presence of LQRSV in HCM was associated with larger incidence of functional deterioration (31% vs. 14%; P = 0.038), stroke (22% vs. 6%; P = 0.008), and implantable cardioverter defibrillator (ICD) implant (27% vs. 10%; P = 0.015). No clinical events occurred in LQRSV athletes without initial evidence of cardiac disease. CONCLUSION LQRSV are relatively common (11%) in HCM and have clinical relevance, being predictive over a medium term for a worsening functional class, incidence of stroke, and ICD implant. Instead, LQRSV are rare (2.3%) in athletes but may occasionally be a marker that raises suspicion for underlying cardiac disease at risk.
Collapse
Affiliation(s)
- Antonio Pelliccia
- Department of Cardiology, Institute of Sport Medicine and Science, Largo Piero Gabrielli 1, 00197 Rome, Italy
| | - Mario Tatangelo
- Department of Cardiology, Policlinico Casilino Via Casilina 1049, 00169 Roma, Italy
| | - Cristian Borrazzo
- Department of Public Health and Infectious Disease, University Sapienza, Piazzale Aldo Moro, 5, 00185 Roma, Italy
| | - Domenico Zampaglione
- Department of Cardiology, Institute of Sport Medicine and Science, Largo Piero Gabrielli 1, 00197 Rome, Italy
| | - Federica Mango
- Department of Cardiology, Institute of Sport Medicine and Science, Largo Piero Gabrielli 1, 00197 Rome, Italy
| | - Elisa Fedele
- Department of Cardiology, Policlinico Casilino Via Casilina 1049, 00169 Roma, Italy
| | - Chiara Lanzillo
- Department of Cardiology, Policlinico Casilino Via Casilina 1049, 00169 Roma, Italy
| | - Annamaria Martino
- Department of Cardiology, Policlinico Casilino Via Casilina 1049, 00169 Roma, Italy
| | - Cinzia Crescenzi
- Department of Cardiology, Policlinico Casilino Via Casilina 1049, 00169 Roma, Italy
| | - Viviana Maestrini
- Department of Cardiology, Institute of Sport Medicine and Science, Largo Piero Gabrielli 1, 00197 Rome, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Science and Public Health, University of Padua, Via Giustiniani, 2 - 35128 Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Science and Public Health, University of Padua, Via Giustiniani, 2 - 35128 Padova, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino Via Casilina 1049, 00169 Roma, Italy
| |
Collapse
|
9
|
Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Cardiol Clin 2023; 41:35-49. [PMID: 36368810 PMCID: PMC10292923 DOI: 10.1016/j.ccl.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
Collapse
Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
10
|
Abela M, Yamagata K, Buttigieg L, Xuereb S, Bonello J, Soler JF, Camilleri W, Grech N, Xuereb R, Sapiano K, Abela E, Callus A, Farrugia M, Felice T, Burg M, Sammut M, Xuereb RG, Grech V. The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT). Int J Cardiol 2023; 371:508-515. [PMID: 36087635 DOI: 10.1016/j.ijcard.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 09/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain. AIM This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years. METHODS Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V1-V2 or extended TWI (V1-V3/4). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance. RESULTS The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months). CONCLUSION Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.
Collapse
Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta; Medical School, University of Malta, Malta; St. George's, University of London, London, United Kingdom.
| | | | - Lisa Buttigieg
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Sara Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - John Bonello
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | | | | | - Neil Grech
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Rachel Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Karl Sapiano
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Estelle Abela
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Adrian Callus
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Maria Farrugia
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Tiziana Felice
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Melanie Burg
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Mark Sammut
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Robert G Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Victor Grech
- Medical School, University of Malta, Malta; Department of Paediatrics, Mater' Dei Hospital, Tal-Qroqq, Malta
| |
Collapse
|
11
|
Metformin and Dapagliflozin Attenuate Doxorubicin-Induced Acute Cardiotoxicity in Wistar Rats: An Electrocardiographic, Biochemical, and Histopathological Approach. Cardiovasc Toxicol 2023; 23:107-119. [PMID: 36790727 PMCID: PMC9950216 DOI: 10.1007/s12012-023-09784-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
Doxorubicin is a widely used anticancer drug whose efficacy is limited due to its cardiotoxicity. There is no ideal cardioprotection available against doxorubicin-induced cardiotoxicity. This study aimed to investigate the anticipated cardioprotective potential of metformin and dapagliflozin against doxorubicin-induced acute cardiotoxicity in Wistar rats. At the beginning of the experiment, cardiac screening of experimental animals was done by recording an electrocardiogram (ECG) before allocating them into the groups. Thereafter, a total of thirty healthy adult Wistar rats (150-200 g) were randomly divided into five groups (n = 6) and treated for eight days as follows: group I (normal control), group II (doxorubicin control), group III (metformin 250 mg/kg/day), group IV (metformin 180 mg/kg/day), and group V (dapagliflozin 0.9 mg/kg/day). On the 7th day of the treatment phase, doxorubicin 20 mg/kg was administered intraperitoneal to groups II, III, IV, and V. On the 9th day (immediately after 48 h of doxorubicin administration), blood was collected from anesthetized animals for glucose, lipid profile, CK-MB & AST estimation, and ECG was recorded. Later, animals were sacrificed, and the heart was dissected for histopathological examination. We found that compared to normal control rats, CK-MB, AST, and glucose were significantly increased in doxorubicin control rats. There was a significant reversal of doxorubicin-induced hyperglycemia in the rats treated with metformin 250 mg/kg compared to doxorubicin control rats. Both metformin (180 mg/kg and 250 mg/kg) and dapagliflozin (0.9 mg/kg) significantly altered doxorubicin-induced ECG changes and reduced the levels of cardiac injury biomarkers CK-MB and AST compared to doxorubicin control rats. Metformin and dapagliflozin protected the cellular architecture of the myocardium from doxorubicin-induced myocardial injury. Current study revealed that both metformin and dapagliflozin at the FDA-recommended antidiabetic doses mitigated doxorubicin-induced acute cardiotoxicity in Wistar rats. The obtained data have opened the perspective to perform chronic studies and then to clinical studies to precisely consider metformin and dapagliflozin as potential chemoprotection in the combination of chemotherapy with doxorubicin to limit its cardiotoxicity, especially in patients with comorbid conditions like type II diabetes mellitus.
Collapse
|
12
|
Bula K, Bisaga J, Feret B, Razik M, Rozpiątkowska B, Tometczak M, Mizia-Stec K. Electro- and echocardiographic features of left ventricle hypertrophy in patients with hypertrophic cardiomyopathy. Ann Noninvasive Electrocardiol 2022; 27:e12992. [PMID: 35855565 PMCID: PMC9484024 DOI: 10.1111/anec.12992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Standard 12‐lead electrocardiogram (ECG), next to medical history and physical examination, is a basic screening tool for hypertrophic cardiomyopathy in General practice. There are many electrocardiographic criteria of left ventricular hypertrophy, but their accuracy is usually weak in patients with systemic hypertension or aortic stenosis. Sensitivity of these criteria in patients with HCM has not been well described. Aim To assess the prevalence of electrocardiographic criteria for LVH in patients with HCM and their relationship with echocardiographic parameters. Material and methods A total of 49 patients with HCM (mean age 53.2 ± 15.4 years; men/women: 31/18) were enrolled to study. Eight electrocardiographic criteria for LVH were evaluated and correlated with echocardiographic parameters. Results The ECG features of LVH were found in 36 (73.5%) subjects. These patients had increased thickness of intraventricular septum (20.5 ± 4.7 vs. 17.3 ± 3.2 mm, p = .03), LVM (340.5 ± 104.8 vs. 264.0 ± 61.5 g; p = .02), and LVMI (178.9 ± 48.8 vs. 125.9 ± 22.5; p = .002). All of ECG criteria for LVH had low sensitivity (14.3%–40.8%) for LVH diagnosis confirmed by echocardiography. The most common positive criterion was Cornell Voltage (20 patients; 40.8%). A total of 41 (83.4%) patients had T‐wave inversion in limb and/or precordial leads. LVMI correlated positively with R‐wave amplitude in aVL (R = 0.34; p = .03), Gubner‐Ungerleider voltage (R = 0.4; p = .009), and Cornell Voltage (R = 0.31; p = .04). Conclusion ECG criteria for LVH are characterized by poor sensitivity in patients with HCM. Cornell Voltage and criteria based on limb leads correlate positively with LVMI.
