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Lucas R, Roberts P. Macrotroponin as a cause for an elevated troponin in a 14-year-old boy. J Paediatr Child Health 2020; 56:1632-1633. [PMID: 31997463 DOI: 10.1111/jpc.14797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Ryan Lucas
- Department of General Medicine, The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Philip Roberts
- The Heart Centre for Children, The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
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Abstract
Hyperkalemia is a potentially life-threatening electrolyte disorder appreciated with greater frequency in patients with renal disease, heart failure, and with use of certain medications such as renin angiotensin aldosterone inhibitors. The traditional views that hyperkalemia can be reliably diagnosed by electrocardiogram and that particular levels of hyperkalemia confer cardiotoxic risk have been challenged by several reports of patients with atypic presentations. Epidemiologic data demonstrate strong associations of morbidity and mortality in patients with hyperkalemia but these associations appear disconnected in certain patient populations and in differing clinical presentations. Physiologic adaptation, structural cardiac disease, medication use, and degree of concurrent illness might predispose certain patients presenting with hyperkalemia to a lower or higher threshold for toxicity. These factors are often overlooked; yet data suggest that the clinical context in which hyperkalemia develops is at least as important as the degree of hyperkalemia is in determining patient outcome. This review summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation.
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Affiliation(s)
- John R Montford
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; .,Renal Section, Medicine Service, Veterans Affairs Eastern Colorado Health System, Denver, Colorado; and
| | - Stuart Linas
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Division of Nephrology, Department of Medicine, Denver Health and Hospitals, Denver, Colorado
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Rizzo C, Monitillo F, Iacoviello M. 12-lead electrocardiogram features of arrhythmic risk: A focus on early repolarization. World J Cardiol 2016; 8:447-455. [PMID: 27621772 PMCID: PMC4997525 DOI: 10.4330/wjc.v8.i8.447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/30/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
The 12-lead electrocardiogram (ECG) is still the most used tool in cardiology clinical practice. Considering its easy accessibility, low cost and the information that it provides, it remains the starting point for diagnosis and prognosis. More specifically, its ability to detect prognostic markers for sudden cardiac death due to arrhythmias by identifying specific patterns that express electrical disturbances of the heart muscle, which may predispose to malignant arrhythmias, is universally recognized. Alterations in the ventricular repolarization process, identifiable on a 12-lead ECG, play a role in the genesis of ventricular arrhythmias in different cardiac diseases. The aim of this paper is to focus the attention on a new marker of arrhythmic risk, the early repolarization pattern in order to highlight the prognostic role of the 12-lead ECG.
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Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, Olson KR, Ramoska EA, Lange RA. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila) 2016; 54:345-64. [PMID: 26919414 DOI: 10.3109/15563650.2016.1142090] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death. OBJECTIVE The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse. METHODS MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and β/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of β-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined β/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine. CONCLUSIONS High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.
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Affiliation(s)
- John R Richards
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Dariush Garber
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Erik G Laurin
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Timothy E Albertson
- b Department of Internal Medicine, Divisions of Toxicology, Pulmonary and Critical Care , University of California Davis Medical Center , Sacramento , CA , USA
| | - Robert W Derlet
- a Department of Emergency Medicine , University of California Davis Medical Center , Sacramento , CA , USA
| | - Ezra A Amsterdam
- c Department of Internal Medicine, Division of Cardiology , University of California Davis Medical Center , Sacramento , CA , USA
