B.L. Chia

Usefulness of ST elevation II/III ratio and ST deviation in lead I for identifying the culprit artery in inferior wall acute myocardial infarction.

In a study of 92 patients presenting with inferior wall acute myocardial infarction, the infarct-related artery was the right coronary artery in 72 patients (78%) and the left circumflex artery in 20 (22%). An ST II/III ratio of 1 or an isoelectric ST in lead I are sensitive and specific markers of left circumflex artery occlusion, whereas an ST II/III ratio <1 (ST elevation in lead III >II) or ST depression in lead I are sensitive and specific markers of right coronary artery occlusion.

The long-term predictive value of the neutrophil-to- lymphocyte ratio in Type 2 diabetic patients presenting with acute myocardial infarction

BACKGROUND Patients with diabetes mellitus have worse long-term outcomes after acute myocardial infarction (AMI) than non-diabetics. This may be related to differential contribution of neutrophil and lymphocyte to inflammation during AMI in diabetics vs. non-diabetics. We aim to determine the predictive value of neutrophil-to-lymphocyte ratio (NLR) for major adverse events post-AMI in Type 2 diabetics vs. non-diabetics. METHODS AND RESULTS A total of 2559 consecutive patients admitted for AMI (61 ± 14 years, 73% male and 43% diabetic) were analyzed. A complete blood count was obtained and the NLR computed for each patient on admission. Across the cohort, the 1-year reinfarction rate was 8.4% (n = 214) and 1-year mortality was 14.5% (n = 370). Univariate determinants of the composite endpoint included age, hypertension, hyperlipidemia, smoking, revascularization and NLR (P < 0.001 for all). The cohort was divided into NLR quartiles. Admission NLR was significantly higher in the diabetic group, 5.2 ± 5.8 vs. 4.6 ± 5.4 (P = 0.007). A step-wise increase in the incidence of the composite endpoint was noted across NLR quartiles for diabetic subjects; hazard ratio (HR) was 2.41 for fourth vs. first quartile (95% confidence interval = 1.63-3.53, P < 0.001). Multivariate analysis of the diabetic group showed that NLR remains as an independent predictor of the composite endpoint (adjusted HR = 1.53, 95% confidence interval = 1.00-2.33, P = 0.048). However, in non-diabetics, HR for NLR was not significant (P = 0.35). CONCLUSION Increased NLR post-AMI is an independent predictor of major adverse cardiac events in diabetics. Monitoring this easily obtainable new index allows prognostication and risk stratification.

Stokes-Adams attacks due to acute nonspecific myocarditis.

Ten patients, all below 30 years of age (8 females and 2 males) developed Stokes-Adams attacks from complete heart block due to acute nonspecific myocarditis. Coexisting thyrotoxicosis was present in two patients and cardiogenic shock was seen in four. Temporary transvenous pacing was instituted in all but one patient. Except for two patients who developed permanent complete heart block, normal A-V conduction returned in between 1 to 12 hours after ventricular pacing in seven patients and after 12 hours of isoprenaline therapy in the final patient. The ECG returned to normal in six patients and all 10 patients survived their acute illness.

Right sided chest lead electrocardiographic abnormalities in acute pulmonary embolism

Twelve lead electrocardiograms together with right-sided chest leads V4R, V5R and V6R were recorded in four patients with acute pulmonary embolism. All four patients showed ST segment elevation and a qs or qr pattern (with prominent q waves) in one to three of the leads V4R, V5R and V6R. These abnormalities were absent in the repeat electrocardiograms which were recorded after the acute illness.

Familial Wolff-Parkinson-White syndrome

Familial occurrence of Wolff-Parkinson-White (WPW) syndrome is uncommon and to date only seven instances have been documented in the literature. We describe another unusual family in which the proband, his father and two of his five brothers (including one who died suddenly) showed WPW conduction. A younger sister showed evidence of Lown-Ganong-Levin (LGL) pre-excitation. This pedigree is consistent with autosomal dominant inheritance and supports the importance of testing asymptomatic family members of patients with WPW because it is a potentially life-threatening conduction disorder.

Electrocardiographic patterns in posterior chest leads (V7, V8, V9) in normal subjects

The electrocardiographic patterns in leads V7, V8, and V9 were studied in 225 young, normal men (age range 17 to 21 years). The prevalence of 0.5- to 1.0-mm ST-segment elevation in leads V7, V8, and Vg 0.08 second after the J point was 8.9%, 5.8%, and 3.1%, respectively; the ST-segment elevation was not >1.0 mm in any subject.

Sino-atrial Wenckebach conduction in thyrotoxic periodic paralysis: a case report

A 28-year-old male presented with thyrotoxic periodic paralysis. On admission to hospital the serum potassium level was 1.4 mmol/l. The ECG showed classical features of hypokalaemia. In addition, sino-atrial block with Wenckebach conduction was also present. With the normalization of the serum potassium, the ECG became completely normal and showed no evidence of any arrhythmia.

Electrocardiographic abnormalities of congestive cardiac failure due to lightning stroke

A 24-year-old Chinese woman who presented with electrocardiographic abnormalities and congestive cardiac failure due to lightning injury is described. When reviewed 6 months later, the electrocardiogr

Anomalous chordae tendinae. A source of echocardiographic confusion

A unique instance of an anomalous chorda tendinae visualized in the left ventricular outflow tract during M-Mode and two-dimensional echocardiog raphy, and subsequently confirmed during surgery for concomitant severe rheumatic valvular disease, is described. The M-Mode appearance can be confused with more serious forms of heart disease manifesting extraneous echoes in the outflow tract, and an approach to these echoes is described, based on a review of the literature.

Simultaneous ST-segment elevation in lead V1 and depression in lead V2. A discordant ECG pattern indicating right ventricular infarction.

The major electrocardiographic change in right ventricular infarction (RVI) is ST-segment elevation in leads V4R-V6R. The authors describe a discordant electrocardiographic pattern of ST-segment elevation in lead V1 and ST-segment depression in lead V2 in five patients presenting with acute transmural (Q wave) inferior infarction and RVI. There were 51 patients with transmural inferior infarction from a thrombolytic trial. In 25 patients, the ST-segment in the right-sided precordial leads was elevated by > or = 1 mm indicating the presence of RVI. In 5 of these 25 patients, simultaneous ST-segment elevation of 1.0-8.0 mm (mean, 2.8 +/- 2.9 mm) in lead V1 and ST-segment depression of 2.5 to 4.0 mm (mean, 3.3 +/- 0.6 mm) in lead V2 were also present. The discordant pattern of the ST-segments in leads V1 and V2 is an important and specific sign for RVI.