Collapse
Affiliation(s)
- Karolina Bula
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| | - Joanna Bisaga
- Students' Scientific Club of First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| | - Bartłomiej Feret
- Students' Scientific Club of First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| | - Michał Razik
- Students' Scientific Club of First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| | - Barbara Rozpiątkowska
- Students' Scientific Club of First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| | - Mateusz Tometczak
- Students' Scientific Club of First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| | - Katarzyna Mizia-Stec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper Silesian Medical Centre, Katowice, Poland
| |
Collapse
|
13
|
Kellett J, Bogh SB, Ekelund U, Brabrand M. Can the ECG be used to estimate age-related survival? QJM 2022; 115:298-303. [PMID: 33970281 DOI: 10.1093/qjmed/hcab134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/19/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are few reports of the relationship between electrocardiogram (ECG) findings and the age-related survival of acutely ill patients. AIM This study compared the 1-year survival curves of patients attending two Danish emergency departments (EDs) with normal and abnormal ECGs. Patients were divided into age groups from 20 to 90 years of age, and an abnormal ECG was defined as low QRS voltage (i.e. lead I + II <1.4 mV) or QTc interval prolongation >434 ms. METHODS A retrospective register-based observational study on 35 496 patients attending two Danish EDs, with 100% follow-up for 1 year. RESULTS ECG abnormality increases linearly with age, and between 30 and 70 years of age. Patients aged 20-29 years with ECG abnormalities are more than four times more likely to die within a year than patients of the same age with a normal ECG. An individual with an abnormal ECG has the same risk of dying within a year as an individual with a normal ECG who is 10 years older. After 70 years of age this tight relationship ends, but for younger individuals with an abnormal ECG the increase in mortality is even higher. CONCLUSION An ECG may be a simple practical estimate of age-related survival. For a patient under 70 years, an abnormal QRS voltage or a prolonged QTc interval may increase 1-year mortality to that of a patient ∼10 years older.
Collapse
Affiliation(s)
- J Kellett
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S B Bogh
- Odense Patient Data Explorative Network, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - U Ekelund
- Department of Emergency and Internal Medicine, Skåne University Hospital at Lund, Lund, Sweden
| | - M Brabrand
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| |
Collapse
|
14
|
Aufiero S, Bleijendaal H, Robyns T, Vandenberk B, Krijger C, Bezzina C, Zwinderman AH, Wilde AAM, Pinto YM. A deep learning approach identifies new ECG features in congenital long QT syndrome. BMC Med 2022; 20:162. [PMID: 35501785 PMCID: PMC9063181 DOI: 10.1186/s12916-022-02350-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/24/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Congenital long QT syndrome (LQTS) is a rare heart disease caused by various underlying mutations. Most general cardiologists do not routinely see patients with congenital LQTS and may not always recognize the accompanying ECG features. In addition, a proportion of disease carriers do not display obvious abnormalities on their ECG. Combined, this can cause underdiagnosing of this potentially life-threatening disease. METHODS This study presents 1D convolutional neural network models trained to identify genotype positive LQTS patients from electrocardiogram as input. The deep learning (DL) models were trained with a large 10-s 12-lead ECGs dataset provided by Amsterdam UMC and externally validated with a dataset provided by University Hospital Leuven. The Amsterdam dataset included ECGs from 10000 controls, 172 LQTS1, 214 LQTS2, and 72 LQTS3 patients. The Leuven dataset included ECGs from 2200 controls, 32 LQTS1, and 80 LQTS2 patients. The performance of the DL models was compared with conventional QTc measurement and with that of an international expert in congenital LQTS (A.A.M.W). Lastly, an explainable artificial intelligence (AI) technique was used to better understand the prediction models. RESULTS Overall, the best performing DL models, across 5-fold cross-validation, achieved on average a sensitivity of 84 ± 2%, 90 ± 2% and 87 ± 6%, specificity of 96 ± 2%, 95 ± 1%, and 92 ± 4%, and AUC of 0.90 ± 0.01, 0.92 ± 0.02, and 0.89 ± 0.03, for LQTS 1, 2, and 3 respectively. The DL models were also shown to perform better than conventional QTc measurements in detecting LQTS patients. Furthermore, the performances held up when the DL models were validated on a novel external cohort and outperformed the expert cardiologist in terms of specificity, while in terms of sensitivity, the DL models and the expert cardiologist in LQTS performed the same. Finally, the explainable AI technique identified the onset of the QRS complex as the most informative region to classify LQTS from non-LQTS patients, a feature previously not associated with this disease. CONCLUSIONS This study suggests that DL models can potentially be used to aid cardiologists in diagnosing LQTS. Furthermore, explainable DL models can be used to possibly identify new features for LQTS on the ECG, thus increasing our understanding of this syndrome.
Collapse
Affiliation(s)
- Simona Aufiero
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands. .,Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Hidde Bleijendaal
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tomas Robyns
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bert Vandenberk
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christian Krijger
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Connie Bezzina
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Yigal M Pinto
- Department of Experimental Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Abrams JL, Fermi D, Belligund P, McFarlane SI. Amiodarone-Induced Hypothyroidism Related to Pericardial Effusion With Tamponade Physiology. Cureus 2022; 14:e22932. [PMID: 35399422 PMCID: PMC8986330 DOI: 10.7759/cureus.22932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/05/2022] Open
|
16
|
Chen L, Doodnauth AV, Guo US, Patel KH, Qu YS, Mitre CA. The Abnormal Sinus Rhythm: Myxedema Coma Complicated by Subacute Cardiac Tamponade. Cureus 2021; 13:e19535. [PMID: 34934554 PMCID: PMC8668145 DOI: 10.7759/cureus.19535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/13/2021] [Indexed: 11/05/2022] Open
Abstract
Subacute cardiac tamponade (SCT) is a potentially life-threatening condition that requires immediate medical attention. Combining careful history taking, focused physical exam, and the use of point of care ultrasound (POCUS) for early diagnosis with aggressive management can minimize potential complications. In patients with severe hypothyroidism and myxedema coma, clinical signs of cardiac tamponade may be masked and lead to delayed diagnosis. We present a case of a 67-year-old female with SCT secondary to myxedema coma, necessitating emergent pericardiocentesis following the identification of a large pericardial effusion with tamponade physiology. This case highlights the importance of thorough history taking with focused diagnostic workup, including POCUS in patients with an insidious presentation of SCT.
Collapse
Affiliation(s)
- Lu Chen
- Cardiology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Andrew V Doodnauth
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Uta S Guo
- Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Krunal H Patel
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Yongxia S Qu
- Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Cristina A Mitre
- Cardiology, Veterans Affairs New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, USA
| |
Collapse
|
17
|
Low QRS Voltage in Limb Leads Indicates Accompanying Precordial Voltage Attenuation Resulting in Underestimation of Left Ventricular Hypertrophy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182412867. [PMID: 34948477 PMCID: PMC8700898 DOI: 10.3390/ijerph182412867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 12/01/2022]
Abstract
Low QRS voltage (LQRSV) in electrocardiography (ECG) often occurs in limb leads without apparent cause. However, its clinical significance is obscure in healthy populations. We reviewed patients aged over 60 who were scheduled for non-cardiac surgery in two hospitals. Patients underwent pre-operative ECG, echocardiography, pulmonary function test, and chest X-ray. Patients with LQRSV isolated to limb leads and patients without LQRSV were selected from separate hospitals. Among the 9832 patients screened in one hospital, 292 (3.0%) showed LQRSV in limb leads. One-hundred and ninety-four without LQRSV were selected as the control from the 216 patients screened at the other hospital. For primary analysis, patients with structural heart disease or classic etiologies of LQRSV were excluded. Patients with LQRSV had a higher proportion of male and a greater body mass index. Precordial QRS voltages were smaller, whereas left ventricular mass index and the prevalence of echocardiographic left ventricular hypertrophy (LVH) was higher in patients with LQRSV than in those without. Consequentially, diagnostic performance of precordial voltage criteria for LVH was particularly poor in patients with LQRSV in limb leads. LQRSV in limb leads frequently occurs without apparent etiologies. ECG voltage criteria may underestimate LVH in a relatively healthy population with LQRSV in limb leads.
