bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of serum potassium on the electrocardiographic pattern of left ventricular hypertrophy in primary hyperaldosteronism
Authors: Maciejewska M. , Dabrowska B.
Published: February 2009

Only a few studies deal with electrocardiographic (ECG) signs of left ventricular hypertrophy (LVH) in patients with primary hyperaldosteronism, although it may be presumed that many factors such as arterial hypertension, hypokalemia, increased blood volume, and decreased activity of the renin‐angiotensin system can modify LVH pattern in this entity. For that reason, we evaluated ECG signs of LVH in 55 patients with primary hyperaldosteronism hospitalized in our department from 1971 to 1990. These data were compared with age, serum potassium level, plasma renin activity (PRA) and—in 14 patients—with left ventricular mass, measured echocardiographically.

We found inverse correlation between serum potassium concentration and the Sokolow‐Lyon index: SV1 + RV5/6 (r = –0.47, p<0.001). Among 24 patients with only abnormal QRS voltage, without ST‐T changes suggestive of LVH, 19 (79.2%) had hypokalemia. In multivariate analysis, potassium concentration was the single independent predictor of an abnormal QRS voltage: –0.743, p = 0.01 vs. 0.153 (age), –0.337 (PRA) and 0.454 (LV mass).

Our observations suggest that hypokalemia is an important factor influencing an amplitude of QRS complexes and may be responsible for false‐positive LVH diagnosis.
A fast fourier transform analysis of coronary reperfusion‐induced ventricular fibrillation and the modification by dibutyryl cyclic amp in a cat model
Authors: Tashiro Noritami , Kumagai Kouichirou , Yamanouchi Yoshio , Matsuo Kunihiro , Hiroki Tadayuki , Arakawa Kikuo
Published: February 2009

To investigate the effect of dibutyryl cyclic AMP (dbcAMP) on ventricular fibrillation after coronary reperfusion, the proximal portion of the anterior descending branch of left coronary artery was reperfused 20 min after ligation in 24 cats. McFee X Y Z electrocardiograms were recorded and ventricular fibrillation was analyzed using a fast Fourier transform analysis (FFT). Ventricular fibrillation occurred in 20 of 24 cases. Sixty seconds after the occurrence of ventricular fibrillation, an intracardiac infusion of dbcAMP was administered. Nine of the 20 were defibrillated and converted to sinus rhythm or junctional rhythm after the administration of dbcAMP. The amplitude and frequency of the main power spectrum of the ventricular fibrillation waves were analyzed by FFT before and after the infusion of saline or dbcAMP. In the saline group there was no significant change in FFT. However, in the dbcAMP group, the amplitude increased significantly from 0.036±0.015 (MV∧2) to 0.054±0.013 (MV∧2) (p<0.01) and the frequency decreased significantly from 4.22± 1.37 (Hz) to 1.33±0.91 (Hz) (p<0.01). Those results indicate that dbcAMP increased the amplitude and decreased the frequency of the main power spectrum of ventricular fibrillation analyzed by FFT. These distinctive changes in FFT analysis were associated with defibrillation in 9 of 20 cases.
Embolus in transit
Authors: Thompson Richard , Slack John D. , Taliercio Charles P. , Waller Bruce
Published: February 2009

Since the advent of echocardiography, embolus in transit, historically found during surgical exploration or on postmortem examination, has been found with increasing frequency on antemortem examination. There is an inherent high mortality rate with this condition and awareness of the association between deep venous thrombosis and embolus in transit is paramount. On echocardiography the embolus is typically seen as a pleomorphic mass moving in a tumbling fashion. The most frequent symptoms are dyspnea and near syncopal episodes. The most common signs are diastolic “tumor plop” and a systolic ejection murmur heard on auscultation. Despite the success of some medical interventions, surgery should be strongly considered in patients with embolus in transit.
Inotropic therapy of the failing myocardium
Authors: Om Anil , Hess Michael L.
Published: February 2009

The clinical syndrome of congestive heart failure remains a therapeutic dilemma and challenge for the physician in 1992. This is a disease process that appears to be increasing in frequency and continues to carry an unacceptably high mortality rate. For years it has been well recognized that the combination of digoxin, Lasix and vasodilator therapy improved symptoms in these patients and decreased hospitalization, but did not increase survival. It was not until 1986 that the combination of digoxin, Lasix, Isordil, and hydralazine was shown to increase survival. Further significant improvement in quality of life and survival has recently been established in three large clinical trials, and it is now safe to say that the standard of care for symptomatic congestive heart failure in 1992 is digoxin, furosemide, and an ACE inhibitor, with the survival trials favoring the ACE inhibitor enalapril. The IV inotropic drug dobutamine remains the mainstay of pharmacological therapy for the treatment of severely refractory heart failure. Unfortunately, the phosphodiesterase inhibitors—amrinone, milrinone, and enoximone—have demonstrated unacceptable clinical side effects and have been withdrawn from further clinical study. In spite of these promising developments, the mortality and morbidity of congestive heart failure remains unacceptably high, and continued investigation in the new fields of pharmacology and the pathophysiology of congestive heart failure still must be aggressively pursued.
Usefulness of ckmb and troponin t determinations in patients with acute myocardial infarction complicated by ventricular fibrillation
Authors: Zabel Markus , Köster Wolfgang , Hohnloser Stefan H.
Published: February 2009

