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Background: Remote rhythm monitoring with wearable devices is increasingly used especially for early detection of atrial fibrillation/flutter (AF/Afl), being the access to hospital discouraged, especially for frail elderly patients, due to the burden and risk of COVID-19 pandemic. Whereas devices using photo plethysmography (PPG) may misinterpret as AF pulse irregularities due to extrasystoles, patient-directed recording of a single (usually wrist-to-wrist) lead ECG (LEAD I) with hand-held devices or smartwatches have been developed to increase accuracy in AF detection. However, although recent studies validating such devices single-lead ECG recording have shown high sensitivity and specificity, false negative findings such as those reported here are still possible and must be prevented [1]. Purpose(s): Given previous experience of diagnostic uncertainty or failure of the smartwatch ECG (SW-ECG) LEAD I to detect AF/Afl, we have tested if false negative diagnosis could be avoided by recording in addition at least one right precordial (pseudo-V1) lead analyzed by a trained healthcare professional. Method(s): Over one calendar year observation, five patients with previous history of ablated supraventricular arrhythmias suffering sudden palpitations suspected of paroxysmal AF/Afl were instructed to record with their smartwatch at least one precordial lead in addition to LEAD I, to monitor ECG until the termination of symptoms. The SW-ECG strips were sent by telephone for professional interpretation. Diagnostic accuracy based on LEAD I and pseudo-V1 were independently validated by two cardiologists (diagnostic goldstandard - DGS). Result(s): 22 AF/Afl events occurred. Pharmacological cardioversion to sinus rhythm (SR) was obtained in 64%. 192 ECG strips were transmitted. 43,7% of the strips were automatically classified as not significant (or not valid ). Compared to DGS, out of 108 valid strips, correct automatic identification of AF/Afl was obtained in 36,4% with LEAD I, in 33,3% with pseudo V1 and in 54,5% with combined leads, respectively. Interestingly, the SW algorithm has wrongly diagnosed as SR, not only LEAD I, but also 39,4% of pseudo-V1 strips, despite clear-cut evidence of typical flutter waves (Figure 1), when RR intervals were regular due to high degree (e.g., 4:1) A-V block. Conclusion(s): With simple instructions, patients (or their relatives) can easily record an additional precordial (pseudo-V1) SW-ECG lead, that may enhance sensitivity and specificity for remote detection of AF/Afl. However, at present, visual interpretation of SW-ECG by a trained healthcare professional is still needed to guarantee 100% correct diagnosis of AF/Afl, crucial to reduce thromboembolic risk and timely initiate the appropriate treatments. The automatic interpretation of SW's ECG could be improved by appropriate training of a machine learning approach to detect and analyze the atrial waveform provided by an additional pseudo-V1 lead.
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Background: Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players. Method(s): We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves;(b) reduction in T-wave amplitude by 50% in contiguous leads;(c) ST-segment depression;(d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads;(e) tall T-waves >=1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes. Result(s): Athletes were aged 22+/-5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3+/-4 days. The post COVID ECG was performed 14+/-16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID- 19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae;pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8+/-8 days v 2+/-4 days;p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3). Conclusion(s): 3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.
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Background Brachial artery thrombosis can be seen with thromboembolism, hypercoagulability, and arterial thoracic outlet syndrome. Case A 33-year-old healthy female construction worker presented with right hand discoloration and pain. She suffered a COVID-19 infection 8 weeks prior with hand symptoms developing shortly thereafter. She could no longer work due to the pain. Duplex ultrasound and CTA of the right upper extremity (Figure) demonstrated localized thrombosis of the right brachial artery. The workup yielded no aortic or intracardiac thrombus, and cardiac event monitor showed no atrial arrhythmia. She underwent thrombectomy with brachial artery stenting and was found, during surgery, to have distal ulnar artery occlusion. Two days post-op, she had recurrent pain and was found to have brachial artery recurrent thrombosis. She underwent urgent brachial-brachial bypass. Arm pain continued despite graft patency, so ulnarpalmar bypass was performed. Decision-making Hypercoagulability workup, including antiphospholipid antibody, protein C, protein S, homocysteine, and Lp(a), was negative. Neither central thrombus on TEE nor evidence of thoracic outlet syndrome was found. As a diagnosis of exclusion, brachial artery thrombosis was ascribed to COVID infection. Despite rivaroxaban, the patient developed gangrene (Panel C) requiring partial digit amputation. Conclusion We present a case of COVID-19-induced recurrent brachial artery thrombosis despite surgical intervention. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Triangular QRS-ST-T waveform electrocardiography pattern, so-called "shark fin sign," is a rare and highly mortal electrocardiography finding, which usually occurs in adult patients with coronary occlusion. Here, we reported the first paediatric case occurring in a striking "triangular waveform electrocardiography pattern" due to myocarditis during COVID-19 infection.
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Background and Aim: Awareness of electrocardiographic (ECG) changes is crucial in patients who receive coronavirus disease 2019 (COVID-19) treatment. In this study, we aimed to evaluate ECG parameters in patients under COVID-19 therapy and their relationship with the severity of lung involvement and the disease on the basis of thoracic computerized tomography (TCT) findings and laboratory parameters. Material(s) and Method(s): Of 350 patients hospitalized due to COVID-19 between March 2020 and June 2020, 300 patients with available data were retrospectively analyzed. Blood analysis, electrocardiographic, and clinical findings were evaluated. Six-month follow-up data were also recorded. Result(s): The patients were categorized into two groups: Survivor (n = 206, 68.7%, Group 1) and nonsurvivor patients (n = 94, 31.3%, Group 2). The mean total follow-up period was 125.39 +/- 73.09 days. The mean age was similar in both groups. In multivariate regression analysis that aimed to predict COVID-19 disease severity, it was found that besides increased C-reactive protein and D-dimer levels, and >=50% lung involvement in TCT, which are well known as bad prognostic factors, the corrected QT interval duration (QTc) prolongation >=60 miliseconds (msn) during hospitalization was associated with worse prognosis in COVID-19 patients during follow-up. Conclusion(s): Our study is the first study that demonstrated that the presence of >=60 msn QTc prolongation during hospital stay was found to be the most valuable ECG parameter to predict the prognosis and had a significant association with >=50% lung involvement in TCT in patients under anti-COVID therapy. Close monitoring of this ECG parameter is important both in terms of treatment planning and interpretation of disease progression. Copyright © 2022 Society of Cardiovascular Academy. All rights reserved.