Collapse
|
18
|
Beukema JC, de Groot C, Plukker JTM, Vliegenthart R, Langendijk JA, van Luijk P, van Melle JP, Prakken NHJ, Muijs CT. Late cardiac toxicity of neo-adjuvant chemoradiation in esophageal cancer survivors: A prospective cross-sectional pilot study. Radiother Oncol 2021; 167:72-77. [PMID: 34864136 DOI: 10.1016/j.radonc.2021.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Although cure rates in esophageal cancer (EC) have improved since the introduction of neoadjuvant chemoradiation (nCRT), evidence for treatment-related cardiac toxicity is growing, of which the exact mechanisms remain unknown. The primary objective of this study was to identify (subclinical) cardiac dysfunction in EC patients after nCRT followed by surgical resection as compared to surgery alone. MATERIALS AND METHODS EC survivors followed for 5-15 years after curative resection with (n = 20) or without (n = 20) nCRT were enrolled in this prospective cross-sectional pilot study. All patients underwent several clinical and diagnostic tests in order to objectify (sub)clinical cardiac toxicity including cardiac CT and MRI, echocardiography, ECG, 6-minutes walking test, physical examination and EORTC questionnaires. RESULTS We found an increased rate of myocardial fibrosis (Linear late gadolinium enhancement (LGE) 4 vs. 1; p = 0.13; mean extracellular volume (ECV) 28.4 vs. 24.0; p < 0.01), atrial fibrillation (AF) (6 vs. 2; p = 0.07) and conduction changes in ECG among patients treated with nCRT as compared to those treated with surgery alone. The results suggested an impact on quality of life in terms of worse role functioning for this patient group (95.0 vs. 88.8; p = 0.03). CONCLUSION Based on our analyses we hypothesize that in EC patients, radiation-induced myocardial fibrosis plays a central role in cardiac toxicity leading to AF, conduction changes and ultimately to decreased role functioning. The results emphasize the need to verify these findings in larger cohorts of patients.
Collapse
Affiliation(s)
- Jannet C Beukema
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
| | - Crystal de Groot
- Department of Radiation Oncology, Isala Hospital, Zwolle, The Netherlands
| | - John T M Plukker
- Department of Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Niek H J Prakken
- Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| |
Collapse
|
19
|
Prognostic Value of Electrocardiographic QRS Diminution in Patients Hospitalized With COVID-19 or Influenza. Am J Cardiol 2021; 159:129-137. [PMID: 34579830 PMCID: PMC8349698 DOI: 10.1016/j.amjcard.2021.07.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 01/06/2023]
Abstract
During the clinical care of hospitalized patients with COVID-19, diminished QRS amplitude on the surface electrocardiogram (ECG) was observed to precede clinical decompensation, culminating in death. This prompted investigation into the prognostic utility and specificity of low QRS complex amplitude (LoQRS) in COVID-19. We retrospectively analyzed consecutive adults admitted to a telemetry service with SARS-CoV-2 (n = 140) or influenza (n = 281) infection with a final disposition-death or discharge. LoQRS was defined as a composite of QRS amplitude <5 mm or <10 mm in the limb or precordial leads, respectively, or a ≥50% decrease in QRS amplitude on follow-up ECG during hospitalization. LoQRS was more prevalent in patients with COVID-19 than influenza (24.3% vs 11.7%, p = 0.001), and in patients who died than survived with either COVID-19 (48.1% vs 10.2%, p <0.001) or influenza (38.9% vs 9.9%, p <0.001). LoQRS was independently associated with mortality in patients with COVID-19 when adjusted for baseline clinical variables (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.9 to 33.8, p <0.001), presenting and peak troponin, D-dimer, C-reactive protein, albumin, intubation, and vasopressor requirement (OR 13.8, 95% CI 1.3 to 145.5, p = 0.029). The median time to death in COVID-19 from the first ECG with LoQRS was 52 hours (interquartile range 18 to 130). Dynamic QRS amplitude diminution is a strong independent predictor of death over not only the course of COVID-19 infection, but also influenza infection. In conclusion, this finding may serve as a pragmatic prognostication tool reflecting evolving clinical changes during hospitalization, over a potentially actionable time interval for clinical reassessment.
Collapse
|
20
|
Chen CC, Kuo KT, Chang SC, Liu SH. Pseudomyocardial Infarction: An Atypical Presentation of Chest Wall Necrotizing Fasciitis. Int J Infect Dis 2021; 114:192-194. [PMID: 34774780 DOI: 10.1016/j.ijid.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Chun-Chao Chen
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuang-Tai Kuo
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Division of Thoracic Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shun-Cheng Chang
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shuen-Hsin Liu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
21
|
Seko Y, Kato T, Yamaji Y, Haruna Y, Nakane E, Haruna T, Inoko M. Discrepancy between left ventricular hypertrophy by echocardiography and electrocardiographic hypertrophy: clinical characteristics and outcomes. Open Heart 2021; 8:openhrt-2021-001765. [PMID: 34556560 PMCID: PMC8461736 DOI: 10.1136/openhrt-2021-001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/07/2021] [Indexed: 11/06/2022] Open
Abstract
Background The clinical significance of the discrepancy between left ventricular hypertrophy (LVH) by echocardiography and ECG remains to be elucidated. Methods After excluding patients who presented with pacemaker placement, QRS duration ≥120 ms and cardiomyopathy and moderate to severe valvular disease, we retrospectively analysed 3212 patients who had undergone both scheduled transthoracic echocardiography (echo) and ECG in a hospital-based population. Cornell product >2440 mm · ms was defined as ECG-based LVH; left ventricular mass index >115 g/m2 for men and >95 g/m2 for women was defined as echo-based LVH. The study population was categorised into four groups: patients with both ECG-based and echo-based LVH (N=131, 4.1%), those with only echo-based LVH (N=156, 4.9%), those with only ECG-based LVH (N=409, 12.7%) and those with no LVH (N=2516, 78.3%). Results The cumulative 3-year incidences of a composite of all-cause death and major adverse cardiovascular events were 32.0%, 33.8%, 19.2% and 15.7%, respectively. After adjusting for confounders, the HRs relative to that in no LVH were 1.63 (95% CI 1.16 to 2.28), 1.68 (95% CI 1.23 to 2.30) and 1.09 (95% CI 0.85 to 1.41) in patients with both ECG-based and echo-based LVH, those with only echo-based LVH, and those with only ECG-based LVH, respectively. Conclusions Echo-based LVH without ECG-based LVH was associated with a significant risk of adverse clinical events, and the risk was comparable to that in patients with both echo-based and ECG-based LVH.
Collapse
Affiliation(s)
- Yuta Seko
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuhei Yamaji
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yoshisumi Haruna
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Eisaku Nakane
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tetsuya Haruna
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| |
Collapse
|
22
|
Low and Slow. Ann Emerg Med 2021; 77:601-603. [PMID: 34030775 DOI: 10.1016/j.annemergmed.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Indexed: 11/22/2022]
|
23
|
Electrocardiographic Patterns in Patients with Neurally Mediated Syncope. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57080808. [PMID: 34441014 PMCID: PMC8399501 DOI: 10.3390/medicina57080808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022]
Abstract
The baseline electrocardiogram (ECG) is less informative in neurally mediated syncope (NMS) than in arrhythmic syncope. However, some of the ECG patterns present in NMS can have diagnostic and prognostic value in such patients. Electrocardiographic documentation of a syncopal spell and thus identification of the ECG changes can be performed during tilt table test (TTT) or during prolonged ECG monitoring. This work reviews the specific ECG patterns in NMS, which are primarily related to the cardioinhibitory reflex. In addition, there are other ECG findings present in patients with NMS that are being analyzed, such as increased heart rate variability as well as specific QRS voltage patterns. In addition to the diagnostic and prognostic value, these ECG patterns in NMS may help improving the selection of patients for pacemaker implant.
