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Evaluation of P wave duration and P wave dispersion in adult patients with secundum atrial septal defect during normal sinus rhythm

BACKGROUND Paroxysmal atrial arrhythmias especially atrial fibrillation (AF) are frequently encountered in adult patients with atrial septal defect (ASD). Previously it was shown that maximum P wave duration and P wave dispersion in 12-lead surface electrocardiograms are significantly increased in individuals with a history of paroxysmal AF. The aim of this study was to determine whether P maximum and P dispersion in adult patients with ASD and without AF are increased as compared to healthy controls. In addition, the relationship of pulmonary to systemic flow ratio (Qp/Qs) and these P wave indices were investigated. METHODS AND RESULTS Sixty-two consecutive patients [39 women, 23 men; mean age 33+/-13 years (range 16 to 61 years)] with ostium secundum type ASD and 47 healthy subjects [25 women, 22 men; mean age 36.6+/-9.5 years (range 18 to 50 years)] were investigated. P maximum, P minimum and P dispersion (maximum minus minimum P wave duration) were measured from the 12-lead surface ECG. There were no significant differences with respect to age (P=0.08), gender (P=0.3), heart rate (P=0.3), left atrial diameter (P=0.5) and left ventricular ejection fraction (P=0.3) between patients and controls. Pulmonary artery peak systolic pressure was significantly higher in patients with ASD as compared to controls (P<0.0001). P maximum was significantly longer in patients with ASD as compared to controls (P<0.0001). In addition, P dispersion of the patients was significantly higher than controls (P=0.001). P minimum was not different between groups (P=0.12). Mean Qp/Qs of the patients with ASD was 2.5+/-0.7 (minimum 1.5; maximum 4.1) and found to be significantly correlated with P maximum (r=0.34; P=0.006) and P dispersion (r=0.61; P<0.0001). CONCLUSIONS Prolongation of P maximum and increased P dispersion could represent mechanical and electrical changes of atrial myocardium in patients with ASD. These changes of atrial myocardium may be more prominent with higher left to right shunt volumes.

Increased P‐Wave Duration and P‐Wave Dispersion in Patients with Aortic Stenosis

Background: P‐wave dispersion (PWD), defined as the difference between the maximum and minimum P‐wave duration, has been proposed as being useful for the prediction of paroxysmal atrial fibrillation (AF). AF is the most common arrhythmia and an important prognostic indicator for clinical deterioration in patients with aortic stenosis (AS). The aim of the present study was to evaluate PWD in patients with AS.

QT Dispersion in Single Coronary Artery Disease: Is There a Relation Between QT Dispersion and Diseased Coronary Artery or Lesion Localization?

It has been shown that QT dispersion (QTD) increases during episodes of myocardial ischemia or infarction. However, no extensive data on the relation between the diseased coronary artery or the localization of stenosis and the QTD are available. The aim of the study was to examine the relation between QTD and diseased coronary artery and lesion localization during exercise stress test in patients with single coronary artery disease without prior myocardial infarction. One hundred nineteen patients with single coronary artery disease and 53 patients with normal coronary arteries were enrolled in study. All patients underwent exercise stress test with modified Bruce protocol, and QT interval parameters were measured at rest and at minute 2 of the recovery (rec-2) period. QT dispersion at rest was found higher in all single-vessel disease groups compared with that in the control group, and corrected QT dispersion at rec-2 period was also markedly higher in left anterior descending, circumflex, and right coronary artery groups compared with that in the control group. No relation was found between QT dispersion and diseased coronary artery or the lesion localization. In conclusion, no qualitative difference was found between QT dispersion and diseased coronary artery or proximal or distal lesion localization. However, it was observed that patients with single-vessel disease had wider baseline QT dispersion as compared with that in the control group, which further increased significantly with exercise. This finding supports the idea that severity of localized ischemia rather than extent of coronary artery disease would be expected to have a greater effect on inducible QT dispersion.

Left ventricular aneurysm formation after anterior myocardial infarction: clinical and angiographic determinants in 809 patients.

