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Umair Javaid M, Ikrama M, Abbas S, Saad Javaid M, Danial Khalid M, Riaz N, Ahsan Safdar M. Exploring Roemheld syndrome: a comprehensive review with proposed diagnostic criteria. Herz 2024:10.1007/s00059-024-05249-y. [PMID: 38714552 DOI: 10.1007/s00059-024-05249-y] [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: 10/07/2023] [Revised: 01/31/2024] [Accepted: 04/03/2024] [Indexed: 05/10/2024]
Abstract
Roemheld syndrome (RS) is a condition that triggers cardiac symptoms due to gastrointestinal compression of the heart. It is often misdiagnosed as other types of cardiac or digestive disorders, leading to unnecessary treatments and reduced quality of life. Here, we provide a thorough review of RS, covering its pathogenesis, etiology, diagnosis, treatment, and outcome. We found that a number of conditions, including gallstones, hiatal hernia, excessive gas, and gastroesophageal reflux syndrome, can cause RS. The symptoms of RS can include chest pain, palpitations, shortness of breath, nausea, vomiting, bloating, and abdominal pain. Clinical history, physical examination, electrocardiograms, and improvement in symptoms following gastrointestinal therapy can all be used to identify RS. We also propose a set of criteria, the IKMAIR criteria, to improve the diagnostic approach for this condition. Dietary changes, lifestyle adjustments, pharmaceutical therapies, and surgical procedures can all be used to control RS. Depending on the underlying etiology and the outcome of treatment, RS has a varying prognosis. We conclude that RS is a complicated and understudied disorder that needs more attention from researchers and patients as well as from medical professionals. We recommend the inclusion of RS in the differential diagnosis for individuals with gastrointestinal problems and unexplained cardiac symptoms. Additionally, we advise treating RS holistically by attending to its cardiac and gastrointestinal components.
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Affiliation(s)
| | | | - Shafqat Abbas
- Services Institute of Medical Sciences, Lahore, Pakistan
| | | | | | - Nabeel Riaz
- Services Institute of Medical Sciences, Lahore, Pakistan
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Zhu J, Li M, Liu R. Myocardial ischemia simulation based on a multi-scale heart electrophysiology model. Technol Health Care 2024; 32:27-38. [PMID: 38759037 PMCID: PMC11191480 DOI: 10.3233/thc-248003] [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] [Indexed: 05/19/2024]
Abstract
BACKGROUND Myocardial ischemia, caused by insufficient myocardial blood supply, is a leading cause of human death worldwide. Therefore, it is crucial to prioritize the prevention and treatment of this condition. Mathematical modeling is a powerful technique for studying heart diseases. OBJECTIVE The aim of this study was to discuss the quantitative relationship between extracellular potassium concentration and the degree of myocardial ischemia directly related to it. METHODS A human cardiac electrophysiological multiscale model was developed to calculate action potentials of all cells simultaneously, enhancing efficiency over traditional reaction-diffusion models. RESULTS Contrary to the commonly held view that myocardial ischemia is caused by an increase in extracellular potassium concentration, our simulation results indicate that level 1 ischemia is associated with a decrease in extracellular potassium concentration. CONCLUSION This unusual finding provides a new perspective on the mechanisms underlying myocardial ischemia and has the potential to lead to the development of new diagnostic and treatment strategies.