Collapse
|
24
|
Lampert J, Miller M, Halperin JL, Oates C, Giustino G, Feinman J, Miller MA, Dukkipati SR, Goldman ME, Reddy VY. Prognostic Value of Electrocardiographic QRS Diminution in Patients With COVID-19. J Am Coll Cardiol 2021; 77:2258-2259. [PMID: 33926663 PMCID: PMC8074875 DOI: 10.1016/j.jacc.2021.02.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 12/02/2022]
|
25
|
Ahmed AZ, Satyam SM, Shetty P, D'Souza MR. Methyl Gallate Attenuates Doxorubicin-Induced Cardiotoxicity in Rats by Suppressing Oxidative Stress. SCIENTIFICA 2021; 2021:6694340. [PMID: 33510932 PMCID: PMC7822703 DOI: 10.1155/2021/6694340] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 12/24/2020] [Indexed: 05/05/2023]
Abstract
Doxorubicin-induced cardiotoxicity is the leading cause of morbidity and mortality among cancer survivors. The present study was aimed to investigate the cardioprotective potential of methyl gallate; an active polyphenolic nutraceutical, against doxorubicin-induced cardiotoxicity in Wistar rats. Twenty-four female Wistar rats (150-200 g) were divided into four groups (n = 6) which consist of normal control (group I), doxorubicin control (group II), test-A (group III), and test-B (group IV). Group III and group IV animals were prophylactically treated with methyl gallate 150 mg/kg/day and 300 mg/kg/day orally, respectively, for seven days. Doxorubicin (25 mg/kg; single dose) was administered through an intraperitoneal route to group II, III, and IV animals on the seventh day to induce acute cardiotoxicity. On the 8th day, besides ECG analysis, serum CK, CK-MB, LDH, AST, MDA, and GSH were assayed. Following gross examination of isolated hearts, histopathological evaluation was performed by light microscopy. A significant (p < 0.05) cardiac injury, as well as oxidative stress, was observed in doxorubicin control rats in comparison to normal control rats. Methyl gallate at both the doses significantly (p < 0.05) reduced doxorubicin-induced ECG changes, dyslipidaemia, and elevation of CK, CK-MB, LDH, AST, MDA and increased GSH level. Methyl gallate reversed the doxorubicin-induced histopathological changes in the heart. The present study revealed that methyl gallate exerts cardioprotection against doxorubicin-induced cardiotoxicity in female Wistar rats by suppressing oxidative stress. Our study opens the perspective to clinical studies for consideration of methyl gallate as a potential chemoprotectant nutraceutical in the combination chemotherapy with doxorubicin to limit its cardiotoxicity.
Collapse
Affiliation(s)
- Akheruz Zaman Ahmed
- Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| | - Shakta Mani Satyam
- Department of Pharmacology, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| | - Prakashchandra Shetty
- Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| | - Melanie Rose D'Souza
- Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| |
Collapse
|
26
|
Rett E, Manka R, Brunckhorst CB. [CME-ECG 70: Chest Pain in a Young Patient - Differential Diagnoses beyond the Acute Coronary Syndrome]. PRAXIS 2021; 110:947-954. [PMID: 34875858 DOI: 10.1024/1661-8157/a003795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
CME-ECG 70: Chest Pain in a Young Patient - Differential Diagnoses beyond the Acute Coronary Syndrome Abstract. Older patients with chest pain and typical ECG changes are most likely to be diagnosed with cardiovascular diseases. However, younger patients with similar symptoms may reveal different disease patterns. In this case report, differential diagnoses and diagnostic steps, with particular attention to the ECG, will be discussed.
Collapse
Affiliation(s)
- Eva Rett
- Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Zürich
| | - Robert Manka
- Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Zürich
| | - Corinna B Brunckhorst
- Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Zürich
| |
Collapse
|
27
|
Green MA, Miles L, Sage E, Smith J, Carlson G, Hogan K, Bogucki J, Ferenzi L, Hartman E, Tao Y, Peng Y, Roche AI, Bolenbaugh MA, Wienkes C, Garrison Y, Eilers S. Cardiac biomarkers of disordered eating as a function of diagnostic subtypes. Eat Behav 2020; 39:101425. [PMID: 32916550 PMCID: PMC7704766 DOI: 10.1016/j.eatbeh.2020.101425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 08/13/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to identify cardiac biomarkers of disordered eating as a function of diagnostic subtype as assessed via self-report inventory. METHOD Mean heart rate (HR), systolic and diastolic blood pressure, mean R wave amplitude (mV), mean T wave amplitude (mV), QTc interval (sec), Tpeak-Tend interval prolongation (sec), QTc interval prolongation (sec), QRS prolongation (sec), and spectral indicators of cardiac dysfunction (LF/HF spectral ratio, HF spectral power) were assessed via electrocardiography among women with no eating disorder symptoms (n = 32), subclinical eating disorder symptoms (n = 92), anorexia nervosa (n = 7), bulimia nervosa (n = 89), binge eating disorder (BED: n = 20), and other specified feeding and eating disorders (OSFED: n = 19). RESULTS MANOVA results showed statistically significant group differences. Follow-up tests revealed significantly decreased mean R wave amplitude among participants with self-indicated clinical (bulimia nervosa, binge eating disorder) and subclinical forms of disordered eating compared to asymptomatic controls. DISCUSSION Results suggest decreased mean R wave amplitude is a promising cardiac biomarker of disordered eating.
Collapse
Affiliation(s)
- M. A. Green
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - L. Miles
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - E. Sage
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - J. Smith
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - G. Carlson
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - K. Hogan
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - J. Bogucki
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - L. Ferenzi
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - E. Hartman
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - Y. Tao
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - Y. Peng
- Cornell College Eating Disorder Institute, Cornell College, 600 First Street SW, Mt. Vernon, IA 52314
| | - A. I. Roche
- University of Iowa, Department of Psychological and Brain Sciences, W311 Seashore Hall, Iowa City, IA 52242
| | - M. A. Bolenbaugh
- University of Iowa, Department of Psychological & Quantitative Foundations, 240 South Madison Street, Iowa City, Iowa 52240
| | - C. Wienkes
- University of Iowa, Department of Psychological & Quantitative Foundations, 240 South Madison Street, Iowa City, Iowa 52240
| | - Y. Garrison
- University of Iowa, Department of Psychological & Quantitative Foundations, 240 South Madison Street, Iowa City, Iowa 52240
| | - S. Eilers
- Mercy Medical Center, 1340 Blairs Ferry Rd NE, Hiawatha, IA 52233
| |
Collapse
|
28
|
Xiang KR, Soliman EZ, Bhave PD, Singleton MJ. Prognostic value of Goldberger's electrocardiographic criteria for left ventricular dysfunction. J Electrocardiol 2020; 64:18-22. [PMID: 33278775 DOI: 10.1016/j.jelectrocard.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ability of the Goldberger electrocardiographic (ECG) triad criteria to detect left ventricular dysfunction (LVD) is well-established. However, the prognostic significance of this triad as a predictor of poor outcomes is not known. OBJECTIVE We explored the association between the Goldberger ECG-LVD triad with all-cause mortality and cardiovascular mortality in the general population. METHODS This analysis included 8426 participants (60.5 ± 13.6 years, 51.5% women, 50% non-Hispanic white) from the Third National Health and Nutrition Examination Survey. The Goldberger ECG-LVD triad was defined as follows: high precordial QRS voltage (SV1 or SV2 + RV5 or RV6 ≥ 3500 μV); low limb lead QRS voltage (mean QRS amplitude in each of the limb leads ≤800 μV); and poor R wave progression (RV4/SV4 < 1). Mortality was ascertained using the National Death Index. RESULTS At baseline, 1384 (47.3%) of the participants had at least one of the criteria of Goldberger triad (1193 had only one and 191 participants had 2 or more). During a median follow up of 13.8 years, 3184 deaths occurred, of which 1405 were cardiovascular. In multivariable-adjusted Cox proportional hazards models, presence of at least one of the Goldberger triad criteria (vs. none) was associated with increased risk of all-cause (HR 1.17, 95% CI 1.08-1.26, p ≤0.0001) and cardiovascular mortality (1.19, 1.06-1.33, p = 0.003). CONCLUSION The Goldberger ECG-LVD triad for left ventricular dysfunction may offer prognostic value in addition to its reported diagnostic utility.
Collapse
Affiliation(s)
- Kang Rui Xiang
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America.