The usefulness of creatine kinase (CK) time activity curves for diagnosis of acute myocardial infarction in patients who have been defibrillated for ventricular fibrillation is limited due to the release of the enzyme as a result of the countershock. The present study of four patients with acute infarction complicated by primary ventricular fibrillation indicates that analysis of CKMB and even more so of troponin T, a specific cardiac antigen, permits reliable diagnosis of acute myocardial infarction in this particular setting. Furthermore, the data indicate that noninvasive assessment of coronary artery patency may be also possible in these patients by means of these two serum markers.
Inadvertent thrombolytic therapy for cardiovascular diseases masquerading as acute coronary thrombosis
Authors: Kahn Joel K.
Published: February 2009

We report three cases of inadvertent thrombolytic administration to patients with cardiovascular diagnoses masquerading as acute coronary thrombosis presenting to a tertiary care private hospital. Despite a final diagnosis of myocarditis, aortic dissection, and pericarditis, the initial presentation and electrocardiogram were believed to indicate an acute myocardial infarction due to coronary thrombosis. Intravenous thrombolytic agents were administered early in their presentation. Cardiac catheterization in two of the patients revealed normal coronary arteriography and in the third patient confirmed an aortic dissection. The patient with an aortic dissection died while the other two recovered without adverse consequences of the thrombolytic agents. Prior reports of five patients, treated with intravenous thrombolytic agents for suspected coronary thrombosis, who proved to have a final diagnosis of pericarditis or aortic dissection are reviewed. Death or tamponade occurred in four of five. The consequences of inadvertently administering intravenous thrombolytic agents to patients with nonthrombotic cardiac disorders can be serious. If the diagnosis of acute myocardial infarction due to coronary thrombosis is uncertain, serial electrocardiograms, bedside echocardiography, or urgent cardiac catheterization may be appropriate before administering these agents.
Effect of oral captopril on premature ventricular complexes in patients with preserved left ventricular systolic function: A randomized clinical trial
Authors: Steinman Russell T. , Ghxey Deborah , Gunther Stephen , Fromm Barbara S. , Lehmann Michael H.
Published: February 2009

Some studies have suggested that angiotensin‐converting enzyme (ACE) inhibition in patients with heart failure is associated with a decrease in frequency of spontaneous premature ventricular complexes (PVCs). It is not clear whether such a finding represents a primary effect of ACE inhibition or, instead, a secondary result of treatment of heart failure. For a primary drug effect to be present, PVC suppression during ACE inhibition should also occur in patients with preserved left ventricular systolic function. We therefore undertook a randomized double‐blind placebo‐controlled crossover clinical trial to assess the effect of oral captopril (50 mg. b. i. d.) on ventricular arrhythmia frequency in 11 patients with > 30 PVCs/h (during a 48‐h ambulatory recording) and a left ventricular ejection fraction of ≥ 45% (measured by radionuclide multigated acquisition scan). Pharmacologic activity of the administered drug was evidenced by an increase in median plasma renin activity to 2. 4 ng/AI/ml/h from a value of 1.1 ng/AI/ml/h during placebo (p = 0.001) and an 8.5 ± 10.3 drop in mean diastolic blood pressure during captopril versus placebo (p < 0.03).

During captopril treatment, a mean of 491 ± 378 PVCs/h were observed compared with 389 ± 169 PVCs/h during placebo, a nonsignificant difference. There was also no significant change in left ventricular ejection fraction, plasma catecholamines, or serum potassium during captopril treatment. Thus, ACE inhibition in patients with preserved left ventricular systolic function fails to suppress ventricular ectopic activity. Extrapolated to patients with heart failure, our observations argue against a primary PVC suppressive action of ACE inhibitors but do not rule out possible secondary antiarrhythmic effects of these agents.
Ventricular arrhythmias in patients recovering from myocardial infarction: Do residual myocardial ischemia and anti‐ischemic medical intervention influence the one‐month prevalence?
Authors: Jespersen Christian M. , Vaage‐Nilsen Merete
Published: February 2009

The relationship between myocardial ischemia revealed by exercise testing and ventricular arrhythmias on Holter monitoring, and the effect of anti‐ischemic intervention on the incidence of ventricular arrhythmias in patients with residual ischemia were studied in 125 patients recovering from myocardial infarction.

Prior to discharge exercise testing and 24‐h Holter monitoring were carried out In patients with ST‐segment depression (n = 34), ventricular arrhythmias on Holter monitoring were seen in 7 (21%) compared with 20 (22%) patients without ST‐segment depression (NS). Patients were hereafter double‐blindly randomized to intervention with verapamil (n = 63) or placebo (n = 62). One month after discharge, 24‐h Holter monitoring was repeated. In the verapamil group ventricular arrhythmias increased from 25 to 33% (NS). In the placebo group the figures were 18 and 27%, respectively (NS). In patients with ST‐segment depression and verapamil treatment, the prevalence increased from 25 to 38% (NS). In the placebo group the figures were 17 and 22%, respectively (NS). The differences between the groups were not significant. A significantly increased prevalence of ventricular arrhythmias was found in patients with either heart failure or non‐Q‐wave infarct. In these patients myocardial ischemia during exercise did not correlate with ventricular arrhythmias either. ST‐segment depression during predischarge exercise testing correlated with neither the prevalence nor the incidence of ventricular arrhythmias, and anti‐ischemic intervention with verapamil did not influence the incidence of ventricular arrhythmias in both patients with and without myocardial ischemia.
Unstable angina: Relationship of clinical presentation, coronary artery pathology, and clinical outcome
Authors: Bertolet Barry D. , Dinerman Jay , Hartke Ralph , Richard Conti C.
Published: February 2009