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Affiliation(s)
- Junjiang Zhu
- School of Mechanical and Electrical Engineering, China Jiliang University, Hangzhou, Zhejiang, China
| | - Mengyang Li
- School of Mechanical and Electrical Engineering, China Jiliang University, Hangzhou, Zhejiang, China
| | - Renjie Liu
- School of Mechanical and Electrical Engineering, China Jiliang University, Hangzhou, Zhejiang, China
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Yang N, Han X, Zhang J, Zhang S, Sun J. What can we find in QRS in patients with ST-segment-elevation myocardial infarction? J Electrocardiol 2022. [DOI: 10.1016/j.jelectrocard.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Birnbaum Y, Rankinen J, Jneid H, Atar D, Nikus K. The Role of ECG in the Diagnosis and Risk Stratification of Acute Coronary Syndromes: an Old but Indispensable Tool. Curr Cardiol Rep 2022; 24:109-118. [PMID: 35028816 DOI: 10.1007/s11886-021-01628-7] [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] [Accepted: 10/14/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Since its inception in 1902 by Willem Einthoven, the electrocardiogram (ECG) has fundamentally undergone minimal technological advances. Nevertheless, its clinical utility is critical, and it remains an essential tool to diagnose, risk stratify, and guide reperfusion and invasive strategies in patients with suspected acute coronary syndromes. ECG reading can be demanding, with many healthcare professionals lacking the necessary expertise to accurately interpret them. This is exacerbated by the need to constantly revisit old dogmas pertinent to the interpretation of ECGs. RECENT FINDINGS Notably, ECG leads record the global electrical activity of the heart toward and away from each electrode rather than local events. The long-held central paradigm that the various ECG leads record local events underneath specific electrodes should therefore be reassessed. For example, ST segment elevation in leads V1 and V2 usually denote antero-apical rather than septal infarction, often a misnomer utilized by the majority of clinicians. The ECG diagnosis of ST-elevation myocardial infarction (STEMI) is sometimes challenging and discerning it from non-ST-elevation myocardial infarction (NSTEMI) is of paramount importance to implement timely acute reperfusion therapy. In fact, when qualifications for emergency reperfusion therapy are based on STEMI ECG criteria, nearly one-third of cases with acute coronary occlusion are missed. Diagnostic ST elevation in the absence of left ventricular (LV) hypertrophy or left bundle-branch block (LBBB) is defined by a specific set of sex-specific criteria for new ST elevation at the J point in contiguous precordial or limb leads. However, other ECG criteria need to be kept in mind. These include, but are not limited to, new or presumably new left bundle branch block (LBBB), which is often considered as an STEMI-equivalent; ST depression in two or more precordial leads (V1-V4), denoting a true inferolateral transmural myocardial infarction; and the infrequent presentation with hyperacute T-wave changes. As our understanding of the pathology of ischemic reperfusion injury has evolved and following the introduction of new imaging modalities such as cardiac magnetic resonance imaging, we need to re-assess the old dogmas pertinent to the interpretation of ECGs and update the terms and classifications.
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Affiliation(s)
- Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, MS: BCM620, 77030, USA.
| | - Jani Rankinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, MS: BCM620, 77030, USA
| | - Dan Atar
- Dept. of Cardiology, Institute of Clinical Medicine, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway, Norway
| | - Kjell Nikus
- Heart Center, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere University, Tampere, Finland
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Han X, Chen Z, Wang Y, Zhang J, Zhang Y, Su Q, Pan Z, Sun J, Wang Y. Prognostic significance of QRS distortion and frontal QRS-T angle in patients with ST-elevation myocardial infarction. Int J Cardiol 2021; 345:1-6. [PMID: 34715207 DOI: 10.1016/j.ijcard.2021.10.139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/27/2021] [Accepted: 10/22/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND QRS distortion (G3I) and frontal QRS-T angle (fQRS-T angle) are both electrocardiographic (ECG) signs of ongoing ischemia and depolarization-repolarization heterogeneity, which always occur in patients with ST-segment elevation acute myocardial infarction (STEMI). METHODS We retrospectively collected 592 STEMI patients who underwent coronary angiography and follow-up for 42 months. 1. We divided the patients into two groups according to whether they had G3I on admission, compared the differences in examination data and endpoint events between these two groups. 2. Group patients according to whether the endpoint events happened in hospital, at 12 and 42 months, compare whether there is a difference in fQRS-T angle at the same time point, and find out the predictive cutoff value of all-cause death. 3. Combined G3I and fQRS-T angle together to enhance the predictive value. RESULTS G3I and fQRS-T angle are both independent risk factors for all-cause death in STEMI patients within 12 months (G3I P = 0.014, fQRS-T angle P < 0.001) and within 42 months (P < 0.001). The cutoff values of fQRS-T angle for predicting all-cause death are 66.5° at 12 months and 90.5° at 42 months. When G3I and fQRS-T angle are combined used to predict the mortality, the specificity is significantly improved, but the sensitivity decreased. CONCLUSIONS G3I and fQRS-T angles are valuable in the prognostic assessment of STEMI patients, especially when combined. These findings help clinicians to identify high-risk patients early for more aggressive treatment.