| | - Kent R Olson
- d Departments of Medicine and Clinical Pharmacy , University of California, San Francisco, Medical Director, California Poison Control System, San Francisco Division , San Francisco , CA , USA
| | - Edward A Ramoska
- e Department of Emergency Medicine , Drexel University , Philadelphia , PA , USA
| | - Richard A Lange
- f Department of Internal Medicine, Division of Cardiology , Texas Tech University Health Sciences Center , El Paso , TX , USA
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Malhotra VK, Singh N, Bishnoi RS, Chadha DS, Bhardwaj P, Madan H, Dutta R, Ghosh AK, Sengupta S, Perumal P. The prevalence of abnormal ECG in trained sportsmen. Med J Armed Forces India 2015; 71:324-9. [PMID: 26663958 DOI: 10.1016/j.mjafi.2015.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/08/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Competitive sports training causes structural and conductive system changes manifesting by various electrocardiographic alterations. We undertook this study to assess the prevalence of abnormal ECG in trained Indian athletes and correlate it with the nature of sports training, that is endurance or strength training. METHODS We evaluated a standard resting, lying 12 lead Electrocardiogram (ECG) in 66 actively training Indian athletes. Standard diagnostic criteria were used to define various morphological ECG abnormalities. RESULTS 33/66 (50%) of the athletes were undertaking endurance training while the other 33 (50%) were involved in a strength-training regimen. Overall 54/66 (81%) sportsmen had significant ECG changes. 68% of these changes were considered as normal training related features, while the remaining 32% were considered abnormal. There were seven common training related ECG changes-Sinus Bradycardia (21%), Sinus Arrhythmia (16%), 1st degree Atrioventricular Heart Block (6%), Type 1 2nd-degree Atrioventicular Heart Block (3%), Incomplete Right bundle branch block (RBBB) (24%), Early Repolarization (42%), Left Ventricular Hypertrophy (LVH) (14%); while three abnormal ECG changes--T-wave inversion (13%), RBBB(4%), Right ventricular hypertrophy (RVH) with strain (29%) were noted. Early repolarization (commonest change), sinus bradycardia, and incomplete RBBB were the commoner features noticed, with a significantly higher presence in the endurance trained athletes. CONCLUSION A high proportion of athletes undergoing competitive level sports training are likely to have abnormal ECG recordings. Majority of these are benign, and related to the physiological adaptation to the extreme levels of exertion. These changes are commoner during endurance training (running) than strength training (weightlifting).
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Affiliation(s)
- V K Malhotra
- Sports Physiologist, Army Sports Institute, Pune 411036, India
| | - Navreet Singh
- Classified Specialist (Medicine) and Cardiologist, Army Hospital (Research & Referral), New Delhi, 110011, India
| | - R S Bishnoi
- Commanding Officer, Army Sports Institute, Pune 411036, India
| | - D S Chadha
- Senior Adviser (Medicine) and Cardiology, Military Hospital (Cardiothoracic Center), Pune 411040, India
| | - P Bhardwaj
- Consultant (Medicine) and Cardiologist, Army Hospital (Research & Referral), New Delhi 110011, India
| | - H Madan
- Senior Adviser (Medicine) and Cardiologist, Army Hospital (Research & Referral), New Delhi 110011, India
| | - R Dutta
- Consultant (Medicine) and Cardiologist, & Commandant, Armed Forces Clinic, Dalhousie Road, New Delhi 110001, India
| | - A K Ghosh
- Senior Adviser (Medicine) and Cardiology, Command Hospital (Southern Command), Pune 411040, India
| | - S Sengupta
- Classified Specialist (Medicine) and Cardiologist, Military Hospital Jalandhar, Punjab, India
| | - P Perumal
- Nursing Assistant (Cardiology), Command Hospital (Southern Command), Pune 411040, India
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Nable JV, Lawner BJ. Chameleons: Electrocardiogram Imitators of ST-Segment Elevation Myocardial Infarction. Emerg Med Clin North Am 2015; 33:529-37. [PMID: 26226864 DOI: 10.1016/j.emc.2015.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The imperative for timely reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) underscores the need for clinicians to have an understanding of how to distinguish patterns of STEMI from its imitators. These imitating diagnoses may confound an evaluation, potentially delaying necessary therapy. Although numerous diagnoses may mimic STEMI, several morphologic clues may allow the physician to determine if the pattern is concerning for either STEMI or a mimicking diagnosis. Furthermore, obtaining a satisfactory history, comparing previous electrocardiograms, and assessing serial tests may provide valuable clues.