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston-Salem, NC, United States of America; Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America.
| | - Prashant D Bhave
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America.
| | - Matthew J Singleton
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America.
| |
Collapse
|
29
|
Pugliese M, La Maestra R, Passantino A, Cristarella S, De Majo M, Biondi V, Quartuccio M. Electrocardiographic Findings in Bitches Affected by Closed Cervix Pyometra. Vet Sci 2020; 7:vetsci7040183. [PMID: 33233788 PMCID: PMC7711823 DOI: 10.3390/vetsci7040183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/07/2020] [Accepted: 11/18/2020] [Indexed: 11/16/2022] Open
Abstract
Pyometra is considered the most common disease in intact bitches, being associated with potentially life-threatening disorders. Myocardial damage is a potentially life-threatening consequence of pyometra. The aim of this study was to describe the electrocardiographic patterns in bitches affected by closed cervix pyometra, to assess the clinical relevance of electrocardiographic changes with the occurrence of pyometra, and to relate their severity with laboratory and clinical findings. A total of 39 bitches with closed cervix pyometra and 10 healthy female dogs were included in this study. During the hospitalization, bitches underwent a complete physical examination. An electrocardiographic examination before the ovariohysterectomy was performed. Blood samples for biochemical and hematological analysis were also evaluated. Bitches suffering pyometra at least one arrhythmia 31/39 (79.4%), sinus tachycardia (22/39, 56.4%), ventricular premature complexes (9/39, 23%), increased amplitude of T wave (7/39, 17.9%), ST depression (4/39, 10.2%), second-degree atrioventricular block (2/39, 5.1%), increase of QT interval (2/39, 5.1%), sinus bradycardia (2/39, 5.1%), and first-degree atrioventricular block (1/39, 2.5%). Some bitches were also detected with low wave amplitude (17/39, 43.5%). Cardiac arrhythmias associated with canine pyometra are frequent events. These data suggest that arrhythmias may be the consequence of one or more factors that can occur during pyometra, such as myocardial damage, electrolyte/metabolic disorders, and/or sepsis.
Collapse
|
30
|
Absence of electrocardiographic left ventricular hypertrophy in patients undergoing Transcatheter aortic valve replacement is associated with increased mortality. J Electrocardiol 2020; 63:12-16. [DOI: 10.1016/j.jelectrocard.2020.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 01/15/2023]
|
31
|
Bogh SB, Kellett J, Ekelund U, Brabrand M. Relation of QRS Voltage and Prolonged QTc Interval to One-Year Mortality. Am J Cardiol 2020; 134:138-142. [PMID: 32892990 DOI: 10.1016/j.amjcard.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/26/2022]
Abstract
The association between QRS voltage and QTc interval prolongation with mortality for up to 1 year after recording an ECG on patients attending emergency departments (EDs) was examined in a retrospective register-based observational study on 37,473 patients attending 2 Danish EDs. Of 37,473 patients who had an ECG performed on their first ED presentation 2,164 (5.8%) died within 30 days of presentation and 6,395 (17.1%) died within a year. Compared with survivors, patients who died had significantly longer QRS intervals and lower QRS voltages. A combined lead I and II QRS voltage <=1.4 mV was consistently associated with approximately twice the risk of mortality for up to at least 1 year after the ECG recording and this risk was not influenced by the length of the QTc interval. The increased mortality risk of a low QRS voltage remained even after adjustment for age, gender, Charlson co-morbidity index, and abnormal sodium and urea levels. In conclusion, low QRS voltage is a simple measurement that could potentially be used as an objective prognostic marker.
Collapse
Affiliation(s)
- Søren Bie Bogh
- Odense Patient data Explorative Network, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.
| | - Ulf Ekelund
- Department of Emergency and Internal Medicine, Skåne University Hospital at Lund, Lund, Sweden
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| |
Collapse
|
32
|
Valentini F, Anselmi F, Metra M, Cavigli L, Giacomin E, Focardi M, Cameli M, Mondillo S, D'Ascenzi F. Diagnostic and prognostic value of low QRS voltages in cardiomyopathies: old but gold. Eur J Prev Cardiol 2020; 29:1177-1187. [PMID: 33624098 DOI: 10.1093/eurjpc/zwaa027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/13/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
The interpretation of 12-lead resting electrocardiogram (ECG) in patients with a definitive diagnosis or with the suspicion of a cardiomyopathy represents a cornerstone for the diagnostic work up and management of patients. Although low electrocardiographic QRS voltages (LQRSV) detected by 12-lead resting ECG have historically been acknowledged by physicians, in view of recent evidence on the demonstration of myocardial scar by cardiac magnetic resonance and its relevance as a cause of sudden cardiac death even in young individuals, a new interest has been raised about the utility of LQRSV in the clinical practice. Beyond their diagnostic value, LQRSV have also demonstrated a prognostic role in different cardiomyopathies. The present review summarizes the diagnostic and prognostic value of LQRSV in cardiomyopathies, reporting the new evidence, primarily based on advanced imaging studies, supporting the clinical utility of this parameter.
Collapse
Affiliation(s)
- Francesca Valentini
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Elisa Giacomin
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| |
Collapse
|
33
|
Slivnick JA, Wallner AL, Vallakati A, Truong VT, Mazur W, Elamin MB, Tong MS, Raman SV, Zareba KM. Indexed left ventricular mass to QRS voltage ratio is associated with heart failure hospitalizations in patients with cardiac amyloidosis. Int J Cardiovasc Imaging 2020; 37:1043-1051. [PMID: 33068247 PMCID: PMC7969486 DOI: 10.1007/s10554-020-02059-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/05/2020] [Indexed: 12/14/2022]
Abstract
In cardiac amyloidosis (CA), amyloid infiltration results in increased left ventricular (LV) mass disproportionate to electrocardiographic (EKG) voltage. We assessed the relationship between LV mass-voltage ratio with subsequent heart failure hospitalization (HHF) and mortality in CA. Patients with confirmed CA and comprehensive cardiovascular magnetic resonance (CMR) and EKG exams were included. CMR-derived LV mass was indexed to body surface area. EKG voltage was assessed using Sokolow, Cornell, and Limb-voltage criteria. The optimal LV mass-voltage ratio for predicting outcomes was determined using receiver operating characteristic curve analysis. The relationship between LV mass-voltage ratio and HHF was assessed using Cox proportional hazards analysis adjusting for significant covariates. A total of 85 patients (mean 69 ± 11 years, 22% female) were included, 42 with transthyretin and 43 with light chain CA. At a median of 3.4-year follow-up, 49% of patients experienced HHF and 60% had died. In unadjusted analysis, Cornell LV mass-voltage ratio was significantly associated with HHF (HR, 1.05; 95% CI 1.02-1.09, p = 0.001) and mortality (HR, 1.05; 95% CI 1.02-1.07, p = 0.001). Using ROC curve analysis, the optimal cutoff value for Cornell LV mass-voltage ratio to predict HHF was 6.7 gm/m2/mV. After adjusting for age, NYHA class, BNP, ECV, and LVEF, a Cornell LV mass-voltage ratio > 6.7 gm/m2/mV was significantly associated with HHF (HR 2.25, 95% CI 1.09-4.61; p = 0.03) but not mortality. Indexed LV mass-voltage ratio is associated with subsequent HHF and may be a useful prognostic marker in cardiac amyloidosis.
Collapse
Affiliation(s)
- Jeremy A Slivnick
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Alexander L Wallner
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Ajay Vallakati
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Vien T Truong
- Division of Cardiology, The Christ Hospital Health Network, Cincinnati, OH, USA
| | - Wojciech Mazur
- Division of Cardiology, The Christ Hospital Health Network, Cincinnati, OH, USA
| | - Mohamed B Elamin
- Division of Cardiovascular Medicine, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Matthew S Tong
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Subha V Raman
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Karolina M Zareba
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA.