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Affiliation(s)
- Xiaorong Han
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Zhongbo Chen
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Yinghui Wang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Jin Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Ying Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Qiang Su
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Zhenghu Pan
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Jian Sun
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Yonggang Wang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
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Zhan ZQ, Nikus K, Birnbaum Y. Different ECG patterns of left main coronary artery occlusion signifying varying degrees of ischemic severity. J Electrocardiol 2020; 60:12-14. [PMID: 32208175 DOI: 10.1016/j.jelectrocard.2020.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/07/2020] [Accepted: 02/20/2020] [Indexed: 11/18/2022]
Abstract
Many ischemic ECG patterns are found in patients with acute left main coronary artery occlusion. We present a patient with dynamic ECG changes that corresponded to changes in his clinical symptoms and hemodynamic status. These changes signify different severity of myocardial ischemia caused by left main coronary artery disease. Take-home Message: Our case with left main coronary artery disease illustrated three distinct ECG patterns with different severity of clinical symptoms signifying varying severity of ischemia. In left main coronary artery disease, the ST deviations in the precordial leads can be relatively minor. Left axis deviation or left anterior fascicular block with broad QRS possibly reflects left ventricular depolarization delay secondary to extensive ischemia.
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Affiliation(s)
- Zhong-Qun Zhan
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, PR China.
| | - Kjell Nikus
- Department of Cardiology, Heart Center, Tampere University Hospital, Tampere and Faculty of Medicine and Health Technology, Tampere University, Finland.
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine and Texas Heart Institute, Baylor St. Luke Medical Center, Houston, TX, USA.
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Effect of Ischemic Preconditioning and Postconditioning on Exosome-Rich Fraction microRNA Levels, in Relation with Electrophysiological Parameters and Ventricular Arrhythmia in Experimental Closed-Chest Reperfused Myocardial Infarction. Int J Mol Sci 2019; 20:ijms20092140. [PMID: 31052231 PMCID: PMC6540096 DOI: 10.3390/ijms20092140] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 12/11/2022] Open
Abstract
We investigated the antiarrhythmic effects of ischemic preconditioning (IPC) and postconditioning (PostC) by intracardiac electrocardiogram (ECG) and measured circulating microRNAs (miRs) that are related to cardiac conduction. Domestic pigs underwent 90-min. percutaneous occlusion of the mid left anterior coronary artery, followed by reperfusion. The animals were divided into three groups: acute myocardial infarction (AMI, n = 7), ischemic preconditioning-acute myocardial infarction (IPC-AMI) (n = 9), or AMI-PostC (n = 5). IPC was induced by three 5-min. episodes of repetitive ischemia/reperfusion cycles (rI/R) before AMI. PostC was induced by six 30-s rI/R immediately after induction of reperfusion 90 min after occlusion. Before the angiographic procedure, a NOGA endocardial mapping catheter was placed again the distal anterior ventricular endocardium to record the intracardiac electrogram (R-amplitude, ST-Elevation, ST-area under the curve (AUC), QRS width, and corrected QT time (QTc)) during the entire procedure. An arrhythmia score was calculated. Cardiac MRI was performed after one-month. IPC led to significantly lower ST-elevation, heart rate, and arrhythmia score during ischemia. PostC induced a rapid recovery of R-amplitude, decrease in QTc, and lower arrhythmia score during reperfusion. Slightly higher levels of miR-26 and miR-133 were observed in AMI compared to groups IPC-AMI and AMI-PostC. Significantly lower levels of miR-1, miR-208, and miR-328 were measured in the AMI-PostC group as compared to animals in group AMI and IPC-AMI. The arrhythmia score was not significantly associated with miRNA plasma levels. Cardiac MRI showed significantly smaller infarct size in the IPC-AMI group when compared to the AMI and AMI-PostC groups. Thus, IPC led to better left ventricular ejection fraction at one-month and it exerted antiarrhythmic effects during ischemia, whereas PostC exhibited antiarrhythmic properties after reperfusion, with significant downregulaton of ischemia-related miRNAs.