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Affiliation(s)
- Jose V Nable
- Department of Emergency Medicine, MedStar Georgetown University Hospital, Georgetown University School of Medicine, 3800 Reservoir Rd NW, G-CCC, Washington, DC 20007, USA.
| | - Benjamin J Lawner
- Department of Emergency Medicine, University of Maryland School of Medicine, 6th floor, Suite 200110 South Pace Street, Baltimore, MD 21201, USA
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7
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Arrhythmogenic right ventricular dysplasia back in force. Am J Cardiol 2014; 114:655-6. [PMID: 25086785 DOI: 10.1016/j.amjcard.2014.05.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 05/30/2014] [Indexed: 11/23/2022]
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Abstract
Ensuring the safety of young athletes is a priority among health care providers. Controversy remains as to the best method of preparticipation screening. The American Academy of Pediatrics and the American Heart Association currently recommend screening with history and physical examination, without routine electrocardiogram or echocardiography. Meticulous conduction of a cardiac focused history and exam during the preparticipation evaluation can help identify those who may be at risk for sudden cardiac arrest. Understanding presenting signs of the most common cardiac diseases is useful in recognizing those in need of a directed cardiac evaluation before sports participation.
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Affiliation(s)
- James M Galas
- Division of Pediatric Cardiology, The Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201-2119, USA.
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9
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Early Repolarization: Innocent or Dangerous? Am J Med Sci 2013; 346:226-32. [DOI: 10.1097/maj.0b013e3182783a59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kobza R, Cuculi F, Abächerli R, Toggweiler S, Suter Y, Frey F, Schmid JJ, Erne P. Twelve-lead electrocardiography in the young: physiologic and pathologic abnormalities. Heart Rhythm 2012; 9:2018-22. [PMID: 23102624 DOI: 10.1016/j.hrthm.2012.08.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Indexed: 11/26/2022]
Abstract
UNLABELLED BACKGROUND/ OBJECTIVE: The purpose of the present study was to analyze the prevalence of physiologic and pathologic ECG abnormalities in a cohort of young conscripts that represents the whole young generation of today. METHODS ECGs of all Swiss citizens who underwent conscription for the army during a 29-month period were analyzed manually. RESULTS ECGs of 43,401 conscripts (mean age 19.2 ± 1.1 years) were analyzed; 158 conscripts were female. Incomplete right bundle branch block was found in 5870 (13.5%) and left anterior fascicular block in 360 (0.83%). First-degree AV block was present in 329 (0.8%) and Mobitz type I (Wenckebach) second-degree AV block in 3 (0.01%). Early repolarization was observed in 1035 (2.4%), T-wave inversion in 39 (0.09%), and minor T-wave changes in 182 (0.42%). Brugada-like abnormalities were observed in 6 (0.01%). None of the conscripts had atrial fibrillation or flutter. CONCLUSION ECG abnormalities can be found in a relatively large proportion of young individuals. Incomplete right bundle branch block, left fascicular block, and first-degree AV block are the most frequent findings. No conscript presented with atrial fibrillation or flutter.
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Affiliation(s)
- Richard Kobza
- Division of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
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Ramirez FD, Femenía F, Simpson CS, Redfearn DP, Michael KA, Baranchuk A. Electrocardiographic findings associated with cocaine use in humans: a systematic review. Expert Rev Cardiovasc Ther 2012; 10:105-27. [PMID: 22149529 DOI: 10.1586/erc.11.152] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cocaine remains highly prevalent and accessible in the general population, continues to represent one of the most commonly reported substances in drug-related presentations to emergency departments, and is frequently implicated in drug-related deaths. Fatal cardiac arrhythmias are often suspected in the latter cases. In spite of this, its complex effects on the human cardiac conduction system remain poorly elucidated. In this article we sought to systematically review the medical literature to identify the electrocardiographic findings that have been linked to cocaine use in humans in an effort to highlight what physicians can expect to encounter when managing patients using the drug. The evidence is discussed, common findings are emphasized and clinical recommendations are proposed.