Patients with unstable angina are heterogeneous with respect to presentation, coronary artery morphology, and clinical outcome. Subclassification of these patients based on clinical history has been proposed as a means of identifying individuals at increased cardiac risk. We applied such a classification system to 129 patients discharged from a coronary care unit with a diagnosis of acute myocardial ischemia. Patients were then assessed for cardiac events (recurrent angina requiring revascularization, myocardial infarction, death) 12 months following hospital discharge. Patients were classified as recent onset unstable angina preinfarction (n = 42), crescendo unstable angina preinfarction (n = 48), and unstable angina postinfarction (n = 39). Within each of these groups, the patients were further subclassified based on the occurrence of angina on effort, at rest, or both. No attempt was made to subset patients taking antiischemic drugs at the time of clinical presentation to the physician. Coronary angiographic pathology (morphology and number of vessels involved) was similar in the subgroups, but coronary artery thrombus was statistically more likely to be found in patients with crescendo rest angina preinfarction or with frequent anginal episodes at rest postinfarction. Mortality was significantly higher for patients with unstable angina postinfarction (7.7%) than preinfarction (1.1%). No statistical differences were noted between the subgroups with respect to the occurrence of myocardial infarction or recurrent unstable angina requiring revascularization. These data suggest that subclassification of unstable angina patients based on clinical characteristics at presentation is not useful to predict subsequent myocardial infarction or recurrent angina requiring revascularization. However, as one might expect, patients with recurrent angina postinfarction have a higher mortality rate than patients with unstable angina preinfarction, and patients with recurrent rest angina, either pre‐ or postinfarction, are more likely to have intracoronary thrombus than patients with new onset angina or crescendo effort angina; however, the presence of thrombus did not predict a poor clinical outcome.
Efficacy of once‐daily lisinopril monotherapy in systemic hypertension
Authors: Hwang Yeo‐Shin , Yen Hsueh‐Wei
Published: February 2009

Lisinopril is a new, long‐acting angiotensin‐converting enzyme inhibitor formulated for once‐daily treatment of hypertension. This study assessed the 24‐h efficacy and tolerability of lisinopril in Chinese patients with mild to moderate hypertension of World Health Organization Stages I to II. A total of 30 patients aged 30 to 60 years (mean 47 ± 9) entered a 2‐week washout period. All patients had ambulatory diastolic blood pressure (BP) > 90 mmHg and were given active treatment with lisinopril for 4 to 7 weeks. The dose of lisinopril was titrated from 10 to 40 mg daily (at 8‐9 A. M.). In each patient, 24‐h ambulatory blood pressure (BP) monitoring (SpaceLabs 90202) was performed twice, once before and once following treatment. Mean 24‐hour systolic/diastolic BPs after lisinopril were significantly decreased compared with baseline values (132 ± 12/86 ± 7 vs. 150 ± 11/98 ± 7 mmHg; p < 0.0005/ 0.0005). The average dose of lisinopril was 14.5 ± 5 mg daily after a titration period of 5 weeks of treatment. Mean daytime (6 A. M. to 6 P. M.) BP decreased from 152 ± 11/100 ± 8 to 134 ± 12/87 ± 8 mmHg (p < 0.0005/0.0005) and nighttime (6 P.M. to 6 A. M.) BP from 147 ± 14/95 ± 9 to 128 ± 14/83 ± 8 mmHg ( p < 0.0005/0.0005). BP reduction was more pronounced during the night. Before treatment, the circadian variation showed a peak BP at 11 A. M. and nadir at 3 P. M. After treatment, significant BP reduction (p < 0.0005/0.0005) was seen throughout the 24‐h period. The circadian rhythm of BP was preserved as indicated by similar BP standard deviations (14 ± 3/11 ± 2 vs. 13 ± 3/10 ± 2 mmHg). Mean heart rate increased from 76 to 80 beats/min (p < 0.05). Four patients reported having a nonproductive cough. Thus, lisinopril administered as once‐daily monotherapy provided effective BP control over a 24‐h period with preserved circadian rhythm.
Idiopathic verapamil‐sensitive sustained left ventricular tachycardia
Authors: Ohe Tohru
Published: February 2009

Idiopathic verapamil‐sensitive left ventricular tachycardia (VT) has characteristic QRS configurations during VT: right bundle‐branch block with either left axis or right axis (less common) deviation. QRS duration is relatively narrow (0.13‐0.16s) and frequently endocardial activation prior to QRS is recorded during VT, which is the basis of its being called fascicular tachycardia. The mechanism is probably reentry, but the nature of the slow conduction necessary for the occurrence of reentry is quite different from that of other sustained monomorphic VT associated with structural heart disease. Chronic oral verapamil therapy is the drug of choice for alleviation of symptoms. Long‐term prognosis is good.
Coronary artery‐right ventricular fistula after coronary artery bypass grafting
Authors: Tami Luis F.
Published: February 2009

Development of a coronary artery fistula rarely occurs after cardiac surgery. We report the appearance of a coronary artery‐right ventricular fistula as a consequence of coronary artery bypass grafting. Possible mechanisms and consequences are discussed.
Electrocardiographic prediction of ejection fraction and site of LAD occlusion in anterior myocardial infarction
Authors: H. Strauss Bradley , Green Martin
Published: February 2009