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Yılmaz A, Demir K, Karataş R, Çelik M, Avcı A, Keleş F, Erseçgin A, Aygül N, Altunkeser BB. Long–term prognostic significance of terminal QRS distortion on patients with stemi and its correlation with the GRACE scoring system. J Electrocardiol 2019; 52:17-21. [DOI: 10.1016/j.jelectrocard.2018.10.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/14/2018] [Accepted: 10/28/2018] [Indexed: 11/27/2022]
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Fakhri Y, Melgaard J, Andersson HB, Schoos MM, Birnbaum Y, Graff C, Sejersten M, Kastrup J, Clemmensen P. Automatic electrocardiographic algorithm for assessing severity of ischemia in ST-segment elevation myocardial infarction. Int J Cardiol 2018; 268:18-22. [PMID: 30041784 DOI: 10.1016/j.ijcard.2018.04.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/26/2018] [Accepted: 04/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Terminal QRS distortion on the electrocardiogram (ECG) is a sign of severe ischemia in patients with STEMI and can be quantified by the Sclarovsky-Birnbaum Severity of Ischemia. Due to score complexity, it has not been applied in clinical practice. Automatic scoring of digitally recorded ECGs could facilitate clinical application. We aimed to develop an automatic algorithm for the severity of ischemia. METHODS Development set: 50 STEMI ECGs were manually (Manual-score) and automatically (Auto-score) scored by our designed algorithm. The agreement between Manual- and Auto-score was assessed by kappa statistics. Test set: ECGs from 199 STEMI patients were assigned a severity grade (severe or non-severe ischemia) by the Auto-score. Infarct size estimated by median peak Troponin T (TnT) and Creatinine Kinase Myocardial Band (CKMB) was tested between the groups. RESULTS The agreement between Manual- and Auto-score was 0.83 ((95% CI 0.55-1.00), p < 0.0001), sensitivity 75% and specificity 100%, PPV 100% and NPV 94.6%. In the test set 152 (76%) patients were male, mean age 61 ± 12 years. The Auto-score designated severe ischemia in 42 (21%) and non-severe ischemia in 157 (79%) patients. Patients with ECG signs of severe vs. non-severe ischemia had significantly higher levels of biomarkers of infarct size. In multiple linear regression, ECG sign of severe ischemia was an independent predictor for higher TnT and CKMB levels. CONCLUSION The automatic ECG algorithm for severity of ischemia in STEMI performs adequately for clinical use. Severe ischemia obtained by the Auto-score was associated with biomarker estimated larger infarct size.
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Affiliation(s)
- Yama Fakhri
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Medicine, Nykøbing Falster Hospital, Nykøbing F, Denmark.
| | - Jacob Melgaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Hedvig Bille Andersson
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | | | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Maria Sejersten
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens Kastrup
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Medicine, Nykøbing Falster Hospital, Nykøbing F, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of General and Interventional Cardiology, University Heart Center Hamburg, Eppendorf, Hamburg, Germany
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Analysis and interpretation of the electrocardiogram by the computer. Int J Cardiol 2018; 268:38-39. [PMID: 29804704 DOI: 10.1016/j.ijcard.2018.05.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 05/18/2018] [Indexed: 11/23/2022]
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Almer J, Elmberg V, Bränsvik J, Nordlund D, Khoshnood A, Ringborn M, Carlsson M, Ekelund U, Engblom H. Ischemic QRS prolongation as a biomarker of myocardial injury in STEMI patients. Ann Noninvasive Electrocardiol 2018; 24:e12601. [PMID: 30265437 DOI: 10.1111/anec.12601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Patients with acute coronary occlusion (ACO) may not only have ischemia-related ST-segment changes but also changes in the QRS complex. It has recently been shown in dogs that a greater ischemic QRS prolongation (IQP) during ACO is related to lower collateral flow. This suggests that greater IQP could indicate more severe ischemia and thereby more rapid infarct development. Therefore, the purpose was to evaluate the relationship between IQP and measures of myocardial injury in patients presenting with acute ST-elevation myocardial infarction (STEMI). METHODS Seventy-seven patients with first-time STEMI were retrospectively included from the recently published SOCCER trial. All patients underwent a cardiac magnetic resonance (CMR) examination 2-6 days after the acute event. Infarct size (IS), myocardium at risk (MaR), and myocardial salvage index (MSI) were assessed and related to IQP. IQP measures assessed were; computer-generated QRS duration, QRS duration at maximum ST deviation, absolute IQP and relative IQP, all derived from a pre-PCI, 12-lead ECG. RESULTS Median absolute IQP was 10 ms (range 0-115 ms). There were no statistically significant correlations between measures of IQP and any of the CMR measures of myocardial injury (absolute IQP vs IS, r = 0.03, p = 0.80; MaR, r = -0.01, p = 0.89; MSI, r = -0.05, p = 0.68). CONCLUSIONS Unlike previous experimental studies, the IQP was limited in patients presenting at the emergency room with first-time STEMI and no correlation was found between IQP and CMR variables of myocardial injury in these patients. Therefore, IQP does not seem to be a suitable biomarker for triaging patients in this clinical context.