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Affiliation(s)
- F Daniel Ramirez
- Cardiac Electrophysiology and Pacing, Arrhythmia Service, Kingston General Hospital, Queen's University, Kingston, ON, K7L 2V7, Canada
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12
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Perez MV, Uberoi A, Jain NA, Ashley E, Turakhia MP, Froelicher V. The prognostic value of early repolarization with ST-segment elevation in African Americans. Heart Rhythm 2012; 9:558-65. [DOI: 10.1016/j.hrthm.2011.11.020] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Indexed: 01/15/2023]
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Senecal EL, Rosenfield K, Caldera AE, Passeri JJ. Case records of the Massachusetts General Hospital. Case 36-2011. A 93-year-old woman with shortness of breath and chest pain. N Engl J Med 2011; 365:2021-8. [PMID: 22111721 DOI: 10.1056/nejmcpc1103565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Emily L Senecal
- Department of Emergency Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, USA
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Roukoz H, Wang K. ST elevation and inverted T wave as another normal variant mimicking acute myocardial infarction: the prevalence, age, gender, and racial distribution. Ann Noninvasive Electrocardiol 2011; 16:64-9. [PMID: 21251136 DOI: 10.1111/j.1542-474x.2010.00410.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Early repolarization (ERP) as a normal variant is a well-recognized ECG entity. There is another normal variant of ST elevation (STTNV) in the midprecordial leads, which is distinctively different from ERP in that the T waves are inverted in these leads while they are upright and tall in ERP. These findings can be easily mistaken for acute myocardial infarction or pericarditis. The purpose of this study is to publicize this entity and to determine its prevalence, age, gender, and racial distributions. METHODS All ECGs taken in adults at a Minneapolis hospital in 2007 were reviewed and individuals with the following ECG findings were identified: 1-3 mm ST elevation ending in an inverted T wave in midprecordial leads with preserved R waves. RESULTS A total of 11,424 patients (5997 men, 5427 women) had one or more ECGs in 2007. STTNV was seen in 101 patients, 97 (96%) of whom were black. Seventy-seven of 2084 (3.7%) black men and 20 of 2020 (1%) black women had STTNV. It was rare in other races (0 to 0.7%), particularly in white patients (1 of 5099 patients). It seems to be evenly distributed throughout the age. The ECG findings normalized in all 6 patients who underwent a treadmill stress test. CONCLUSIONS This entity is seen almost exclusively in blacks (3.7% of men, 1% of women), and is more or less evenly distributed throughout the age. Whether this variant is more often associated with malignant ventricular arrhythmias remains to be determined.
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Affiliation(s)
- Henri Roukoz
- Cardiovascular Division, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
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Computerized STEMI recognition: an example of the art and science of building ECG algorithms. J Electrocardiol 2010; 43:497-502. [DOI: 10.1016/j.jelectrocard.2010.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Indexed: 11/22/2022]
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Lellouche N, Sacher F, Jorrot P, Cariou A, Spaulding C, Aurore A, Combes X, Fichet J, Teiger E, Jais P, Dubois-Randé JL, Haissaguerre M. Sudden cardiac arrest: ECG repolarization after resuscitation. J Cardiovasc Electrophysiol 2010; 22:131-6. [PMID: 20731741 DOI: 10.1111/j.1540-8167.2010.01871.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Early repolarization (ERep) abnormalities on electrocardiogram (ECG) are common immediately following cardiac arrest. We characterized and correlated electrocardiographic repolarization abnormalities immediately after cardiac arrest with acute coronary angiography. METHODS AND RESULTS We studied 225 consecutive patients presenting with out-of-hospital cardiac arrest. All these patients had successful cardiopulmonary resuscitation and acute coronary angiography. The first ECG recorded after successful resuscitation was analyzed by two independent cardiologists. Patients were categorized according to their repolarization pattern. Pattern 1: No ST segment elevation or ERep. Pattern 2: ST segment elevation without ERep. Pattern 3: ST segment elevation and ERep. Pattern 4: ERep only. Patterns 1, 2, 3, and 4 were found in 112 (50%), 74 (33%), 19 (8%), and 20 (9%) patients, respectively. Cardiac arrest was due to acute myocardial ischemia in 45%, 82%, 39%, and 15% of patients in groups 1, 2, 3 and 4, respectively (P < 0.0001). Sensitivity and specificity of pattern 2 was 50% and 88%, respectively, for acute coronary lesion, whereas isolated ERep pattern occurred in 9% of cases and was associated with a nonischemic event (80%). Among 65 patients (29%) who survived, 7% of patients with pattern 1, 13% with pattern 2, 60% with pattern 3, and 88% with pattern 4 exhibited ERep on ECG during the follow-up. CONCLUSION In the context of cardiac resuscitation, an ECG with ST elevation favors acute myocardial infarction, whereas the presence of ERep is a marker of a nonischemic event and future ERep syndrome.
