Paulo Ginefra

Ionic Mechanisms and Vectorial Model of Early Repolarization Pattern in the Surface Electrocardiogram of the Athlete

Background: The electrocardiogram (ECG) of the athlete displays particular characteristics as a consequence of both electrophysiological and autonomic remodeling of the heart that follows continued physical training. However, doubts persist on how these changes directly interact during ventricular activation and repolarization ultimately affecting surface ECG waveforms in athletes.

O eletrocardiograma de alta resoluçäo no domínio da frequencia. Utilizaçäo de técnicas estatísticas de correlaçäo espectral para identificaçäo de pacientes com taquicardia ventricular monomórfica sustentada

PURPOSE: To evaluate the diagnostic accuracy of monomorphic ventricular tachycardia (MVT), in patients with structural heart diseases and episodes of sustained MVT, using the signal-averaged ECG (SAECG) in the time (TD) and the frequency domain (FD) with statistical techniques of spectral correlation. METHODS: Twenty seven patients with at least one episode of sustained MVT, 30 patients with structural heart diseases and no evidence of ventricular arrhythmias and 80 subjects with no evidence of heart disease have been studied. SAECG was performed in all patients with the following parameters: duration of the filtered QRS, RMS 40 and LAS40 in TD and the mean and the standard deviation of both signal energy intersegmentar spectral correlation and energy frequency edge track in FD. RESULTS: The sensitivity(S) and positive predict value (PPV) of the SAECG in TD, in FD and combined analysis of both domains were: S = 59.3%, 63.0%, 81.5% and PPV = 80.0%, 81.0%, 84.6%, respectively. CONCLUSION: The combined analysis of SAECG in TD and in FD improves the diagnostic accuracy in patients with S sustained MVT.PURPOSE To evaluate the diagnostic accuracy of monomorphic ventricular tachycardia (MVT), in patients with structural heart diseases and episodes of sustained MVT, using the signal-averaged ECG (SAECG) in the time (TD) and the frequency domain (FD) with statistical techniques of spectral correlation. METHODS Twenty seven patients with at least one episode of sustained MVT, 30 patients with structural heart diseases and no evidence of ventricular arrhythmias and 80 subjects with no evidence of heart disease have been studied. SAECG was performed in all patients with the following parameters: duration of the filtered QRS, RMS 40 and LAS40 in TD and the mean and the standard deviation of both signal energy intersegmentar spectral correlation and energy frequency edge track in FD. RESULTS The sensitivity(S) and positive predict value (PPV) of the SAECG in TD, in FD and combined analysis of both domains were: S = 59.3%, 63.0%, 81.5% and PPV = 80.0%, 81.0%, 84.6%, respectively. CONCLUSION The combined analysis of SAECG in TD and in FD improves the diagnostic accuracy in patients with S sustained MVT.

Diretriz de interpretação de eletrocardiograma de repouso

Jose Alves Pinho (BA), Mario Sergio de Carvalho Bacellar (BA),Demostenes G. Lima Ribeiro (CE), Rubens Nassar Darwich (MG),Antonio Luiz Pinho Ribeiro (MG), Marcelo Marcos Eloy Dunda (PB),Helio Germiniani (PR), Francisco Faustino Franca (PE),Laurindo Saraiva (PE), Clebia Maria Rios Ribeiro (PE),Paulo Ginefra (RJ), Iseu Gus (RS), Eney Fernandes (SC),Andres Riera (SC), Anisio Pedrosa (SP),Antonio Americo Friedman (SP), Antonio Carlos Firmiani (SP),Cesar Grupi (SP), Claudio Pinho (SP),Eduardo Vilaca Lima (SP), Elisabeth Kaiser (SP),Fabio Sandoli Brito (SP), Gilberto Luiz Castro Vinhas (SP),Helio Schwartz (SP), Jose Grindler (SP), Jose Luiz Aziz (SP),Marcio Figueiredo (SP), Marcos S. Molina (SP),Martino Martinelli (SP), Nancy Tobias (SP),Paulo Cesar R. Sanches (SP), Paulo Jorge Moffa (SP),Severino Attanes Neto (SP), Silvana Nishioka (SP)

The Frequency Analysis of Signal‐Averaged ECG of P Wave as Predictor of Efficacy of Class III Antiarrhythmic Drugs to Maintain Sinus Rhythm in Recurrent Idiopathic Atrial Fibrillation

Background: The use of class III antiarrhythmic drugs (ADIII) has been considered a good predictor of sinus rhythm in patients post‐cardioversion from atrial fibrillation (AF). Several studies using frequency domain analysis of signal‐averaged ECG (FDSAECG) of the P wave were able to identify patients at risk for AF. The aim of this study was to assess the FDSAECG in predicting recurrence of idiopathic persistent AF (IPAF) in patients under ADIII therapy.