BACKGROUND Previous studies have reported controversial results regarding the clinical and angiographic factors involved in the left ventricular aneurysm (LVA) formation after myocardial infarction (MI). OBJECTIVE This study was performed to determine the clinical and angiographic factors that are priori predictors of LVA following anterior myocardial infarction and so to provide a paradigm which may identify patients who were candidates for aneurysm formation. METHODS Of the patients who underwent coronary angiography during the interval between 1995 and 2000 in our clinic, 809 were found to have anterior MI and LVA (aneurysm group) (677 men, 132 women, mean age 53.3+/-11.4 years). The clinical and the angiographic data of these patients were compared with those of 446 patients (399 men, 47 women, mean age 55.2+/-10.5 years) with previous anterior MI and without LVA (control group). RESULTS LVA was found to occur more frequently in females (16.3% in women and 10.4%, in men, P=0.03) and in patients without previous angina (23.5 vs. 8.2%, P<0.0001). Major cardiovascular risk factors, previous anti-anginal medication and thrombolytic therapy did not show a significant difference between the two groups. Angiographic examination revealed that single-vessel disease, proximal left anterior descending artery (LAD) stenosis, total LAD occlusion, mean stenosis in LAD artery, end-diastolic pressure and left ventricular score were all higher in the aneurysm group compared to control group. After adjustment for other clinical and angiographic variables, single-vessel disease [odds ratio (OR) 5.89, 95% confidence interval (CI)=3.68-9.28, P<0.0001), absence of previous angina (OR=4.21, 95% CI=2.1-7.48, P=0.0003), total LAD occlusion (OR=2.63, 95% CI=1.97-3.53, P<0.0017) and female gender (OR=1.60, 95% CI=1.20-2.28, P=0.043) remained the independent determinants of LVA formation after anterior MI. CONCLUSION In patients with LVA, logistic regression analysis revealed that (1) single-vessel disease, (2) absence of previous angina, (3) total LAD occlusion and (4) female gender were independent determinants in the formation of LVA after anterior MI. Coronary collateral status and risk factors, such as hypertension, diabetes mellitus, hypercholesterolemia, smoking and family history of CAD were not found to be important determinants in the aneurysm formation.

Poor coronary collateral circulation is associated with higher concentrations of soluble adhesion molecules in patients with single-vessel disease.

ObjectiveAs the endothelium and inflammatory cells play a crucial role in the development of collaterals after a sudden or slowly progressing stenosis of coronary arteries, the levels of soluble endothelial adhesion molecules (CAMs) including vascular cell adhesion molecule (VCAM-1) intercellular adhesion molecule-1 (ICAM-1) and E-selectin were compared between patients with poor coronary collaterals and patients with well-developed collaterals. MethodsIn the study, 97 non-diabetic subjects with single-vessel disease were included. Collateral supply to the stenotic coronary artery was determined by angiographic grading system of 0–3 (Rentrop et al. J Am Coll Cardiol 1985; 5:587–592). Serum levels of adhesion molecules were measured by enzyme-linked immunosorbent assay. ResultsPatients were divided into two groups according to the collateral degree (group A: 50 patients with grade 0 and 1; group B: 47 patients with grade 2 and 3 collaterals). The groups were well matched with respect to baseline clinical and angiographic characteristics. Levels of soluble VCAM-1 (mean±SEM; 875±26.6 versus 742.7±35.1 ng/ml; P=0.004), ICAM-1 (322.4±12.4 versus 269.4±13.3 ng/ml; P=0.005), and E-selectin (43.6±2.6 versus 33±2.4 ng/ml; P=0.004) were found to be significantly higher in group A in comparison with group B. In addition, when patients were divided into four groups according to the collateral degree, patients with grade 0 collaterals had the highest values and those with grade 3 collaterals had the lowest values for all these molecules. ConclusionsWe concluded that poor collateral circulation is associated with increased levels of soluble CAMs in patients with obstructive coronary artery disease. However, further studies are needed to elucidate the exact role of these inflammatory markers in the setting of poor collateral circulation.

Dispersion of repolarization in paroxysmal atrial fibrillation

Widened dispersion of refractoriness has been considered to lead to an increase in atrial vulnerability. In this study, we obtained simultaneous monophasic action potential recordings by 2 special catheters from 2 different loci in the right atrium in 9 normal subjects (Group 1) and in 7 patients with paroxysmal atrial fibrillation (Group 2). We measured action potential duration at 50% (APD50) and 90% (APD90) repolarization from both loci in the right atrium during steady-state through one of the two catheters. The differences between APD50 and APD90 recorded by the two catheters were designated as dispersion of APD50 and dispersion of APD90, respectively. While, the mean APD50 and APD90 were 149.7+/-16.9 and 228.3+/-44.7 ms respectively in Group 1, the corresponding values for Group 2 were 145.7+/-33.5 and 213.5+/-53.1 ms. The difference between the 2 groups was not statistically significant. However, the dispersion of APD50 and APD90 were 13.8+/-13.8 and 10.0+/-9.7 ms in Group 1 and 42.8+/-19.6 and 57.1+/-32.4 in Group 2, respectively and the difference between the 2 groups for both measurements was statistically significant (P<0.01). Another finding was a high correlation between age and dispersion of APD90 in the whole population studied (r=0.82, P<0.001). With these findings, although one can not derive the conclusion that patients with paroxysmal atrial fibrillation have a greater dispersion of repolarization, our finding of increasing dispersion of repolarization with age could be an explanatory factor for the increased prevalence of atrial fibrillation with advanced age.