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Affiliation(s)
- Nicolas Lellouche
- Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris et INSERM U 841, Creteil, France.
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Corrado D, Pelliccia A, Heidbuchel H, Sharma S, Link M, Basso C, Biffi A, Buja G, Delise P, Gussac I, Anastasakis A, Borjesson M, Bjørnstad HH, Carrè F, Deligiannis A, Dugmore D, Fagard R, Hoogsteen J, Mellwig KP, Panhuyzen-Goedkoop N, Solberg E, Vanhees L, Drezner J, Estes NAM, Iliceto S, Maron BJ, Peidro R, Schwartz PJ, Stein R, Thiene G, Zeppilli P, McKenna WJ. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 2009; 31:243-59. [PMID: 19933514 DOI: 10.1093/eurheartj/ehp473] [Citation(s) in RCA: 513] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.
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Affiliation(s)
- Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Via Giustiniani 2, Padova, Italy.
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Turnipseed SD, Trythall WS, Diercks DB, Laurin EG, Kirk JD, Smith DS, Main DN, Amsterdam EA. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009; 16:495-9. [PMID: 19426294 DOI: 10.1111/j.1553-2712.2009.00420.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS. METHODS This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55-105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. "Normal" excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients' initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating >70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented. RESULTS A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25-90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4). CONCLUSIONS Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram.
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Affiliation(s)
- Samuel D Turnipseed
- Department of Emergency Medicine, University of California, Davis Medical Center Sacramento, CA, USA.
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ST Elevation Myocardial Infarction in a Teenager: Case Report and Review of the Literature. South Med J 2009; 102:523-6. [DOI: 10.1097/smj.0b013e31819984fc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Di Grande A, Tabita V, Lizzio MM, Giuffrida C, Bellanuova I, Lisi M, Le Moli C, Amico S. Early repolarization syndrome and Brugada syndrome: is there any linkage? Eur J Intern Med 2008; 19:236-40. [PMID: 18471670 DOI: 10.1016/j.ejim.2007.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Revised: 06/18/2007] [Accepted: 06/28/2007] [Indexed: 12/01/2022]
Abstract
Early repolarization syndrome (ERS) is characterized by the presence, in most cases in mid-to-lateral precordial leads, of a J wave on the downsloping portion of the QRS complex, followed by an elevation of the ST-segment with upward concavity. ERS is considered a benign electrocardiographic pattern of ventricular repolarization and, thus far, clinical interest in this syndrome has been confined to its differential diagnosis from myocardial infarction and pericarditis. Brugada syndrome (BS), an inherited cardiac disease first described in 1992, exhibits a characteristic electrocardiographic pattern consisting of a J wave mimicking a right bundle branch block with typical ST-segment elevation in the right precordial leads. Believed to be a normal repolarization variant for more than three decades, the syndrome is now known instead to be associated with a high incidence of life-threatening ventricular tachyarrhythmias and is responsible for a number of sudden deaths in young adults worldwide. Although clinical findings seem to differentiate the two syndromes, similarities between BS and ERS in terms of response to heart rate, pharmacologic agents, and neuromodulation could suggest a linkage in their pathophysiological mechanism. The authors review the clinical and experimental data in order to test this hypothesis.
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Affiliation(s)
- Aulo Di Grande
- U.O.C. di Medicina e Chirurgia d'Accettazione e d'Urgenza, Az. Osp. S. Elia-Caltanissetta, Italy.
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Sovari AA, Assadi R, Lakshminarayanan B, Kocheril AG. Hyperacute T wave, the early sign of myocardial infarction. Am J Emerg Med 2007; 25:859.e1-7. [PMID: 17870505 DOI: 10.1016/j.ajem.2007.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2006] [Revised: 10/31/2006] [Accepted: 02/08/2007] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ali A Sovari
- Department of Internal Medicine, University of Illinois, COM-UC, Urbania, IL 61801, USA.