| |
Collapse
|
34
|
Carré F, Schnell F. ECG in the athlete, QRS voltage value never matters, really? Eur J Prev Cardiol 2020; 27:1539-1541. [DOI: 10.1177/2047487320920045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- François Carré
- Univ Rennes 1, CHU Rennes, Inserm, LTSI - UMR 1099, France
| | | |
Collapse
|
35
|
Monzo L, Martino A, Lanzillo C, Bencivenga S, Acitelli A, Fedele E, Salustri E, Bona RD, Maresca L, Silvetti E, Canestrelli S, Minati M, Penco M, Calò L. Electrocardiographic voltage criteria in patients with hypertrophic cardiomyopathy. J Cardiovasc Med (Hagerstown) 2020; 21:696-703. [PMID: 32639329 DOI: 10.2459/jcm.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Several ECG voltage criteria have been proposed for the diagnosis of left ventricular hypertrophy (LVH). Notably, ECG criteria have been historically validated in concentric LVH but not in hypertrophic cardiomyopathy (HCM), wherein the hypertrophy pattern is typically asymmetric. OBJECTIVES The aim of our study was to evaluate the performance of ECG voltage criteria for LVH diagnosis in the HCM population. MATERIAL AND METHODS The electrocardiograms of 92 HCM patients and 41 sex- and age-matched controls were evaluated with the most frequently used ECG voltage criteria for LVH diagnosis. Cardiac magnetic resonance (MRI) was performed in HCM and controls in order to quantify LVH and its distribution. RESULTS In the HCM population, the maximal diagnostic accuracy was achieved by Amplitude total and Amplitude total product criteria (58% for both), while the Cornell Voltage best performed in septal HCM (62%), the Sokolov in aVL and Gubner criteria in apical HCM (79% for both) and the Cornell Voltage and Product in anterior HCM (86% for both). All the ECG voltage criteria showed a poor correlation with left ventricular mass and maximal thickness measured by cardiac MRI. CONCLUSIONS In our study, only a few ECG voltage criteria used for the detection of LVH in clinical practice showed an acceptable performance in the HCM population. Further studies are needed to clarify the role of ECG for LVH detection in HCM patients.
Collapse
Affiliation(s)
- Luca Monzo
- Department of Cardiology, Policlinico Casilino.,Department of Clinical, Anaesthetic and Cardiovascular Sciences, 'Sapienza' University, Rome
| | | | | | - Sabrina Bencivenga
- Department of Cardiology, Policlinico Casilino.,Department of Cardiology, University of L'Aquila, L'Aquila
| | - Angelo Acitelli
- Department of Cardiology, Policlinico Casilino.,Department of Cardiology, University of L'Aquila, L'Aquila
| | | | | | | | | | | | | | | | - Maria Penco
- Department of Cardiology, University of L'Aquila, L'Aquila
| | | |
Collapse
|
36
|
Mango F, Caselli S, Luchetti A, Pelliccia A. Low QRS voltages in Olympic athletes: Prevalence and clinical correlates. Eur J Prev Cardiol 2020; 27:1542-1548. [PMID: 32228059 DOI: 10.1177/2047487320914758] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recently, novel interest in low QRS voltages was prompted by the observation that low QRS voltages are present in arrhythmogenic cardiomyopathy patients, even before occurrence of symptoms/events. AIM The purpose of this study was to assess prevalence and clinical correlates of low QRS voltages in Olympic athletes, evaluated and followed-up within our cardiovascular screening programme. METHODS Five hundred and sixteen athletes consecutively examined (2010-2011) were included in this study. A low QRS voltage was defined as amplitude of QRS <0.5 mV in limb and/or <1.0 mV in precordial leads. Cardiovascular evaluation included 12-lead and exercise electrocardiogram, echocardiography and, selectively, additional tests to confirm diagnosis. Athletes were followed-up for 5 ± 2 (1-9) years. RESULTS The majority of athletes (493; 96%) showed normal/increased R/S-wave voltages, but 23 (4%) had low QRS voltages. No differences were observed in low QRS voltage athletes compared to normal/increased QRS voltages for QRS duration, QTc and PR intervals, left ventricular cavity size and mass, or gender and sport participated. However, premature ventricular beats, occurred more frequently in low QRS voltages (39% vs 7%; p < 0.001), with patterns suggesting origin from left or right free wall. No diseases or events were registered in low QRS voltage athletes over the follow-up. CONCLUSIONS In Olympic athletes, the prevalence of low QRS voltages was 4%. Athletes with low QRS voltages did not differ from other athletes according to sport participated in or cardiac dimensions. However, more frequently (39% vs 7%) they showed premature ventricular beats, originating from either the left or right free ventricular wall. Therefore, long-term follow-up with serial clinical evaluations is needed in low QRS voltage athletes, in order to definitely clarify the clinical significance.
Collapse
Affiliation(s)
| | - Stefano Caselli
- Institute of Sport Medicine and Science, Italy.,Cardiovascular Center Zurich, Switzerland
| | | | | |
Collapse
|
37
|
Toma L, Stanciu AM, Zgura A, Bacalbasa N, Diaconu C, Iliescu L. Electrocardiographic Changes in Liver Cirrhosis-Clues for Cirrhotic Cardiomyopathy. ACTA ACUST UNITED AC 2020; 56:medicina56020068. [PMID: 32050594 PMCID: PMC7073951 DOI: 10.3390/medicina56020068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.
Collapse
Affiliation(s)
- Letitia Toma
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Adriana Mercan Stanciu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
| | - Anca Zgura
- Chemotherapy Department, OncoFort Hospital, 022328 Bucharest, Romania;
| | - Nicolae Bacalbasa
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Camelia Diaconu
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 022328 Bucharest, Romania;
| | - Laura Iliescu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Correspondence: ; Tel.: +407-22-235-695
| |
Collapse
|
38
|
Blendea D, McPherson CA, Pop S, Anton FP, Crisan S, Ruskin JN. Isolated very low QRS voltage predicts response to tilt-table testing in patients with neurally mediated syncope. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1558-1565. [PMID: 31589336 DOI: 10.1111/pace.13815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 09/06/2019] [Accepted: 10/04/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND A number of patients with neurally mediated syncope (NMS) have isolated QRS complexes of very low voltage (≤0.3 mV) in the frontal plane leads on the 12-lead electrocardiogram (ECG). HYPOTHESIS The aim of this study was to assess the importance of QRS voltage in predicting response to tilt-table testing (TTT) in patients with suspected NMS. METHODS We included 216 patients (age: 49 ± 20 years, 103 men) with suspected NMS who had either a positive or negative response to TTT (n = 91 TTT+, and n = 125 TTT-). The QRS voltage was measured in mV on 12-lead ECGs performed within 3 days of the TTT. The lowest QRS voltage (QRSmin), as well as the voltage in each of the 12 leads was also determined. RESULTS Very low voltage (QRSmin ≤ 0.3 mV) in the frontal leads was significantly more prevalent in the TTT+ group than in the TTT- group (74 vs 22%, respectively; P < .001). Patients in the TTT+ group had significantly lower QRSmin when compared to patients in the TTT- group. QRSmin predicted a positive tilt-table test in a multivariate model that also included patient gender, height, history of presyncope, QRS duration, and left ventricular end-diastolic diameter indexed to height. ROC analysis showed that QRSmin of ≥0.3 mV discriminated between TTT+ and TTT- patients with a sensitivity of 78% and specificity of 68%. CONCLUSION Isolated very low QRS voltage in the frontal leads predicts a positive response to TTT in patients with suspected NMS.
Collapse
Affiliation(s)
- Dan Blendea
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu,", Cluj-Napoca, Romania
| | - Craig A McPherson
- Bridgeport Hospital, Yale University School of Medicine, Bridgeport, Connecticut
| | - Sorin Pop
- Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu,", Cluj-Napoca, Romania
| | - Florin P Anton
- Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu,", Cluj-Napoca, Romania
| | - Sorin Crisan
- Municipal Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu,", Cluj-Napoca, Romania
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
39
|
Hamed GM, Morsy WE, Hamid MSAE, Hassan AAEM, Zahra FAA. Effect of Bone Marrow-Derived Mesenchymal Stem Cells on Ischaemic-Reperfused Hearts in Adult Rats with Established Chronic Kidney Disease. Int J Stem Cells 2019; 12:304-314. [PMID: 31022998 PMCID: PMC6657945 DOI: 10.15283/ijsc18114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 12/29/2022] Open
Abstract
Background and Objectives Bone marrow-derived mesenchymal stem cells (BM-MSCs) are adult multipotent non-haematopoietic stem cells that have regeneration potential. The current study aimed to detect the ability of BM-MSCs to improve kidney and cardiac functions in adult rats with established chronic kidney disease. Methods Rats were divided into sham-operated control, untreated sub totally nephrectomised and treated sub totally nephrectomised groups. Body weight, kidney and cardiac tissue weights, plasma creatinine and urea levels and arterial blood pressure were measured. ECG was recorded, and an in vitro isolated heart study was performed. Results Stem cell treatment decreased the elevated plasma creatinine and urea levels and decreased systolic, diastolic and mean arterial blood pressure values. These changes were accompanied by a decrease in glomerular hypertrophy with apparent normal renal parenchyma. Additionally, BM-MSCs shortened Q-To and Q-Tc intervals, all time to peak tension values, the half relaxation value at 30 min of reperfusion and the contraction time at 15 and 30 min of reperfusion. Moreover, stem cell treatment significantly increased the heart rate, QRS voltage, the peak tension at the 15- and 30-min reperfusion time points and the peak tension per left ventricle at the 30-min reperfusion time point compared to the pre-ischaemia baseline. BM-MSCs resolve inter muscular oedema and lead to the re-appearance of normal cardiomyocytes. This improvement occurs with the observations of BM-MSCs in renal and heart tissues. Conclusions BM-MSCs can attenuate chronic kidney disease progression and the associated cardiac electrophysiological and inotropic dysfunction.
