What are the prognostic implications and factors relating to exercise induced electrocardiographic ST segment changes in the setting of a non-ischaemic stress echocardiogram?

Background. Electrocardiographic (ECG) changes during stress testing are a common and perplexing finding during non-ischaemic stress echocardiography (SE). Research has provided conflicting results regarding the implications. Methods. SE was performed after maximal Bruce protocol treadmill exercise. Results. 3020 consecutive patients, mean age 58±12 years, 36% female, were followed-up for up to 9 years (mean 36±21 months) post SE. Time to first cardiac event (composite of heart failure admission, worsening New York Heart Association class, worsening ejection fraction, acute coronary syndrome, revascularization, angina or cardiovascular death) was analyzed and adjusted using Cox proportional hazards regression. Prognostic significance was found with 1.5mm of downsloping or horizontal ST depression. Adjusting for baseline differences, increased risk of composite major adverse cardiac events was shown with at least 1.5mm of exercise induced ST depression (Hazard ratio [HR] of 2.47, 95% Confidence ratio [CI] 1.67-3.72, p<0.0001). Patients achieving high level exercise capacity (≥13 metabolic equivalents or METs) with ST depression lower risk of cardiac events during follow-up Conclusion. Patients with ST segment depression but non-ischaemic stress imaging have poorer prognosis compared to patients with non-ischaemic stress echocardiograms with normal stress ECGs. ST depression of 1.5mm or more was established as a prognostically significance value. High exercise capacity improves prognosis, and ECG changes in that setting can be regarded as false positives. Overall, however, ST depression during non-ischaemic stress imaging is not a benign finding.

Electrocardiographic Changes in Type-1 Diabetes Mellitus Children with Diabetic Ketoacidosis Presenting to Tertiary care Hospital, Karachi

Introduction: Cardiac arrhythmias and arrest have been described in children with diabetic ketoacidosis and generally have been presumed to be caused by electrolyte abnormalities. The rationale of this study was to assess the role and importance of ECG monitoring, as a simple, quick, non-invasive and readily available tool in the diagnosis and confirmation of hypokalemia and hyperkalemia in patients with DKA in the Emergency Department Objective: To Assess the Frequency of electrocardiographic changes in Type-1 diabetes mellitus children with diabetic ketoacidosis presenting to tertiary care hospital, Karachi. Materials and Methods: This retrospective cross sectional study was carried out at the department of pediatric medicine, NICH Karachi. At the time of presentation, the standard 12-lead ECG was recorded by a single pediatric cardiologist having more than 2 years of experience, QT and RR intervals were measured. Three separate measurements were obtained from each ECG, and the mean of these measurements was used as the value for QTC. QTC of at least 0.45s (450ms) was considered as prolonged QTC. QTD was also assessed at the same time and QTD>50 ms was considered as prolonged QTD. Results: One hundred cases of T1DM with DKA were included in this study. Average age of children was 7.9 ±3.5 years (Min – Max = 0.5 – 14 years), male to female ratio was 1: 0.96. Prolong QTc and QTd interval was observed in (56%) and (38%) children respectively, Mean (±SD) QTc and QTd interval was 449.4 ±36.6 mc and 39.3 ±16.1 mc respectively. While ECG changes were found in (58%) cases. Association between ECG changes and the cases with higher RBS (>350 mg/dl) was statistically significant 81 (81%) cases with ECG changes had higher RBS (p<0.0001) while ECG changes were statistically similar in both age groups and gender (p-values > 0.05). Conclusion: The frequency of ECG changes was higher in T1DM children with diabetic ketoacidosis. ECG changes was significantly associated with higher RBS (>350 mg/dl). Key words: T1DM, Diabetic Ketoacidosis, ECG, QTc, QTd