É a cardiomiopatia hipertrófica apical vista em uma amostra na cidade do Rio de Janeiro similar à encontrada no oriente

PURPOSE: To investigate the differences between clinical aspects and evolution of apical hypertrophic cardiomyopathy (AHCM) seen in Rio de Janeiro and the Oriental form, which was the first described. METHODS: In 156 patients with AHCM diagnosed in our institution, there were 13 (8.34%) with the apical form of the disease, whose clinical settings, diagnostic procedures and evolution were studied. RESULTS: There were 8 males and 5 females, between 19 and 75 years old, all white. Electrocardiogram (EKG) showed giant T waves in precordial leads in 10 (76.92%), echocardiogram (ECHO) demonstrated apical hypertrophy in all, 10 (76.92%) had only in the left ventricle, 2 in right ventricle and one involving both. Cineangiography corroborated ECHO findings. Follow-up ranged from 6 to 294 months (x= 95.4). Two deaths occurred in patients with RV involvement, due to large atria, atrial fibrillation, tricuspid or mitral insufficiency and thromboembolism. Among the survivors, the patient with RV disease has diastolic restriction and the ones with LV involvement, 9 are asymptomatic using either propranolol (8) or amiodarone (1), and one uses no medication. CONCLUSION: A HCM seen in Rio de Janeiro is similar to that found in the Orient (Japan) regarding presentation, diagnosis and evolution; but in 3 patients we have found RV disease, not described in Japan, characterizing a distinct group with a worse evolution.

Repolarização precoce no eletrocardiograma do atleta: bases iônicas e modelo vetorial

O padrao eletrocardiografico do atleta mimetiza variasalteracoes encontradas em diversas cardiopatias, fazendocom que, em um passado recente, tenham sido cometidascondutas equivocadas, como a pressuposicao da presencade cardiopatia e afastamento de esportistas de suas ativida-des. Esta revisao procura rever os mecanismos pelos quais oexercicio modifica a modulacao autonomica sobre o coracao epropoe explicacoes, baseadas em mecanismos eletrofisiolo-gicos e na teoria vetorial da ativacao cardiaca, para o padraoeletrocardiografico conhecido como repolarizacao precoce.

Detection of Incipient Left Ventricular Hypertrophy in Mild to Moderate Arterial Hypertension with Normal Electrocardiogram and Echocardiogram. A New Use for Signal-Averaged Electrocardiography

OBJECTIVE To assess signal-averaged electrocardiogram (SAECG) for diagnosing incipient left ventricular hypertrophy (LVH). METHODS A study with 115 individuals was carried out. The individuals were divided as follows: GI - 38 healthy individuals; GII - 47 individuals with mild to moderate hypertension and normal findings on echocardiogram and ECG; and GIII - 30 individuals with hypertension and documented LVH. The magnitude vector of the SAECG was analyzed with the high-pass cutoff frequency of 40 Hz through the bidirectional four-pole Butterworth high-pass digital filter. The mean quadratic root of the total QRS voltage (RMST) and the two-dimensional integral of the QRS area of the spectro-temporal map were analyzed between 0 and 30 Hz for the frequency domain (Int FD), and between 40 and 250 Hz for the time domain (Int TD). The electrocardiographic criterion for LVH was based on the Cornell Product. Left ventricular mass was calculated with the Devereux formula. RESULTS All parameters analyzed increased from GI to GIII, except for Int FD (GII vs GIII) and RMST log (GII vs GIII). Int TD showed greater accuracy for detecting LVH with an appropriate cutoff > 8 (sensitivity of 55%, specificity of 81%). Positive values (> 8) were found in 56.5% of the G II patients and in 18.4% of the GI patients (p< 0.0005). CONCLUSION SAECG can be used in the early diagnosis of LVH in hypertensive patients with normal ECG and echocardiogram.