Collapse
Affiliation(s)
- Gehane M Hamed
- Department of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wessam E Morsy
- Department of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Manal S Abd-El Hamid
- Department of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Fatma A Abu Zahra
- Department of Biochemistry, Medical Research Center, Ain Shams University, Cairo, Egypt
| |
Collapse
|
40
|
Blendea D, McPherson CA, Pop S, Ruskin JN. Isolated very low QRS voltage in the frontal leads predicts recurrence of neurally mediated syncope. Heart Rhythm 2019; 16:1862-1869. [PMID: 31201963 DOI: 10.1016/j.hrthm.2019.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Indexed: 10/26/2022]
Abstract
BACKGROUND The study was prompted by our observation that some patients with neurally mediated syncope (NMS) have an isolated QRS complex, of very low voltage (≤0.3 mV cutoff), in 1 of the frontal leads on the 12-lead electrocardiogram. OBJECTIVE To prospectively evaluate whether the presence of isolated very low voltage (VLV) predicts recurrence of NMS. METHODS We included 205 patients (aged 50 ± 17 years) with a median of 3 syncopal episodes. Tilt testing was performed in all patients and was positive in 87 (42%). The patients were followed for a median of 14 months. RESULTS VLV in frontal leads was present in 92 patients (45%). During the follow-up period 60 patients experienced recurrence of syncope. The actuarial total syncope recurrence rate at 1 year was 32% (95% confidence interval [CI 23%-44%) in patients with isolated VLV in frontal plane leads, and 14% (95% CI 8%-24%) in patients without VLV (log-rank test P < .0001). The significant relationship between the presence of isolated VLV in the frontal leads and syncope recurrence was retained in Cox multivariate analysis that included the history of presyncope and syncope as well as the left ventricular end-diastolic diameter. The presence of isolated VLV in frontal leads was associated with a 3-fold increase of the risk of recurrent syncope. CONCLUSIONS Isolated very low QRS voltage in the frontal leads predicts recurrence of NMS independent of clinical factors that predict recurrence of syncope in such patients. This phenomenon may help generate new diagnostic tools and insights into the pathogenesis of NMS.
Collapse
Affiliation(s)
- Dan Blendea
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
| | - Craig A McPherson
- Bridgeport Hospital, Yale University School of Medicine, Bridgeport, Connecticut
| | - Sorin Pop
- Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
41
|
Santilli RA, Porteiro Vázquez DM, Gerou-Ferriani M, Lombardo SF, Perego M. Development and assessment of a novel precordial lead system for accurate detection of right atrial and ventricular depolarization in dogs with various thoracic conformations. Am J Vet Res 2019; 80:358-368. [PMID: 30919674 DOI: 10.2460/ajvr.80.4.358] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess recording accuracy of right atrial and ventricular depolarization during 12-lead ECG when precordial lead V1 was positioned at each of 5 locations on the thorax of dogs with various thoracic conformations. ANIMALS 60 healthy client-owned dogs. PROCEDURES 20 dogs were allocated to each of 3 groups (brachymorphic, mesomorphic, or dolichomorphic) on the basis of thoracic conformation. Each dog remained unsedated and was positioned in right lateral recumbency for a series of five 12-lead surface ECGs, with V1 located adjacent to the sternum in the fifth intercostal space (ICS; control), at the costochondral junction (CCJ) of the right first ICS (1st-R), at the CCJ of the right third ICS, at the right third ICS where the thorax was the widest, and at the CCJ of the left first ICS. Electrocardiographic variables were compared among the 5 ECG tracings. RESULTS When V1 was at the control location, the P wave was positive for all dogs; however, consistent recording of right atrial and ventricular depolarization (ie, R wave-to-S wave ratio [R/S] < 1) occurred more frequently for brachymorphic dogs (16/20) than for dolichomorphic (7/20) and mesomorphic (6/20) dogs. When V1 was at the 1st-R location, the P wave was negative for most dogs, and R/S was < 1 for the majority of dogs in the brachymorphic (19/20), mesomorphic (17/20), and dolichomorphic (16/20) groups. The median R/S for V1 at the 1st-R location was significantly lower than that for the other 4 V1 locations. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that placement of V1 at the 1st-R location provided correct evaluation of right atrial and ventricular depolarization in most dogs regardless of thoracic conformation.
Collapse
|
42
|
Cardiac biomarkers of disordered eating: A case for decreased mean R wave amplitude. Psychiatry Res 2019; 272:555-561. [PMID: 30616123 DOI: 10.1016/j.psychres.2018.12.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/03/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
Abstract
The purpose of this study was to identify cardiac biomarkers of disordered eating. Mean R wave amplitude (mV), mean T wave amplitude (mV), QRS interval (sec), QTc interval (sec), and Tpeak-Tend interval (sec) were assessed via electrocardiography among women with clinical (n = 53) and subclinical (n = 56) eating disorder symptoms versus asymptomatic controls (n = 32). QRS and QTc intervals were significantly longer and mean T and R wave amplitudes significantly lower among women with clinical symptoms compared to asymptomatic controls. QTc interval length was significantly longer and mean R wave amplitude was significantly lower among women with subclinical symptoms versus asymptomatic controls. Decreased mean R wave amplitude yielded a comparable effect size as QTc when differentiating between asymptomatic and subclinical groups and a larger effect size than QTc when differentiating between asymptomatic and clinical groups, representing a promising clinical biomarker.
Collapse
|
43
|
Kampaktsis PN, Ullal AV, Swaminathan RV, Minutello RM, Kim L, Bergman GS, Feldman DN, Singh H, Wong SC, Okin PM. Absence of electrocardiographic left ventricular hypertrophy is associated with increased mortality after transcatheter aortic valve replacement. Clin Cardiol 2018; 41:1246-1251. [PMID: 30062778 DOI: 10.1002/clc.23034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/27/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Electrocardiographic (ECG) left ventricular hypertrophy (LVH) has been associated with increased mortality in patients with asymptomatic aortic stenosis (AS) and hypertension. However, patients with symptomatic AS undergoing transcatheter aortic valve replacement (TAVR) have higher percentages of myocardial fibrosis or amyloidosis that have been associated with decreased ECG voltage and worse outcomes. HYPOTHESIS We tested the hypothesis that baseline ECG LVH is independently associated with increased all-cause mortality after TAVR. METHODS A total of 231 patients (96 men; mean age 84.7 ± 7.8 years) that underwent TAVR at our institution were included. Cornell voltage, defined as SV3 + RaVL, was used to assess for presence of ECG LVH using gender-specific cut-off values. We used the Kaplan-Meier estimator to derive survival curves. Multivariate Cox regression analysis was used to compare mortality between patients without vs with ECG LVH and adjust for echocardiographic LVH and predictors of mortality in this cohort. RESULTS Over a follow-up time of 16.3 ± 10.4 months, the absence of ECG LVH was significantly associated with increased mortality (40.4% vs 23.6% at 2-years, log rank P = 0.003). After adjusting for echocardiographic LVH and predictors of mortality in our cohort, the absence of ECG LVH remained a predictor of increased mortality (HR = 1.79, CI 95% 1.02-3.14, P = 0.042). CONCLUSIONS The absence of ECG LVH was independently associated with increased mortality in patients undergoing TAVR. Baseline ECG may have an important prognostic role in these patients and could lead to further testing to evaluate for myocardial fibrosis or amyloidosis.