A comparison of the early and midterm results after dynamic cardiomyoplasty in patients with ischemic or idiopathic cardiomyopathy

OBJECTIVE The main goal of this study is to determine the efficiency of the cardiomyoplasty procedure on patients with cardiomyopathy of different origins (ischemic and idiopathic origins). METHOD Between June 1993 and August 1995, 24 patients underwent dynamic cardiomyoplasty with the left latissimus dorsi muscle in our institution. Early and midterm results, as well as the changes in hemodynamics and functional status during follow-up, were compared. RESULTS Early mortality rate was 20.8% (five patients). Concomitant coronary revascularization, a preoperative left ventricular ejection fraction below 20%, and a functional capacity of class IV (intermittently) were associated with early mortality. The mean follow-up time was 17.3 months. Survival analysis (including early mortality) extending to the twenty-fourth month revealed no difference between the ischemic and idiopathic groups (55% vs 85%, respectively, p = 0.09). Functional status improved in the both groups. Ejection fractions were improved after cardiomyoplasty in all patients, regardless of their cause. Cardiac indices were higher 6 months after the operation. Changes in pulmonary capillary wedge pressure, peak pulmonary artery pressure, and left ventricular end-diastolic volume were not significant. CONCLUSION Although cardiomyoplasty improves functional capacity and hemodynamics in patients with both idiopathic and ischemic cardiomyopathy, the idiopathic group is thought to achieve optimal benefit with regard to lower complication rates and lower early mortality expectancy owing to the absence of concomitant coronary revascularization.

Diagnostic value of aVL derivation for right ventricular involvement in patients with acute inferior myocardial infarction.

Background: Right ventricular (RV) involvement is associated with increased morbidity and mortality in patients with acute inferior myocardial infarction (MI). Although electrocardiography is probably the most useful, simple, and objective tool for the diagnosis of acute MI, there are no well‐defined criteria in the standard 12‐lead electrocardiogram to properly identify RV involvement in patients with acute inferior MI. Our objective was to evaluate the value of ST‐segment depression in lead aVL in diagnosing RV involvement in patients with acute inferior MI.

Does p-wave dispersion predict the atrial fibrillation occurrence after direct-current shock therapy?

Supraventricular tachycardia attacks, including atrial fibrillation (AF), occur after both external and internal cardioversions. These attacks of atrial fibrillation after direct-current (DC) shock may be related to hemodynamic impairment, thromboembolic events, or enhanced electrical instability of the ventricular and atrial myocardium, especially in predisposed patients. In this study, the authors aimed to show the importance of P-wave dispersion (PWD), which lead the atrium to fibrillate, in predicting post-DC shock AF after external cardioversion. Thus physicians may be able to choose the patients with high risk for AF occurrence and apply some other therapeutic modalities to those patients. The authors identified 18 patients in whom an AF attack was induced by urgent or elective cardioversion for a ventricular tachycardia attack and compared these patients with a control group composed of 40 patients without AF in regard to some clinical, echocardiographic, and electrocardiographic parameters. Left atrial diameters were greater (4.3 ±0.3 vs 3.5 ±0.5 cm, p=0.001), left ventricular ejection fractions (LVEF) were lower (45.2 ±8.2 vs 54.9 ±7.5, p=0.001), the energy needed for successful cardioversion was higher (166.6 ±59.4 vs 80.8 ±51.6 J, p=0.001), and P max (135.2 ±7.4 vs 118.7 ±10.5 ms, p=0.001) and PWD (53.8 ±12.2 vs 23.8 ±9.5 ms, p=0.001) values were higher in patients with AF when compared to those without AF. Thus, the patients with higher PWD values had a greater risk for development of AF after a DC shock.

Plasma Leukocyte Elastase Concentration and Coronary Artery Disease

It has previously been shown that leukocyte elastase is involved in the pathogenesis of atherosclerosis. Few studies have addressed the relation between leukocyte elastase concentrations and coronary artery disease (CAD). The authors investigated (1) the clinical significance of leukocyte elastase determi nation in the diagnosis of CAD and (2) the relation between plasma leukocyte elastase concentration and lesion morphology. The study included 185 subjects (140 men, 45 women) who underwent coronary angiography during investigation of chest pain; 135 had coronary stenosis (Group I) and 50 had nonstenotic coronaries (Group II). Among Group I patients, those with simple atheromatous plaques were distinguished from those with complex plaques. Elastase concentrations in Group I were greater than in Group II (57.1 ± 1.16 μg I-1 vs 27.6 ± 1.0 μg I-1, P < 0.001), and greater in complex plaque patients than in those with simple plaques (64.5 ± 1.24 μg I- 1 vs 45.9 ±1.01 μg I-1, P < 0.001 ) . Logistic regression analysis showed (1) that elastase concentration, age, and sex had independent value for prediction of CAD and (2) that among Group I patients, the risk of complex plaques was greatest for those with high elastase concentration. These results suggest that plasma leukocyte elastase concentration is a sensitive diag nostic marker of CAD and that high values of elastase may indicate the presence of complex atheromatous plaques.