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Abstract
Young athletes are disproportionately plagued with congenital cardiac disease. Many of these diseases predispose to sudden cardiac death (SCD), a dramatic and tragic outcome for any young athlete. In many cases, conditions that predispose to SCD do not cause symptoms or show signs on examination, making diagnosis of cardiac disease and prevention of SCD difficult. Clinicians should be familiar with common causes of SCD and their symptoms, perform careful evaluations, refer athletes in whom there are concerns, and make sure any concerning findings receive thorough evaluation. Clinicians should also be familiar with and follow recent guidelines on return to play. Unfortunately, most preparticipation examinations are inadequate, due in part to use of inadequate forms. Better forms are available and should replace inadequate ones.
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Affiliation(s)
- Susan Cochella
- Department of Family and Preventive Medicine, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108, USA.
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Turnipseed SD, Bair AE, Kirk JD, Diercks DB, Tabar P, Amsterdam EA. Electrocardiogram differentiation of benign early repolarization versus acute myocardial infarction by emergency physicians and cardiologists. Acad Emerg Med 2006; 13:961-6. [PMID: 16885399 DOI: 10.1197/j.aem.2006.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES ST-segment elevation (STE) related to benign early repolarization (BER), a common normal variant, can be difficult to distinguish from acute myocardial infarction (AMI). The authors compared the electrocardiogram (ECG) interpretations of these two entities by emergency physicians (EPs) and cardiologists. METHODS Twenty-five cases (13 BER, 12 AMI) of patients presenting to the emergency department with chest pain were identified. Criteria for BER required four of the following: 1) widespread STE (precordial greater than limb leads), 2) J-point elevation, 3) concavity of initial up-sloping portion of ST segment, 4) notching or irregular contour of J point, and 5) prominent, concordant T waves. Additional BER criteria were 1) stable ECG pattern, 2) negative cardiac injury markers, and 3) normal cardiac stress test or angiography. AMI criteria were 1) regional STE, 2) positive cardiac injury markers, and 3) identification of culprit coronary artery by angiography in less than eight hours of presentation. The 25 ECGs were distributed to 12 EPs and 12 cardiologists (four in academic medicine, four in community practice, and four in community academics [health maintenance organization] in each physician group). The physicians were informed of the patients' age, gender, and race, and they then interpreted the ECGs as BER or AMI. Undercalls (AMI misdiagnosed as BER) and overcalls (BER misdiagnosed as AMI) were calculated for each physician group. RESULTS Cardiologists correctly interpreted 90% of ECGs, and EPs correctly interpreted 81% of ECGs. The proportion of undercalls (missed AMI/total AMI) was 2.8% for cardiologists (95% confidence interval [CI] = 0.09% to 5.5%) compared with 9.7% for EPs (95% CI = 4.8% to 14.6%) (p = 0.02). The proportion of overcalls (missed BER/total BER) was 17.3% for cardiologists (95% CI = 11.4% to 23.3%) versus 27.6% for EPs (95% CI = 20.6% to 34.6%) (p = 0.03). The mean number of years in practice was 19.8 for cardiologists (95% CI = 19 to 20.5) and 11 years for EPs (95% CI = 10.5 to 12.0) (p < 0.001). CONCLUSIONS Although correct interpretation was high in both groups, cardiologists, who had significantly more years of practice, had fewer misinterpretations than EPs in distinguishing BER from AMI electrocardiographically.
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Affiliation(s)
- Samuel D Turnipseed
- Department of Emergency Medicine, University of California, Davis, Medical Center, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA.
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25
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Abstract
The electrocardiogram performed in the competitive athlete may manifest abnormal electrocardiographic findings; these findings may indicate either normal variant syndromes as well as true cardiac pathology. The normal variant syndromes include ST-segment and T-wave abnormalities, rhythm disturbances, and intraventricular conduction delay--it must be stressed that these electrocardiographic findings are, in fact, normal variants, not indicative of underlying pathology. Other presentations in these same competitive athletes describe significant cardiac pathology, including syndromes predisposing the patient to sudden cardiac death and other potentially dangerous dysrhythmias and diagnostic of acute coronary syndrome. This article reviews the various findings in this group of patients.