Electrocardiographic (ECG) Characteristics among Malaysian Athletes

The electrocardiogram (ECG) is a graphic representation of the heart's electrical activity. Although it has some limitations as a diagnostic or prognostic tool, it contains a wealth of information necessary for the proper care of a patient with a potential cardiovascular disease. Understanding the ECG changes among athletes would allow medical practitioners to distinguish between normal physiological adaptations and abnormal changes. However, there is limited data on the ECG characteristics among multi-ethnic athletes such as in Malaysia. This study aimed to determine the ECG characteristics and its associated factors among Malaysian national athletes. Malaysian national athletes annual pre-participation medical records were retrieved. Information on sociodemographic, sports and medical history including the 12-lead resting ECG tracings were extracted. ECG were assessed and categorised into normal, physiological adaptation changes, and abnormal ECG using the standardised ‘Seattle criteria’. Differences in ECG characteristics between genders, ethnic background, and type of sports was investigated. Additionally, factors associated with the ECG characteristics were assessed using multiple logistic regression. Majority of Malaysian national athletes had physiological adaptation ECG changes (61%). The most frequent changes were early repolarization, sinus bradycardia and isolated left ventricular hypertrophy. We found significantly higher prevalence of physiological adaptation changes among men (÷2(2,371) = 18.9; p = 0.001) and athletes of Chinese ethnicity (both genders) (÷2(2,356) = 13.8; p = 0.002). Factors associated with physiological ECG changes were men (OR=2.67; 95% CI= 1.68, 4.27; p<0.001) and Chinese ethnicity (OR=2.92; 95% CI=1.68, 4.27; p=0.039). Most athletes had physiological adaptation ECG changes which were significantly associated with male gender and Chinese ethnicity. This information would facilitate the development of a specific guideline in interpreting ECG among Malaysian athletes.

Differential Diagnosis of Fulminant Myocarditis and Acute Coronary Syndromes in the Case of Failure of Coronary Angiography: A Case Report

Fulminant myocarditis (FM) is a severe disease with a rapidly progressive and life-threatening course caused mainly by viral infection. The symptoms, laboratory findings, and presence of ECG changes resemble acute coronary syndrome. Therefore, coronary angiography is usually helpful in making the appropriate diagnosis. However, failure to obtain complete coronary artery images due to coronary artery anatomic variations poses a challenge for the diagnosis of FM. Here, we report a case of FM preliminarily diagnosed as acute coronary syndrome (ACS) due to the presence of coronary artery anomaly.

The timing of administering aspirin and nitroglycerin in patients with STEMI ECG changes alter patient outcome

Background Both chewed aspirin and sublingual nitroglycerin are fast acting medications and reach therapeutic levels within a few minutes. Current guidelines for managing acute coronary syndrome (ACS) do not recognize the importance of the order or timing of administering aspirin and nitroglycerin. This retrospective study aimed to examine if there was any benefit to the timing of giving aspirin before or after nitroglycerin in cases of ACS. Methods From the large National Emergency Medical Services Information System (NEMSIS) 2017 Version database, 2594 patients with acute coronary syndrome were identified (based on chest pain and their ECG finding) that received aspirin plus nitroglycerin in prehospital settings. Based on which medication was given first, the patients were separated in 2 groups: an aspirin-first and a nitroglycerin-first group. The 2246 patients who received aspirin first were further stratified based on the time between administration of aspirin and the first dose of nitroglycerin. The other 348 patients who received nitroglycerin first were similarly stratified. Results In patients with STEMI ischemia, giving nitroglycerin 10 min after aspirin dosing (compared to giving them simultaneously) leads to a greater than 20% reduction in need for additional nitroglycerin, a greater than 7% decrease in subjective pain experienced by the patient and reduced need for additional opioids. The aspirin-first group in total, had a 39.6% decrease in subjective pain experience after giving additional nitroglycerin compared to nitroglycerin-first group. Conclusion In patients with ACS, this study found that giving nitroglycerin 10 min after aspirin was associated with a reduction in subjective pain scores, as well as a reduced need for additional nitroglycerin or opioids. Future prospective trials examining the timing of aspirin vs. nitroglycerin are needed to confirm these findings.

Electrocardiographic Changes and Serum Troponin Levels in Patients with Acute Stroke, A Prospective Descriptive Analytical Study from Sudan

Background:Electrocardiographic changes and elevated serum troponin are frequent findings in acute stroke. They may reflect what is known as the neuro-genic myocardial injury. However, as stroke and cardiac diseases share the same risk factors. Coexistence of the two is highly susceptible.Objectives:To determine the electrocardiographic changes and serum troponin level in acute stroke patients and to correlate these changes to the anatomical location and pathological type of the stroke.Methods:A prospective descriptive analytical study was conducted at the national center of neurological Science, from January to December 2019 Study was done at the neurological center in Sudan, The National Center of Neurological sciences. All cases presented with acute stroke during the study period were included. Non-probability sampling, with total coverage during study period was considered. 50 patients were included in the study. Data were analyzed by using (SPSS) version 25. 12 standards ECG were performed in the first hours of admission. 2 samples from each patient were obtained for serum troponin with at least 8 hours apart.Results:All patients had wide variants of ECG changes. But tachycardia was the most frequent one identified in 54% of patients (27/50). Half of them were found to have an anterior circulation stroke. 14% of patients (7/50) have positive troponin; ECG changes identified in all of patients who represent positive troponin100 %( 7patients). Moreover, anterior circulation stroke was recognized in all patients with positive troponin I marker.Conclusion:This study suggests that ECG abnormalities in patients with acute stroke are very common, especially tachycardia. The site of lesion appears to play major factor as a cause of genesis of arrhythmia. Concomitant cardiac diseases may present .Serum troponin elevation may play a role in diagnosing neuro-cardiogenic injury but, ECG appears to be more sensitive and familial.