Noninvasive cardiac assessment in children of women with systemic lupus erythematosus

OBJECTIVE Noninvasive cardiac assessment of newborns and infants of women with systemic lupus erythematosus. The children had no congenital total atrioventricular block and were compared with the children of healthy women. METHODS We prospectively assessed 13 newborns and infants aged 1 to 60 days, children of women with systemic lupus erythematosus and without congenital total atrioventricular block. These children were compared with 30 children of women who had no lupus or anti-Ro/SSA antibodies, and no risk factors for congenital heart disease either. Their age groups matched. The following examinations were performed: cardiological physical examination, electrocardiography, echocardiography, and signal-averaged electrocardiography. RESULTS The statistical analysis showed no significant difference in ventricular function or in the cardiac conduction system between the groups. CONCLUSION In regard to the conduction system and ventricular function in the absence of total atrioventricular block, no statistically significant difference was observed between the children of women with systemic lupus erythematosus and children of healthy women.

Atrial activation during sinus rhythm in patients with rheumatic and non-rheumatic paroxysmal atrial fibrillation. Frequency-domain analysis using signal-averaged electrocardiography

OBJECTIVE Using P-wave signal-averaged electrocardiography, we assessed the patterns of atrial electrical activation in patients with idiopathic atrial fibrillation as compared with patterns in patients with atrial fibrillation associated with structural heart disease. METHODS Eighty patients with recurrent paroxysmal atrial fibrillation were divided into 3 groups as follows: group I - 40 patients with atrial fibrillation associated with non-rheumatic heart disease; group II - 25 patients with rheumatic atrial fibrillation; and group III - 15 patients with idiopathic atrial fibrillation. All patients underwent P-wave signal-averaged electrocardiography for frequency-domain analysis using spectrotemporal mapping and statistical techniques for detecting and quantifying intraatrial conduction disturbances. RESULTS We observed an important fragmentation in atrial electrical conduction in 27% of the patients in group I, 64% of the patients in group II, and 67% of the patients in group III (p=0.003). CONCLUSION Idiopathic atrial fibrillation has important intraatrial conduction disturbances. These alterations are similar to those observed in individuals with rheumatic atrial fibrillation, suggesting the existence of some degree of structural involvement of the atrial myocardium that cannot be detected with conventional electrocardiography and echocardiography.

Avaliação de Potenciais Fragmentados em Presença de Bloqueio de Ramo Direito sem Alterações Estruturais Miocárdicas Ventriculares. Estudo pelo Eletrocardiograma de Alta Resolução no Domínio da Freqüência

PURPOSE: To evaluate if the presence of right bundle branch block (RBBB), without structural myocardial abnormalities (SMA) can generate fragmented potentials (FP) and spectral turbulence on signal-averaged electrocardiogram (SAECG). METHODS: Twelve children with atrial septal defect (ASD) and incomplete right bundle branch block (IRBBB without SMA (group I) were compared to 17 children with post-operative tetralogy of Fallot (TF) with CRBBB, all with SMA, 5 with ventricular premature beats and 2 with sustained ventricular tachycardia (group II). All had SAECG on time (TD) and frequency domain (FD) with 5 variables analysed. RESULTS: All patients of group I had normal variables, in contrast with group II which presented abnormal variables suggesting FP and ST. CONCLUSION: In ASD without SMA, the isolated IRBBB did not generate FP and ST.Objetivo - Em ausencia de alteracoes estruturais miocardicas (AEM), avaliar se o bloqueio de ramo direito (BRD) gera potenciais fragmentados (PF) e turbulencia espectral (TE) no eletrocardiograma de alta resolucao (ECGAR). Metodos - Doze criancas com comunicacao interatrial (CIA) e bloqueio incompleto do ramo direito (BIRD) sem AEM (Grupo I), foram comparadas com 17 criancas com tetralogia de Fallot (TF) operada, BCRD e AEM, 5 com extra sistoles ventriculares e 2 com taquicardia ventricular sustentada (Grupo II). Todas fizeram ECGAR nos dominios do tempo (DT) e da frequencia (DF), com cinco variaveis analisadas. Resultados - Os pacientes do grupo I tiveram as variaveis normais apesar do BIRD. No grupo II, 4 das cinco variaveis foram anormais, sugerindo a presenca de PF e TE atribuiveis a AEM inerentes a malformacao e ao ato cirurgico. Conclusao - Na CIA o BIRD nao complicado de AEM nao gera PF e TE, nao constituindo fator de risco para taquicardia ventricular sustentada. Palavras-chave: eletrocardiograma de alta resolucao, turbulencia espectral, bloqueio do ramo direito.