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Affiliation(s)
- Jakob Almer
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital and Lund University, Lund, Sweden
| | - Viktor Elmberg
- Department of Clinical Physiology, Blekingesjukhuset, Karlskrona, Sweden
| | - Josef Bränsvik
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital and Lund University, Lund, Sweden
| | - David Nordlund
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital and Lund University, Lund, Sweden
| | - Ardavan Khoshnood
- Department of Emergency Medicine, Skåne University Hospital and Lund University, Lund, Sweden
| | | | - Marcus Carlsson
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital and Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Emergency Medicine, Skåne University Hospital and Lund University, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital and Lund University, Lund, Sweden
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Koivula K, Nikus K, Viikilä J, Lilleberg J, Huhtala H, Birnbaum Y, Eskola M. Comparison of the prognostic role of Q waves and inverted T waves in the presenting ECG of STEMI patients. Ann Noninvasive Electrocardiol 2018; 24:e12585. [PMID: 30191632 DOI: 10.1111/anec.12585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/15/2018] [Accepted: 06/23/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Both Q waves and T-wave inversion (TWI) in the presenting ECG are associated with a progressed stage of myocardial infarction, possibly with less potential for myocardial salvage with reperfusion therapy. Combining the diagnostic information from the Q- and T-wave analyses could improve the prognostic work-up in ST-elevation myocardial infarction (STEMI) patients. METHODS We sought to determine the prognostic impact of Q waves and TWI in the admission ECG on patient outcome in STEMI. We formed four groups according to the presence of Q waves and/or TWI (Q+TWI+; Q-TWI+; Q+TWI-; Q-TWI-). We studied 627 all-comers with STEMI derived from two patient cohorts. RESULTS The patients with Q+TWI+ had the highest and those with Q-TWI- the lowest 30-day and one-year mortality. One-year mortality was similar between Q-TWI+ and Q+TWI-. The survival analysis showed higher early mortality in Q+TWI- but the higher late mortality in Q-TWI+ compensated for the difference at 1 year. The highest peak troponin level was found in the patients with Q+TWI-. CONCLUSION Q waves and TWI predict adverse outcome, especially if both ECG features are present. Q waves and TWI predict similar one-year mortality. Extending the ECG analysis in STEMI patients to include both Q waves and TWI improves risk stratification.
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Affiliation(s)
- Kimmo Koivula
- South Karelia Central Hospital, Lappeenranta, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kjell Nikus
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
| | - Juho Viikilä
- Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jyrki Lilleberg
- Department of Internal Medicine, Hyvinkää Hospital, Hyvinkää, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Markku Eskola
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
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Hansen R, Frydland M, Møller-Helgestad OK, Lindholm MG, Jensen LO, Holmvang L, Ravn HB, Kjærgaard J, Hassager C, Møller JE. Association between QRS duration on prehospital ECG and mortality in patients with suspected STEMI. Int J Cardiol 2018; 249:55-60. [PMID: 29121757 DOI: 10.1016/j.ijcard.2017.07.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/16/2017] [Accepted: 07/13/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND QRS duration has previously shown association with mortality in patients with acute myocardial infarction treated with thrombolytics, less is known in patients with suspected ST segment elevation myocardial infarction (STEMI) when assessing QRS duration on prehospital ECG. Thus, the objective was to investigate the prognostic effect of QRS duration on prehospital ECG and presence of classic left and right bundle branch block (LBBB/RBBB) for all-cause mortality in patients with suspected STEMI. METHOD In total 2105 consecutive patients (mean age 64±13years, 72% men) with suspected STEMI were prospectively included. QRS duration was registered from automated QRS measurement on prehospital ECG and patients were divided according to quartiles of QRS duration (<89ms, 89-98ms, 99-111ms and >111ms). Primary endpoint was all-cause 30-day mortality. Predictors of all-cause mortality were assessed using Cox proportional hazards analysis. RESULTS Among all patients median QRS duration was 98ms (IQR 88-112ms). RBBB-morphology was seen in 126 patients (6.0%) and LBBB in 88 patients (4.2%), 80% were treated with percutaneous coronary intervention and the final diagnosis was STEMI in 1777 patients (84%). Thirty-day mortality was 7.6% in patients with suspected STEMI. In multivariable analysis, QRS duration>111ms (hazard ratio (HR) 3.08; 95% confidence interval (CI): 1.71-5.57, p=0.0002), LBBB - morphology (HR 3.0; 95% CI: 1.38-6.53, p=0.006) and RBBB (HR 3.68; 95% CI: 1.95-6.95, p<0.0001) were associated with 30 day all-cause mortality. CONCLUSION In patients with suspected STEMI, QRS prolongation, LBBB, and RBBB on prehospital ECG are associated with increased risk of death.