Q‐wave anterior myocardial infarctions due to occlusion of the left anterior descending artery (LAD) are generally associated with the most extensive left ventricular damage. The presence of abnormal Q waves on the electrocardiogram (ECG) provides important information to localize the site of left ventricular infarction. However, the relationship between abnormalities of the QRS morphology in the precordial leads and angiographic information such as ejection fraction and the site of LAD occlusion (before or after the first septal perforator) has not been studied extensively. Seventy‐three patients with single‐vessel disease with complete LAD occlusion, abnormal QRS morphology in leads V1‐V4 on ECG, and abnormal wall motion with contrast ventriculography were studied retrospectively. LAD occlusions were proximal to the first septal perforator in 33 patients and distal in 40 patients. Q waves were present in 59 patients, and the other 14 patients had either minimal R waves (<0.25 mm), poor R‐wave progression, or R‐wave regression. A significantly higher ejection fraction was associated with the presence of R wave in V2 (0.52 ± 0.18 vs. 0.39 ± 0.15 in the absence of R wave, p<0.003). LAD occlusion after and before the first septal perforator was associated with R wave in V2 in 67 and 36% of patients, respectively. Sensitivity and specificity of predicting occlusion after the first septal perforator based on R wave in V2 was 0.68 and 0.64, respectively. In patients with anterior myocardial infarctions, occluded LAD artery, and abnormal QRS morphology in the precordial leads, the presence of R wave in V2 is a useful predictor of higher ejection fraction. The prediction of site of LAD occlusion in relation to the first septal perforator based on ECG findings is limited and probably not sufficiently specific or sensitive to be of clinical use.
Electrocardiographic responses to jogging in middle‐aged and older men and women
Authors: Jetté M. , Blümchen G. , Treichel P. , Landry F.
Published: February 2009

Recent jogging‐related sudden deaths rekindled the concern among health professionals as to the hazards of strenuous exercise. The purpose of this study was to evaluate the extent of rhythm disturbances and myocardial ischemia in older men and women during a typical strenuous jogging session. Twenty‐two members of a local jogging club (11 men and 11 women) between the ages of 50 and 66 years participated in the study. The CardioData PR3/ST monitor was employed to record heart rate, rhythm disturbances, J point and ST slope during the course of the run. The men ran a 10 km run and the women a 6 km run at a competitive pace. The mean maximal heart rate during the run was 170 ± 15 beats/min for the males and 176 ± 14 beats/min for the females. The mean J point during the run was ‐3.39 ± 1.21 mV for the males and ‐2.97 ± 0.96 mV for the females. Females showed a significantly lower mean ST slope (3.95 + 0.91 mV) during the run than the males (5.56 ± 1.37 mV, p < 0.05). A number of episodes of premature ventricular beats, both uni‐ and multifocal, were observed. Exercise testing of sufficient intensity is recommended to detect those persons susceptible to developing serious arrhythmias during strenuous exercise.
Transient left ventricular aneurysm in a patient with hypertrophic cardiomyopathy and myocarditis
Authors: Z. Fisher Daniel , G. DiSalvo Thomas , Dec G. William , W. DeSanctis Roman
Published: February 2009

Left ventricular wall motion abnormalities, aneurysm formation, and progression to global hypokinesis have been described in patients with myocarditis and in patients with hypertrophic cardiomyopathy. We document a case of reversible aneurysm formation, cardiogenic shock, and complete recovery in a patient with myocarditis and hypertrophic cardiomyopathy. Pathophysiologic mechanisms of myocardial injury and recovery are discussed.
Ethanol‐induced myocardial ischemia: Close relation between blood acetaldehyde level and myocardial ischemia
Authors: Ando Hiroshi , Abe Hirohiko , Hisanou Ryuuichi
Published: February 2009

A patient with vasospastic angina who developed myocardial ischemia following ethanol ingestion but not after exercise was described. Myocardial ischemia was evidenced by electrocardiograms (ECGs) and thallium‐201 scintigrams. The blood acetaldehyde level after ethanol ingestion was abnormally high. The time course and severity of myocardial ischemia coincided with those of the blood ethanol and acetaldehyde level. Coronary arteriography showed ergonovine maleate‐induced coronary vasospasm at the left anterior descending coronary artery. ECG changes similar to those induced by ethanol ingestion were observed at the same time. These findings suggest that the high blood acetaldehyde level might be responsible for the development of coronary vasospasm and myocardial ischemia in this patient.
Sarcoidosis of the Heart
Authors: Shammas Rony L. , Movahed Assad
Published: February 2009

Myocardial involvement in sarcoidosis occurs in about 27% of patients. Clinical manifestations include ventricular arrhythmias, conduction abnormalities, and sudden death. Diagnosis requires clinical suspicion and may be supported by electrocardiography, echocardiography, thallium imaging, gallium‐67 scanning, and myocardial biopsy. Steroids seem to be beneficial in the treatment of myocardial sarcoidosis. Those who do not respond to medical treatment may benefit from cardiac transplantation.
Ventricular arrhythmias late after myocardial infarction are related to hypomagnesemia and magnesium loss: Preliminary trial of corrective therapy
Authors: Ceremużyński Leszek , Van Hao Nguyen
Published: February 2009