Collapse
Affiliation(s)
| | - Ajayram V Ullal
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
| | | | - Robert M Minutello
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Luke Kim
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Geoffrey S Bergman
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Dmitriy N Feldman
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Harsimran Singh
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Shing Chiu Wong
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Peter M Okin
- Greenberg Division of Cardiology, Weill Cornell Medical College, New York, New York
| |
Collapse
|
44
|
Kellett J, Opio MO. QRS voltage is a predictor of in-hospital mortality of acutely ill medical patients. Clin Cardiol 2018; 41:1069-1074. [PMID: 30022511 DOI: 10.1002/clc.23030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/02/2018] [Accepted: 07/16/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Low QRS voltage has been shown to be associated with increased mortality in the general population and in a small pilot study the combined QRS voltage of ECG leads I and II was found to be associated with in-hospital mortality. HYPOTHESIS Confirm that low QRS voltage predicts the in-hospital mortality of acutely ill patients, and compare QRS voltage with other predictors of mortality that can be easily, quickly and cheaply obtained at the bedside. METHODS Prospective observational study of vital signs, QRS voltage and simple tools used to assess mental, functional and nutritional status at the bedside in unselected acutely ill patients admitted to a resource-poor hospital in sub-Saharan Africa. RESULTS Out of 1486 patients, 77 died (5.2%) in hospital. A combined lead I + II voltage <1.8 mV was present in 789 (53.1%) of patients, and significantly associated with in-hospital mortality (odds ratio 3.6, 95% CI 2.0-6.5, χ2 21.2, P < 0.00001). On logistic regression impaired mobility, the National Early Warning Score, male gender and lead I + II voltage were the only independent predictors of mortality. None of the 445 patients who were mobile on admission with a lead I + II voltage ≥ 1.8 mV died in hospital. CONCLUSIONS Low QRS voltage, male gender, NEWS, and impaired mobility were independent predictors of in-hospital mortality in the study population. These four variables, which are easily obtained at the bedside, could potentially provide a rapid, easy, and cheap risk stratification system.
Collapse
Affiliation(s)
- John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | | | | |
Collapse
|
45
|
Kim DH, Verdino RJ. Electrocardiogram voltage discordance: Interpretation of low QRS voltage only in the precordial leads. J Electrocardiol 2017; 50:551-554. [PMID: 28495230 DOI: 10.1016/j.jelectrocard.2017.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To define clinical correlates of low voltage isolated to precordial leads on the surface electrocardiogram (ECG). INTRODUCTION Low voltage (V) on the ECG is defined as QRS V<5mm in all limb leads and <10mm in all precordial leads. The diagnostic use of ECGs with low voltage isolated to the precordial leads with normal limb lead voltages is unclear. METHODS Twelve-lead ECGs with QRS V>5mm in one or more limb leads and <10mm in all precordial leads were collected. Associated clinical conditions were determined from clinical data, echocardiograms, and chest radiographs. RESULTS Low precordial voltage was found in 256 of 150,000 ECGs (~0.2%). 50.4% of patients had discordant ECGs that correlated with classic etiologies, with a higher incidence of LV dilation in those with classic etiologies than those without. CONCLUSION Low precordial voltage is associated with classic etiologies and LV dilation.
Collapse
Affiliation(s)
- Diana H Kim
- Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA, USA.
| | - Ralph J Verdino
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, USA
| |
Collapse
|
46
|
García-Delgado M, Navarrete-Sánchez I. Respuesta de los autores. Med Intensiva 2017; 41:261. [DOI: 10.1016/j.medin.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 12/06/2016] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
|
47
|
Electrocardiographic findings in hepatic cirrhosis and their association with the severity of disease. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
48
|
Opio MO, Kellett J. The association between a simple measure of QRS voltage and the in-hospital mortality of acutely ill medical patients. Eur J Intern Med 2017; 39:e9. [PMID: 28279566 DOI: 10.1016/j.ejim.2017.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 03/01/2017] [Accepted: 03/02/2017] [Indexed: 11/22/2022]
Affiliation(s)
| | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.
| |
Collapse
|
49
|
Maanja M, Wieslander B, Schlegel TT, Bacharova L, Abu Daya H, Fridman Y, Wong TC, Schelbert EB, Ugander M. Diffuse Myocardial Fibrosis Reduces Electrocardiographic Voltage Measures of Left Ventricular Hypertrophy Independent of Left Ventricular Mass. J Am Heart Assoc 2017; 6:JAHA.116.003795. [PMID: 28111363 PMCID: PMC5523623 DOI: 10.1161/jaha.116.003795] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Myocardial fibrosis quantified by myocardial extracellular volume fraction (ECV) and left ventricular mass (LVM) index (LVMI) measured by cardiovascular magnetic resonance might represent independent and opposing contributors to ECG voltage measures of left ventricular hypertrophy (LVH). Diffuse myocardial fibrosis can occur in LVH and interfere with ECG voltage measures. This phenomenon could explain the decreased sensitivity of LVH detectable by ECG, a fundamental diagnostic tool in cardiology. Methods and Results We identified 77 patients (median age, 53 [interquartile range, 26–60] years; 49% female) referred for contrast‐enhanced cardiovascular magnetic resonance with ECV measures and 12‐lead ECG. Exclusion criteria included clinical confounders that might influence ECG measures of LVH. We evaluated ECG voltage‐based LVH measures, including Sokolow‐Lyon index, Cornell voltage, 12‐lead voltage, and the vectorcardiogram spatial QRS voltage, with respect to LVMI and ECV. ECV and LVMI were not correlated (R2=0.02; P=0.25). For all voltage‐related parameters, higher LVMI resulted in greater voltage (r=0.33–0.49; P<0.05 for all), whereas increased ECV resulted in lower voltage (r=−0.32 to −0.57; P<0.05 for all). When accounting for body fat, LV end‐diastolic volume, and mass‐to‐volume ratio, both LVMI (β=0.58, P=0.03) and ECV (β=−0.46, P<0.001) were independent predictors of QRS voltage (multivariate adjusted R2=0.39; P<0.001). Conclusions Myocardial mass and diffuse myocardial fibrosis have independent and opposing effects upon ECG voltage measures of LVH. Diffuse myocardial fibrosis quantified by ECV can obscure the ECG manifestations of increased LVM. This provides mechanistic insight, which can explain the limited sensitivity of the ECG for detecting increased LVM.
Collapse
Affiliation(s)
- Maren Maanja
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Björn Wieslander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Todd T Schlegel
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Nicollier-Schlegel SARL, Trélex, Switzerland
| | - Ljuba Bacharova
- International Laser Center, Bratislava, Slovak Republic.,Institute of Pathophysiology, Medical School, Comenius University, Bratislava, Slovak Republic
| | - Hussein Abu Daya
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yaron Fridman
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy C Wong
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
50
|
Petersen SS, Pedersen LR, Pareek M, Nielsen ML, Diederichsen SZ, Leósdóttir M, Nilsson PM, Diederichsen ACP, Olsen MH. Factors associated with diagnostic discrepancy for left ventricular hypertrophy between electrocardiography and echocardiography. Blood Press 2016; 26:54-63. [DOI: 10.1080/08037051.2016.1235959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Søren Sandager Petersen
- Cardiovascular and Metabolic Preventive Clinic, Department of Endocrinology, Cardiovascular and Metabolic Preventive Clinic, Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| | - Line Reinholdt Pedersen
- Cardiovascular and Metabolic Preventive Clinic, Department of Endocrinology, Cardiovascular and Metabolic Preventive Clinic, Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| | - Manan Pareek
- Cardiovascular and Metabolic Preventive Clinic, Department of Endocrinology, Cardiovascular and Metabolic Preventive Clinic, Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| | - Mette Lundgren Nielsen
- Cardiovascular and Metabolic Preventive Clinic, Department of Endocrinology, Cardiovascular and Metabolic Preventive Clinic, Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| | - Søren Zöga Diederichsen
- Cardiovascular and Metabolic Preventive Clinic, Department of Endocrinology, Cardiovascular and Metabolic Preventive Clinic, Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| | | | - Peter M. Nilsson
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Michael Hecht Olsen
- Cardiovascular and Metabolic Preventive Clinic, Department of Endocrinology, Cardiovascular and Metabolic Preventive Clinic, Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, Odense, Denmark
| |
Collapse
|