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Affiliation(s)
- Rikke Hansen
- Department of Cardiology, Odense University Hospital, Sdr Boulevard 29, DK-5000 Odense C, Denmark
| | - Martin Frydland
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej, DK-2100 Copenhagen, Denmark
| | | | - Matias Greve Lindholm
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej, DK-2100 Copenhagen, Denmark
| | - Lisette Okkels Jensen
- Department of Cardiology, Odense University Hospital, Sdr Boulevard 29, DK-5000 Odense C, Denmark
| | - Lene Holmvang
- Department of Cardiology, Odense University Hospital, Sdr Boulevard 29, DK-5000 Odense C, Denmark
| | - Hanne Berg Ravn
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej, DK-2100 Copenhagen, Denmark
| | - Jesper Kjærgaard
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej, DK-2100 Copenhagen, Denmark
| | - Christian Hassager
- The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej, DK-2100 Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Sdr Boulevard 29, DK-5000 Odense C, Denmark.
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The prognostic value of the combined use of QRS distortion and fragmented QRS in patients with acute STEMI undergoing primary percutaneous coronary intervention. J Electrocardiol 2018; 51:210-217. [DOI: 10.1016/j.jelectrocard.2017.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 11/20/2022]
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Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications. J Electrocardiol 2017; 50:47-73. [DOI: 10.1016/j.jelectrocard.2016.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Elmberg V, Almer J, Pahlm O, Wagner GS, Engblom H, Ringborn M. A 12-lead ECG-method for quantifying ischemia-induced QRS prolongation to estimate the severity of the acute myocardial event. J Electrocardiol 2016; 49:272-7. [DOI: 10.1016/j.jelectrocard.2016.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 11/16/2022]
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17
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Yochai B, Nikus K, Birnbaum Y. About QRS prolongation, distortion and the acuteness score. J Electrocardiol 2016; 49:265-71. [PMID: 26972846 DOI: 10.1016/j.jelectrocard.2016.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Birnbaum Yochai
- The Section of Cardiology, the Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kjell Nikus
- Cardiology Department, Heart Center, Tampere University Hospital and School of Medicine, University of Tampere, Finland
| | - Yochai Birnbaum
- The Section of Cardiology, the Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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Fernandez Machulsky N, Gagliardi J, Fabre B, Miksztowicz V, Lombardo M, García Escudero A, Gigena G, Blanco F, Gelpi RJ, Schreier L, Gidron Y, Berg G. Matrix metalloproteinases and psychosocial factors in acute coronary syndrome patients. Psychoneuroendocrinology 2016; 63:102-8. [PMID: 26431804 DOI: 10.1016/j.psyneuen.2015.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/14/2015] [Accepted: 09/14/2015] [Indexed: 12/20/2022]
Abstract
UNLABELLED Psychosocial factors have been linked to cardiovascular diseases independently of traditional risk factors. The impact of psychosocial factors on plaque destabilizing factors, such as matrix metalloproteinases (MMPs) has been proposed although scarcely studied. OBJECTIVE To evaluate the relationships between hostility, perceived stress and social support with MMPs activity in patients after an Acute Myocardial Infarction (AMI). METHODS Blood samples were obtained from 76 patients on admission, post-angioplasty, 24h, 7 days and 3 months after AMI. Hostility, perceived stress and social support were evaluated by validated questionnaires. RESULTS Social support was positively correlated with patientś ejection fraction (r=0.453, p=0.009). Patients with higher infarct size presented increased MMP-2 activity at admission (p=0.04). Patients with one diseased vessel had more social support than those with three diseased vessels (p=0.05). The highest values of MMP-2 and MMP-9 activity were observed at the acute event, decreasing, with the lowest activity at 3 months post-AMI (p<0.001). Only in patients with low social support, hostility correlated with MMP-2 activity, from AMI onset (r=0.645, p=0.013), to 7 days post AMI (r=0.557, p=0.038). Hostility explained up to 28% of the variance in MMP-2 activity (R(2)=0.28, p=0.005). Finally, in patients with high hostility, MMP-9 was positively correlated with IL-1β (r=0.468, p=0.02). CONCLUSIONS This study adds weight to the idea that two psychosocial factors, namely hostility and social support, acting jointly, may affect MMP-2 activity. Moreover, in hostile patients, there is a link between IL-1β and MMP-9. These findings support the role of psychosocial factors in plaque destabilization and in the inflammatory process in AMI.