It has been well established that in acute myocardial infarction (MI) many patients display low serum magnesium (Mg). This is associated with complex ventricular arrhythmias. The question arises whether predischarge arrhythmias occurring late after MI might also be related to Mg imbalance. In 118 patients subjected to heart rhythm 24 h Hotter monitoring in the second or third week after MI, we investigated (1) the relationship between serum Mg, urinary Mg loss, and ventricular arrhythmias, and (2) the effect of Mg supplementation on heart rhythm disturbances. In patients with undisturbed rhythm or monomorphic ventricular ectopic beats (VEB) (Lown 0‐2; n = 84), mean serum Mg level (mg% ± SD) was 1.83 ± 0.21, whereas in patients with multifocal VEB, pairs, or nonsustained ventricular tachycardia (VT) (Lown 3–4; n=34) serum Mg was decreased to 1.68 ± 0.27 (p < 0.01). Serum Mg normal range in our laboratory is 1.7–2.6 mg%. The lowest serum Mg reaching 1.55 ± 0.27 was found in nonsustained VT (Lown 4 b) subgroup (n = 14). Urinary Mg loss measured in 81 patients was more pronounced in those with Lown 3–4 arrhythmias (n=26) than with Lown 0–2 (n = 55). The daily values were 73 ± 22 and 54.4 ± 26 mg, respectively (p < 0.001). Thirteen patients with complex arrhythmias and low serum Mg received Mg supplementation (MgSO4, 8 g in 500 ml 5% glucose intravenously during 24 h). This resulted in restoration of almost undisturbed rhythm in 10 subjects. In conclusion, a number of patients in late phase of MI displayed hypomagnesemia concomitant with augmented Mg excretion. These alterations were related to the occurrence of arrhythmias: die most threatening heart rhythm disturbances were accompanied by the lowest serum Mg and the highest Mg excretion. Our preliminary observations suggest that supplementation with MgSO4 may be a reasonable approach to the treatment of predischarge complex ventricular arrhythmias after MI. This should be verified in a controlled trial.
Lone atrial fibrillation and anticoagulant therapy
Authors: More R. S. , Brack M. J. , Gershlick A. H.
Published: February 2009

Assessment of risk of thromboembolism and potential benefit of prophylaxis with long‐term anticoagulant therapy in lone atrial fibrillation is hampered by a lack of consensus regarding definition of lone atrial fibrillation. In general, patients less than 60 years of age with normal left ventricular function and left atrial size have a low risk of thromboembolic events and are unlikely to gain any significant benefit with anticoagulants; however, patients older than 60 years with impaired left ventricular function, enlarged left atrium, and/or associated conditions such as hypertension have an increased risk of thromboembolism and would benefit from long‐term anticoagulant therapy. Decisions regarding anticoagulant usage would be simplified by using a scoring system containing clinical and investigational variables.
Anatomy, histology, and pathology of the cardiac conduction system—Part IV
Authors: Waller Bruce F. , Gering Lawrence E. , Branyas Nancy A. , Slack John D.
Published: February 2009

Metastatic tumor involvement of the heart as a basis for the genesis of various cardiac arrhythmias is reviewed. The morphologic basis of pre‐excitation syndromes and right ventricular dysplasia are also reviewed.
Hypothyroid cardiac tamponade presenting with severe systemic hypertension
Authors: Machado Christian , Bhasin Surjit , Nona Wassim , Steinman Russell T.
Published: February 2009

Hemodynamic data are presented which not only depict typical tamponade physiology, but demonstrate that hypotension may not necessarily be present with slow accumulation of pericardial fluid in myxedema patients. This case is unique in that severe hypertension, as part of the presentation of hypothyroid tamponade, has never been reported.
Stress‐induced polymorphous ventricular tachyarrhythmias in two brothers: Unusual pattern of inheritance in the long QT syndrome
Authors: Pfammatter J. P. , Weber J. W. , Stocker F. P. , Gertsch M. , Moser H. , Kappenberger L.
Published: February 2009

Two brothers, 10 and 9 years old, are reported who were treated for years with antiepileptic drugs until the cardiac origin of their syncopal attacks was discovered. Our findings are consistent with the diagnosis of long QT syndrome, although no other family members are affected and only intermittent and mostly borderline QT prolongation could be found. Diagnostic difficulties and genetic implications are discussed.
Interventional techniques for the management of coronary artery lesions: An update
Authors: De Feyter Pim J. , Macleod Donald C. , Foley David , De Jaegere Peter P. T. , Serruys Patrick W.
Published: February 2009

Coronary balloon angioplasty has become standard treatment for ischemic coronary artery disease. Major limitations of angioplasty are the inferior results obtained with unfavorable lesions, the occurrence of abrupt occlusion responsible for in‐hospital mortality and morbidity, and the high restenosis rate at 6 months. New techniques for stents, laser, and atherectomy have been developed to overcome these limitations. Until now, although the initial results are encouraging, these new techniques have not as yet shown to be clearly superior to balloon angioplasty. However, due to the limitations of balloon angioplasty, further development of new techniques should be stimulated so that nonsurgical treatment of coronary artery disease will become safer, more effective, and applicable to a wider spectrum of coronary artery disease.
Transesophageal echocardiography: Increased risk by repeated attempts to insert the transducer in patients with coronary artery disease?
Authors: Grosse‐Hettmeyer Wolfgang , Engberding Rolf
Published: February 2009

The question of whether several attempts at transducer insertion increase the risk of performing transesophageal echocardiography (TEE) in patients with coronary artery disease (CAD) has not been addressed to date. In the course of performing TEE in 45 patients with CAD, two or more attempts to insert the transducer were necessary in 9 cases. During various attempts, heart rate, blood pressure and ST‐segment depression were recorded and correlated with the findings of the exercise electrocardiogram (ECG) and coronary angiography. Insertion was successful in six patients after two attempts and in three other patients after three, four, and five attempts, respectively. Heart rate rose significantly (p<0.005) with the increase of insertion attempts. In one patient, it continued to rise at the fourth attempt, reaching 216% compared with the initial heart rate. Systolic blood pressure rose by 5%, whereas there was hardly any change in diastolic blood pressure. As the number of insertion attempts increased, we recorded a continuous ST‐segment depression in eight patients with angiographic changes of the coronary artery system. The depression was already significant at the first attempt (p<0.05). Compared with the initial reading (0.053 mV), the increase was 335% (p<0.01) after the second attempt (0.231 mV). One patient whose angiographic findings were normal had no ST‐segment depression during TEE. In all eight patients with CAD ST‐segment depression during TEE was > 0.2 mV. Since none of the patients complained of angina pectoris, the ST‐segment depressions satisfied all the criteria of silent myocardial ischemia. Thus, in the performance of TEE in patients with CAD, ST‐segment depression is consistently intensified with each additional attempt to insert the transducer and must be taken as an indicator of myocardial ischemia. Investigators should consider systemic analgesia (conscious sedation) when performing TEE in patients with CAD.
Interobserver variation in interpretation of electrocardiographic signs of atrial infarction
Authors: Christensen Jeppe Hagstrup , Nielsen Finn Erland , Falste‐Jensen Niels , Schmidt Erik Berg
Published: February 2009