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Affiliation(s)
- Jeffrey Wu
- Department of Emergency Medicine, University of Virginia, Charlottesville, 22908-0699, USA
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Klatsky AL, Oehm R, Cooper RA, Udaltsova N, Armstrong MA. The early repolarization normal variant electrocardiogram: correlates and consequences. Am J Med 2003; 115:171-7. [PMID: 12935822 DOI: 10.1016/s0002-9343(03)00355-3] [Citation(s) in RCA: 264] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE We compared the characteristics and outcomes of patients with "early repolarization" electrocardiograms (ECGs) with those who had normal ECGs. METHODS In 1983 to 1985, we collected photocopies of 2234 selected ECGs from 73088 patients undergoing health examinations. Excluding 153 ECGs with missing data or that were judged to be abnormal, the remaining ECGs were reinterpreted in 2000 by cardiologists as showing early repolarization (n = 670), or being borderline (n = 330) or normal (n = 1081). Characteristics and outcomes of persons with early repolarization ECGs were compared with those who had normal ECGs using analysis of variance, logistic regression, or proportional hazards models. Information on exercise was available in 325 patients. RESULTS Patients with early repolarization were more likely to be male (81% [n = 583] vs. 33% [n = 360]), <40 years old (60% [n = 441] vs. 37% [n = 403]), black (48% [n = 384] vs. 26% [n = 280]), and more athletically active (mean [+/- SD], 10.4 +/- 1.3 hours per week of activity vs. 6.4 +/- 1.2 hours per week of activity) than those with normal ECGs. Patients with early repolarization were not more likely to be hospitalized (hazard ratio [HR] = 1.0; 95% confidence interval [CI]: 0.9 to 1.2) or to die (HR = 0.8; 95% CI: 0.6 to 1.2) during follow-up than those with normal ECGs. Outpatient diagnoses were not more common in those with early repolarization; arrhythmias were actually less common (P <0.01). CONCLUSION Although especially prevalent in young, athletic, black men, early repolarization is not rare in other patients. The long-term prognosis of early repolarization is benign.
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Affiliation(s)
- Arthur L Klatsky
- Department of Medicine, Kaiser Permanente Medical Care Program, Oakland, California 94611, USA.
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Dowdy L, Wagner GS, Birnbaum Y, Clemmensen P, Fayn J, Rubel P, Zhou S, Johanson P. Early repolarization: friend or foe? Am J Med 2003; 115:237-40. [PMID: 12935831 DOI: 10.1016/s0002-9343(03)00370-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Somers MP, Brady WJ, Perron AD, Mattu A. The prominent T wave: electrocardiographic differential diagnosis. Am J Emerg Med 2002; 20:243-51. [PMID: 11992348 DOI: 10.1053/ajem.2002.32630] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The prominent T wave is an abnormal T-wave morphology encountered in the earliest phase of ST-segment elevation acute myocardial infarction (AMI). Prominent T waves, however, are associated with other diagnoses, including hyperkalemia, early repolarization, and left ventricular hypertrophy (LVH). This article focuses on the electrocardiographic differential diagnosis of the prominent T wave with the presentation of 4 illustrative cases. We also recommend that the designation hyperacute should refer exclusively to the prominent T waves of ST-segment elevation AMI.
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Affiliation(s)
- Michael P Somers
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Abstract
Acute, or so-called "dry," myopericarditis occurs in the presence of diffuse inflammation of the pericardial sac and superficial epicardium from a multitude of infectious and inflammatory processes. This inflammation results in a current of myocardial injury resulting from the epicardial irritation manifested by a number of electrocardiographic findings. Classically, the electrocardiographic changes have been described as an evolution through several distinct stages involving ST segment elevation with PR segment depression, normalization of the ST segment abnormality with T wave inversion, and eventual normalization of the electrocardiogram over a period of days to several weeks. The following discussion focuses on the electrocardiographic manifestations of acute myopericarditis and includes findings useful in establishing the diagnosis as well as distinguishing the disease from other syndromes, particularly acute myocardial infarction.
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Affiliation(s)
- T C Chan
- Department of Emergency Medicine, University of California San Diego Medical Center, 92103, USA
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