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Affiliation(s)
- Nahuel Fernandez Machulsky
- Lipids and Atherosclerosis Laboratory, Clinical Biochemistry Department, INFIBIOC, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Argentina
| | - Juan Gagliardi
- Hemodynamic Unit, Cardiology Division, General Hospital Dr. Cosme Argerich, Buenos Aires, Argentina
| | - Bibiana Fabre
- Endocrinology Laboratory, Clinical Biochemistry Department, INFIBIOC, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Argentina
| | - Verónica Miksztowicz
- Lipids and Atherosclerosis Laboratory, Clinical Biochemistry Department, INFIBIOC, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Argentina
| | - Micaela Lombardo
- Lipids and Atherosclerosis Laboratory, Clinical Biochemistry Department, INFIBIOC, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Argentina
| | | | - Gerardo Gigena
- Hemodynamic Unit, Cardiology Division, General Hospital Dr. Cosme Argerich, Buenos Aires, Argentina
| | - Federico Blanco
- Hemodynamic Unit, Cardiology Division, General Hospital Dr. Cosme Argerich, Buenos Aires, Argentina
| | - Ricardo J Gelpi
- Institute of Cardiovascular Physiopathology and Department of Pathology, Faculty of Medicine, University of Buenos Aires, Argentina
| | - Laura Schreier
- Lipids and Atherosclerosis Laboratory, Clinical Biochemistry Department, INFIBIOC, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Argentina
| | - Yori Gidron
- Behavior Medicine, Faculty of Medicine & Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Gabriela Berg
- Lipids and Atherosclerosis Laboratory, Clinical Biochemistry Department, INFIBIOC, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Argentina.
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Valle-Caballero MJ, Fernández-Jiménez R, Díaz-Munoz R, Mateos A, Rodríguez-Álvarez M, Iglesias-Vázquez JA, Saborido C, Navarro C, Dominguez ML, Gorjón L, Fontoira JC, Fuster V, García-Rubira JC, Ibanez B. QRS distortion in pre-reperfusion electrocardiogram is a bedside predictor of large myocardium at risk and infarct size (a METOCARD-CNIC trial substudy). Int J Cardiol 2015; 202:666-73. [PMID: 26453814 DOI: 10.1016/j.ijcard.2015.09.117] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/24/2015] [Accepted: 09/28/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND QRS distortion is an electrocardiographic (ECG) sign of severe ongoing ischemia in the setting of ST-segment elevation acute myocardial infarction (STEMI). We sought to evaluate the association between the degree of QRS distortion and myocardium at risk and final infarct size, measured by cardiac magnetic resonance (CMR). METHODS A total of 174 patients with a first anterior STEMI reperfused by primary angioplasty were prospectively recruited. Pre-reperfusion ECG was used to divide the study population into three groups according to the absence of QRS distortion (D0) or its presence in a single lead (D1) or in 2 or more contiguous leads (D2+). Myocardium at risk and infarct size were determined by CMR one week after STEMI. Multiple regression analysis was used to study the association of QRS distortion with myocardium at risk and infarct size, with adjustment for relevant clinical and ECG variables. RESULTS 101 patients (58%) were in group D0, 30 (17%) in group D1, and 43 (25%) in group D2+. Compared with group D0, presence of QRS distortion (groups D2+ and D1) was associated with a significantly adjusted larger extent of myocardium at risk (group D2+: absolute increase 10.4%, 95% CI 6.1-14.8%, p<0.001; group D1: absolute increase 3.3%, 95% CI 1.3-7.9%, p=0.157) and larger infarct size (group D2+: absolute increase 10.1%, 95% CI 5.5-14.7%, p<0.001; group D1: absolute increase 4.9%, 95% CI 0.08-9.8%, p=0.046). CONCLUSIONS Distortion in the terminal portion of the QRS complex on pre-reperfusion ECG in two or more leads is independently associated with larger myocardium at risk and infarct size in the setting of primary angioplasty-reperfused anterior STEMI. QRS distortion in only one lead is independently associated with larger infarct size in this setting. Our findings suggest that QRS distortion analysis could be included in risk-stratification of patients presenting with anterior STEMI.