To the assessment of changes in the electrocardiogram in coronary insufficiency

In the literature there are a number of reports on the effect of physical activity on the coronary circulation, but we did not find any works on the effect of a regimen with restriction of muscle movements on the ECG of patients with coronary insufficiency. This article reports the results of research on this issue. In addition, ECG changes were studied in patients in the subacute stage of myocardial infarction under the influence of walking.

Electrocardiographic findings in COVID-19: analysis of tele-ECGs in Moscow ECG IT Center

BACKGROUND: Coronavirus disease (COVID-19) affects the cardiovascular system and the primary damage to the respiratory system involved in the pathological process. However, in the available literature, the electrocardiography (ECG) analyses are based only on small-sample studies and case reports, which determine the relevance of larger-scale studies to clarify the nature and prevalence of ECG abnormalities in subjects with confirmed coronavirus infection. AIM: To determine the distribution of ECG changes in COVID-19 patients representing a non-selective population of Moscow residents. MATERIALS AND METHODS: We performed a retrospective analysis of ECGs from 42,799 patients from March 10, 2020 to March 10, 2021 with a verified diagnosis of COVID-19 was performed. The study included patients admitted to Moscow clinical hospitals connected to the ECG IT Center. A standard 12-lead ECG was obtained and transmitted via an Internet connection to the server of the ECG IT Center, where the ECG interpretation was performed. RESULTS: ECG changes were detected in 54% of patients. The most common cardiac arrhythmias were supraventricular extrasystole (12.6%) and atrial fibrillation (12.0%) reported in patients. Signs of the overloaded right heart were detected in 12.5% of cases, of which the ECG pattern of pulmonary embolism was confirmed in 485 patients (1.13%). Infarction ECG pattern was observed in 4.5% of patients, among which 3 cases of Brugada ECG pattern were reported. The incidence of ST-T changes was 2.2% of all study patients. Prolonged QT and QTc intervals were recorded in 540 patients (1.26%). In addition, individual cases of ventricular fibrillation, Frederick syndrome, and atrioventricular block of various degrees were reported. CONCLUSION: The distribution of incidence of ECG changes in COVID-19 was shown based on the data obtained. The high incidence of atrial fibrillation, which is a risk factor for thromboembolic complications, was confirmed. Moreover, a significant prevalence of ECG patterns of overloaded right heart was shown, some are associated with pulmonary embolism. Other reported ECG changes were characterized by a significantly lower prevalence, which does not reduce their clinical significance. The data obtained may be used to improve COVID-19 patient management strategy in the future.

Spectrum of Electrocardiographic Changes in Patients Presenting with Acute Organophosphate Compounds Poisoning

BACKGROUND Organophosphate compounds (OPC) are important cause of poisoning in developing countries. They are irreversible cholinesterase inhibitors and produce signs and symptoms pertaining to various organ systems via their muscarinic and nicotinic effects. The cardiac manifestations include hemodynamic instability and various arrhythmias. Here, in this study, we described various electrocardiographic (ECG) changes in patients of OPC poisoning in our population. METHODS This is a descriptive, cross-sectional study conducted at tertiary academic centre. All patients (>14 years and < 75 years) with history of OPC poisoning were included. Diagnosis was made on the basis of history and clinical features. ECG analysis of each patient was done for rate, rhythm, ST segment and T wave changes, PR and QTc interval, conduction defects and atrial and ventricular premature complexes before and after administration of atropine. RESULTS A total of 54 patients with OPC poisoning were included. The mean age was 28 ± 14.5 years. The predominant age group was < 30 years. There was female predominance with male : female ratio of 1 : 1.45. The most common ECG finding was sinus arrhythmia (tachycardia 25.9 % and bradycardia 20.4 %), followed by prolonged QTc (14.8 %), ST - T changes (11.1 %), premature ventricular complexes (PVCs) (7.4 %), prolonged PR interval (3.7 %) and atrial fibrillation (1.9 %). There was no mortality. The mean ICU and Hospital stay was three and six days respectively. CONCLUSIONS Sinus arrhythmia was the most common ECG changes followed by prolonged QTc, ST - T segment changes and PVCs in our setup. Careful observation of these ECG changes and timely intervention can prevent from sudden cardiac death in these patients. KEY WORDS Cardiac, Complications, Electrocardiogram, Organophosphates, Poisoning