The electrocardiogram (ECG) is the only means of diagnosing atrial infarction antemortem. Certain ECG changes (PR‐segment displacements) have been taken earlier as signs of atrial infarction. The purpose of this study was to assess the interobserver variation on suggested ECG signs of atrial infarction in patients admitted with acute myocardial infarction. The ECGs from 290 patients were evaluated by three physicians with respect to the occurrence of each of the following seven criteria suggestive of atrial infarction: (1) PR‐segment elevation > 0.5 mm in lead I; (2) PR‐segment depressions > 0.5 mm in leads II and III; (3) PR‐segment depressions > 1.2 mm in leads I, II, and III; (4) PR‐segment depressions > 0.5 mm in leads V1 and V2; (5) PR‐segment elevations > 0.5 mm in leads V5 and V6; (6) PR‐segment depressions > 1.5 mm in precordial leads; and (7) abnormal P waves. Kappa values ranged from 0.00–0.86. Of the seven criteria tested only criteria 2, 4, and 7 could be detected in a reasonable number of patients. The interobserver variations of these criteria were considerable, although the strength of agreement could be designated as fair to moderate.
Ventricular tachycardia due to sustained bundle branch reentry: Diagnostic and therapeutic considerations
Authors: Blanck Zalmen , Akhtar Masood
Published: February 2009

We have identified bundle‐branch reentry (BBR) as the mechanism of ventricular tachycardia (VT) during electrophysiologic studies in 48 patients at our institution. All but three patients had significant structural heart disease, that is, dilated ischemic or idiopathic cardiomyopathy, the most common of anatomic substrates. Syncope and sudden death were the modes of presentation in up to 70% of these patients. The critical prerequisite for the development of this arrhythmia is conduction delay in the His‐Purkinje system, which was present in all patients and manifests as a nonspecific conduction delay or a left bundle‐branch block (LBBB) in the surface electrocardiogram (ECG) and a prolonged HV interval in the intracardiac recordings. VT with an LBBB morphology is the most common form of BBR, present in 98% of patients. Transcatheter ablation of the right bundle branch (RBB) with the use of radiofrequency current is the treatment of choice, as it effectively eliminates BBR. During long‐term follow‐up, recurrent tachycardia due to BBR was not documented in any patient; however, congestive heart failure was a common cause of death in this population.
Anatomy, histology, and pathology of the cardiac conduction system—part VI
Authors: Waller Bruce F. , Gering Lawrence E. , Branyas Nancy A. , Slack John D.
Published: February 2009

Various pathologic conditions producing atrioventricular block are reviewed. Calcific atrioventricular block (aortic stenosis, mitral valve annular calcium), active infective endocarditis (“ring” abscess), acute and healed myocarditis, various collagen‐vascular diseases, amyloidosis, and tumors are reviewed as causes of atrioventricular block. Various diseases producing bundle‐branch block are also discussed.
Congestive heart failure in a patient with systemic hypertension
Authors: Hackel Donald B. , Wagner Galen S.
Published: February 2009

A 70‐year‐old man developed hypertension many years previously and had a bout with severe congestive heart failure 4 to 5 years before his death. Autopsy showed congestion and edema characteristic of heart failure, an enlarged heart, and slight focal interstitial left ventricular fibrosis, but only slight to moderate coronary atherosclerosis.
Abnormal signal‐averaged electrocardiogram in patients with duchenne muscular dystrophy: Comparison of time and frequency domain analyses from the signal‐averaged electrocardiogram
Authors: Kubo Masahiro , Matsuoka Suguru , Hayabuchi Yasunobu , Akita Hiroshi , Kuroda Yasuhiro , Matsuka Yutaka
Published: February 2009

The clinical significance of an abnormal signal‐averaged electrocardiogram (SA‐ECG) in time‐ and frequency‐domain analyses was assessed in patients with Duchenne muscular dystrophy (DMD). Twenty‐four DMD patients and 20 age‐matched healthy volunteers were studied. The SA‐ECG was recorded by time‐domain signal processing using the vector‐magnitude method and frequency‐domain signal processing using the fast‐Fourier transform. Abnormal SA‐ECGs were based on comparison with controls and eight abnormal SA‐ECGs were detected among 24 DMD patients, seven by frequency‐domain analysis and four by time‐domain analysis. The end‐diastolic left ventricular volume was larger in the patients with abnormal SA‐ECG than in those with normal SA‐ECG (136±32 ml vs. 77±43 ml, p<0.01). Compared with patients with normal SA‐ECGs, the DMD patients with abnormal SA‐ECGs had a lower left ventricular (LV) ejection fraction (54±6 vs. 61 ± 8%, p < 0.05), as an index of LV contractility, and less LV posterior wall velocity (46±9 mm/min vs. 62 ± 16 mm/min, p <0.01), as an index of LV relaxation. The sensitivity and specificity of frequency‐domain analysis for predicting malignant ventricular arrhythmias was 60 and 85%, respectively, compared with 30 and 92%, respectively, for time‐domain analysis. The combination of time‐ and frequency‐domain analyses can facilitate identification of DMD patients with ventricular tachyarrhythmias associated with depression of cardiac performance.
A clinical trial evaluating the 24‐hour effects of bisoprolol/hydrochlorothiazide 5 mg/6.25 mg combination in patients with mild to moderate hypertension
Authors: Lewin A. J. , Lueg M. C. , Targum Shari , Cardenas Pamela
Published: February 2009