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Affiliation(s)
| | - Rodrigo Fernández-Jiménez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Raquel Díaz-Munoz
- Consultorio de Quijorna (Centro de Salud de Villanueva de la Cañada), Spain
| | - Alonso Mateos
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; Servicio de Urgencia Médica de Madrid (SUMMA112), Spain; Universidad Francisco de Vitoria, Madrid, Spain
| | | | | | - Carmen Saborido
- Complejo Hospitalario Universitario de Vigo-Meixoeiro, Pontevedra, Spain
| | | | | | - Luisa Gorjón
- Servicio de Emergencia Médica 061 de Galicia, Spain
| | | | - Valentín Fuster
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA
| | | | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; IIS, Fundación Jiménez Díaz Hospital, Madrid, Spain.
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Birnbaum Y, Nikus K, Kligfield P, Fiol M, Barrabés JA, Sionis A, Pahlm O, Niebla JG, de Luna AB. The role of the ECG in diagnosis, risk estimation, and catheterization laboratory activation in patients with acute coronary syndromes: a consensus document. Ann Noninvasive Electrocardiol 2015; 19:412-25. [PMID: 25262661 DOI: 10.1111/anec.12196] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The electrocardiogram (ECG) is the most widely used imaging tool helping in diagnosis and initial management of patients presenting with symptoms compatible with acute coronary syndrome. Acute ischemia affects the configuration of the QRS complexes, the ST segments and the T waves. The ECG should be read along with the clinical assessment of the patient. ST segment elevation (and ST depression in leads V1 -V3 ) in patients with active symptoms usually indicates acute occlusion of an epicardial artery with ongoing transmural ischemia. These patients should be triaged for emergent reperfusion therapy per current guidelines. However, many patients have ST segment elevation secondary to nonischemic causes. ST depression in leads other than V1 -V3 usually are indicative of subendocardial ischemia secondary to subocclusion of the epicardial artery, distal embolization to small arteries or spasm supply/demand mismatch. ST depression may also be secondary to nonischemic etiologies, such as left ventricular hypertrophy, cardiomyopathies, etc. Knowing the clinical scenario, comparison to previous ECG and subsequent ECGs (in cases that there are changes in the quality or severity of symptoms) may add in the diagnosis and interpretation in difficult cases. This review addresses the different ECG patterns, typically seen in patients with active symptoms, after resolution of symptoms and the significance of such changes when seen in asymptomatic patients.
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Affiliation(s)
- Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Pahlm O, Wagner GS. QRS, ST and T changes of acute transmural myocardial ischemia: Overview editorial. J Electrocardiol 2014; 47:397-401. [DOI: 10.1016/j.jelectrocard.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jennings RB, Wagner GS. Roles of collateral arterial flow and ischemic preconditioning in protection of acutely ischemic myocardium. J Electrocardiol 2014; 47:491-9. [PMID: 24952922 DOI: 10.1016/j.jelectrocard.2014.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Indexed: 10/25/2022]
Abstract
The extent and rate at which necrosis develops in experimental acute myocardial infarction in the dog heart is presented together with an analysis of the role played by protective mechanisms in myocyte death. Preconditioning with ischemia delays but does not prevent myocyte death. Arterial collateral flows exceeding 30% of control flow essentially prevent myocyte death, while lesser amounts of collateral flow delay myocyte death to a variable extent. Flows of <0.09mlmin(-1)g(-1) wet exert no protective effect. Cell death occurs as quickly as it does with zero flow. Electrocardiography provides a means of detection of the preconditioned state in the dog heart in that the amount of ST elevation observed during the preconditioning episode is reduced during subsequent episodes of ischemia. Also, marked depression of arterial collateral flow can be detected by an increase in the duration of the QRS segment.
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