This study used 24‐h ambulatory blood pressure (BP) monitoring to investigate the effectiveness of a novel low‐dose combination of bisoprolol/hydrochlorothiazide in adult patients with mild to moderate essential hypertension. Thirty‐six patients with stable mild to moderate hypertension (sitting diastolic BP 95–114 mmHg) after a placebo run‐in phase received oral bisoprolol/hydrochlorothiazide 5 mg/6.25 mg once daily for 4 weeks in a single‐blind regimen. At office visits, BP and pulse were measured with statistically significant reductions (p<0.01) recorded after 2 and 4 weeks of treatment Twenty‐four‐h ambulatory BP monitoring at the completion of therapy revealed significant reductions (p<0.01) in both systolic and diastolic 24‐h, daytime, and nighttime BP, compared with the end of the placebo treatment phase. Systolic and diastolic load were also reduced (p<0.01). The combination was well tolerated, and overall quality‐of‐life questionnaire scores indicated an improvement after bisoprolol/hydrochlorothiazide therapy (p = 0.02). No clinically significant changes from baseline in laboratory parameters were observed; in particular, serum potassium was unchanged. This is the first study to demonstrate the 24‐h effectiveness of the bisoprolol/hydrochlorothiazide 5 mg/6.25 mg combination, using 24‐h ambulatory BP monitoring. In addition, antihypertensive therapy with low doses of bisoprolol/hydrochlorothiazide in combination may improve tolerability.
Traumatic rupture of an aortic ulcerative atherosclerotic plaque producing aortic dissection: A complication of interscapular back blows used to dislodge objects from the esophagus
Authors: Patterson David L. , Brennan Shawn , Cartwright Thomas , Jolly Walter , Adlam James H. , Waller Bruce F.
Published: February 2009

Penetrating atherosclerotic ulcer of the aorta is a rare entity which usually occurs in the descending thoracic aorta. Herein, we report an unusual case of penetrating aortic ulcer which ruptured into the mediastinum. Interscapular back blows were performed on our patient in an attempt to dislodge an aspirin which she thought was lodged in her esophagus. Unlike previously reported cases of this entity, the penetrating aortic ulcer in our patient was located in the distal thoracic asending aorta. Diagnosis of penetrating aortic ulcer can be made by utilizing aortography, contiguous dynamic contrast‐enhanced computed tomography or magnetic resonance imaging. Treatment consists of adjunctive medical therapy until surgery can be performed.
Successful delivery following myocardial ischemia during the second trimester of pregnancy
Authors: Shalev Yoseph , Epstein Menashe , Ayzenberg Oded , Caspi Abraham , Ben‐Hur Herzl , Hagay Zion , Blickstein Isaac , Gelven Alan
Published: February 2009

Acute myocardial infarction during pregnancy is considered to be associated with approximately 50% mortality of both mother and fetus. However, there are not enough data regarding the role of acute myocardial ischemia. We present a 36‐year‐old, pregnant, white female who was admitted twice at 18 and 20 weeks of gestation with acute myocardial ischemia. Cardiac catheterization revealed 70–80% stenosis of the mid left anterior descending artery (LAD) with normal antegrade flow and very good retrograde filling of the LAD from distal collaterals of the right coronary artery. Therefore, due to angiographic suggestion of protected LAD territory, we recommended medical therapy and scheduled a vaginal delivery that was successfully completed without cardiovascular complications. A stress thallium test performed 6 months later was normal, supporting our clinical judgment. In conclusion, every case of a pregnant woman with coronary insufficiency should be treated according to individual coronary anatomy and blood supply to the territory of the diseased artery, and should not be based on the old data in the literature. The decision for revascularization prior to delivery versus medical therapy, or Caesarean section versus natural delivery, should be made by a team of a cardiologist and an obstetrician.
Magnesium and the heart: Antiarrhythmic therapy with magnesium
Authors: Fazekas Tamás , Scherlag Benjamin J. , Vos Marc , Wellens Hein J. J. , Lazzara Ralph
Published: February 2009

Magnesium is an essential transmembrane and intracellular modulator of the electrical activity of cardiac cells. This review provides an up‐to‐date consideration of the cellular and clinical electrophysiological role of magnesium. This ubiquitous element seems to be important from both the theoretical and clinical point of view, because magnesium salts (MgSO4, MgCl2) administered intravenously are particularly effective in those arrhythmias in which the mechanism involves early or delayed afterdepolarization‐induced triggered activity. The authors share the view that I. V. magnesium is the drug of choice in “torsade de pointes” ventricular tachycardia accompanying acquired long QT/QTU syndrome. It is a complementary therapeutic agent in digitalis‐induced tachycardias. Further studies are needed to elucidate magnesium's mode of action and efficacy in other types of clinical tachyarrhythmias.
Different pressure gradients can be produced in a fixed stenosis— an in vitro study
Authors: Chiang Hung‐Ting , Lin Shoa‐Lin , Hwang Daw‐Yang , Wang Shih‐Pu , Chang Mau‐Song
Published: February 2009

An in vitro study was conducted, using a stenotic model to demonstrate that different pressure gradients can be produced by the same degree of valvular stenosis. This model is comprised of two cylindric chambers with a diaphragm in the center which had a small central hole. An injector was connected to one end of the prestenotic chamber to produce a steady pulsed flow. A rubber tube was connected to the other end of the poststenotic chamber and led upward to a large reservoir which provided a constant afterload pressure. Two pressure transducers were attached to the two connecting tubes, both linked with two pigtail catheters which were accommodated in the chambers just before and after the stenotic diaphragm. Two sets of injection volumes (20 and 30 ml) and multiple injections with different flow rates (5, 10, 15,…49 ml/s) were administered and resulting pressures measured by the two transducers were recorded. Results showed that different pressure gradients could be produced using the same injection volume, the same afterload, and the same degree of stenosis. The greater the flow rate, the higher the pressure gradient. Good correlation existed between the pressure gradient and the injection flow rate (r = 0.95 and 0.97 for the study groups receiving 20 and 30 ml injection volumes, respectively; p< 0.001 in all comparisons). Thus, a higher pressure gradient may not necessarily indicate a severe degree of valvular stenosis. Evaluation of a stenotic lesion should not be made from the degree of pressure gradient alone—other hemodynamic conditions should also be taken into account.
Quantification of left‐side intracardiac pressures and gradients using mitral and aortic regurgitant velocities by simultaneous left and right catheterization and continuous‐wave doppler echocardiography
Authors: Ge Zhi‐Ming , Zhang Yun , Fan Dong‐Sheng , Zhang Mei , Fan Jue‐Xin , Zhao Yu‐Xia
Published: February 2009

Noninvasive determination of left‐side intracardiac pressures is of clinical importance in many cardiac diseases. To test the reliability and accuracy of left‐side intracardiac pressure measurements by continuous‐wave Doppler echocardiography, using left‐side valvular regurgitations, 47 patients with mitral regurgitation, with or without associated aortic regurgitation, underwent simultaneous Doppler and left and right catheterization. Doppler‐derived left atrial and ventricular end‐diastolic pressures were respectively estimated by subtracting mitral regurgitant gradient from systolic blood pressure and by diastolic blood pressure minus aortic regurgitant gradient. There were high correlations of mitral (r = 0.961) and aortic regurgitant gradients (r = 0.896) and of left atrial (r = 0.945) and ventricular end‐diastolic pressures (r=0.854) between noninvasive and invasive measurements. Also, agreement analyses showed that there was close agreement between the two technical measurements for each parameter. The present study concluded that continuous‐wave Doppler echocardiography provides a reliable and accurate method for the noninvasive evaluation of left‐side intracardiac pressures and gradients in patients with mitral and aortic regurgitations.
Myocarditis as a complication in scleroderma patients with myositis
Authors: Kerr Leslie Dubin , Spiera Harry
Published: February 2009

This report describes six diffuse scleroderma (PSS) patients with skeletal muscle myositis accompanied by severe myocarditis, diagnosed by CPK‐MB elevation in conjunction with severe left ventricular (LV) hypokinesis. Although the myositis improved with steroid therapy in all patients, those treated with steroids alone died due to progressive LV failure. This experience suggests that the LV dysfunction in PSS patients with myositis may have an inflammatory component. Since the myocarditis may not be clinically apparent initially, it is suggested that CPK‐MB fractionation and studies of LV function are undertaken in all PSS patients with myositis. The optimal treatment of this disorder, however, has yet to be determined.
Anomalous origin of the circumflex coronary artery from the right sinus of valsalva as a cause of ischemia at old age
Authors: Rozenman Yoseph , Schechter David , Gilon Dan , Gotsman Mervyn S.
Published: February 2009

The case of a patient with an anomalous origin of the circumflex coronary artery causing myocardial ischemia and infarction is presented. Even though the anomalous artery was not located between aorta and pulmonary artery, this anomaly, which is usually considered benign, was responsible for the ischemic symptoms. Transesophageal echocardiographic study demonstrated an acute angulation at the proximal portion of this abnormal vessel, very close to its origin from the right coronary sinus, which we believe caused the abnormality in coronary flow in this patient.
I‐123 metaiodobenzylguanidine—thallium‐201 mismatch following myocardial infarction
Authors: Lekakis John , Antoniou Anna , Vassilopoulos Nicos , Tsinikas Dimitrios , Palaistides Christos , Kostamis Panos , Moulopoulos Spyridon
Published: February 2009

Experimental data show that myocardial infarction (MI) results in regional depletion of myocardial cathecholamines more extensively than necrosis. To investigate the extent of adrenergic denervation post MI in humans, we examined 16 patients, 59 ± 12 years old, with recent (7‐12 days) MI. Resting thallium‐201 (201Tl) single photon emission computerized tomography (SPECT) imaging was performed to assess necrosis; metaiodobenzylguanidine I123 (MIBG) SPECT was used to evaluate adrenergic denervation. 201Tl and I123 MIBG defects were evaluated quantitatively using polar maps, and differences in defects were expressed as percent of total polar map. in all patients, I123 MIBG defect was larger than 201Tl defect, and difference ranged from 19 to 61 % (39.5 ± 13.2%). Thrombolysis and age > 60 did not influence the difference. Anterior MI showed larger differences (44± 13 vs. 32± 11 %, p < 0.05); patients with ischemic electrocardiographic (ECG) changes in leads without abnormal Q waves had larger differences (45 ± 9 vs. 33 ± 14%, p< 0.05). It was concluded that (a) patients with recent MI present denervation larger than 201Tl perfusion defect, and (b) patients with anterior MI and ischemic ECG changes present a larger area of denervation.