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Introduction: One of the unique challenges for obstetricians in pregnancy is cardiovascular changes. This study aimed to evaluate electrocardiographic (ECG) changes in mothers with COVID-19. Materials and Methods: In a retrospective study, 89 pregnant women with positive reverse transcription-polymerase chain reaction for COVID-19, between 19 and 44 years old, were selected for the study, and 12 lead ECGs were extracted and recorded from the medical documents for all cases and all parameters analyzed. Results: Of the 89 patients that met inclusion criteria, only eight patients were admitted to intensive care unit. Of all, 64 cases (71.9%) had normal ECG, three patients showed atrioventricular (AV) block (3.4%), and three patients had first-degree AV block type (PR interval > 200 ms). The mean QTC interval was 428.6 & PLUSMN;37.4 ms and 15 (17%) patients had long QTC intervals (QTC & GE;460 ms). There was a significant relationship between antivirus treatment (P = 0.027), as well as hydroxychloroquine (HCQ) with PR interval (P = 0.002). A significant relationship was found between corticosteroids with QTC (P = 0.019) and antibiotics with QTC (P = 0.018). Conclusion: A significant association between corticosteroids usage and QTC interval as well as antiviral and HCQ treatment with PR interval. These changes during pregnancy and COVID-19 should be interpreted with caution by physicians. Understanding changes in electrocardiography can help in better and early diagnosis and management of pregnant mothers to prevent adverse outcomes.
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Electrocardiographic examination (ECG) is one of the most commonly used non-invasive examination methods for taking and recording electrical impulses of the heart. The nurses and rescuers perform an ECG in relation to the diagnostic and therapeutic plan according to the physician's orders and depending on the changes in patient's health status. The COVID-19 pandemic has brought a greater need for distance education through e-learning courses also in education of nurses and rescuers. The objective of the present study was to find out how the ECG topic is presented in the e-learning course Nursing Procedures and Techniques, and how often it was used by the students. As a research method we used content analysis of the ECG topic in the course Nursing Procedures and Techniques. We analysed electrocardiographic examination in the course Nursing Procedures and Techniques. The analytical categories included: topic structure;objectives;study materials;practice activities;tasks;and test questions in the question bank. We found out that study materials contained three ECG-related resources;they were viewed 246.66 times in the previous ten months. Practice activities contained a 4.25-minute instructional video, viewed 150 times. The tasks focused on the placement of the ECG electrodes on the limbs and chest, colour of the electrodes, operating the ECG monitor, and the issue of heart rhythm;the tasks were completed by 144 students. We recommend designing and using the topics. © 2022 American Institute of Physics Inc.. All rights reserved.
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Background: We have previously described the prognostic utility of QRS amplitude diminution (LoQRS) in predicting mortality and clinical decompensation in patients with COVID-19. However, whether and how COVID-19 vaccination status modulates risk prediction is not currently known. Objective: To assess any effect vaccination status may have on prevalence or risk prediction of LoQRS. Methods: We performed a retrospective analysis of patients admitted with laboratory confirmed COVID-19. Patients were excluded if the ECG was not acquired within 72 hrs of admission. Low QRS Amplitude (LoQRS) was defined by a composite of QRS amplitude <5mm in the limb leads or <10mm in the precordial leads (a composite of V1-V3 and V4-V6), or a ≥ 50% reduction in QRS amplitude. LoQRS was considered present even if found only in leads V1-V3 or V4-V6. Results: Among 3,365 patients, 11% were vaccinated and 89% were unvaccinated. LoQRS occurred in 30.9% of patients (33.5% of vaccinated patients and 30.5% in unvaccinated patients). Mortality occurred in 20.4% of patients without LoQRS compared to 30.2% in patients with LoQRS. The same pattern was seen in ICU admission, with 23.5% of patients without LoQRS being admitted to the ICU compared to 33.4% of patients with LoQRS. In multivariable models, LoQRS was independently associated with mortality and ICU admission regardless of vaccination status (or for mortality in unvaccinated patients: 1.24, 95% CI 1.03-1.49, P<0.01 vs 1.27 (95% CI 1.05-1.52, p<0.01). LoQRS also predicts ICU admission (OR 1.7, 95%CI 1.4-2.0) in unvaccinated patients vs. 1.73 (95%CI 1.5-2.1). In a survival analysis, vaccinated patients demonstrated improved mortality over unvaccinated counterparts, with a marked increase in mortality with, and stratification by, the presence of LoQRS in the unvaccinated. Conclusion: QRS amplitude on either the presenting or follow-up ECG independently predicts mortality and ICU admission in hospitalized patients with COVID-19 regardless of vaccination status. Patients who were vaccinated overall had better outcomes. [Formula presented]
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Aims: We aimed to examine whether there is abnormal value of index of cardiac electrophysiological balance (iCEB=QT/QRS) in patients with confirmed coronavirus disease 2019 (COVID-19), which can predict ventricular arrhythmias (VAs), including non-Torsades de Pointes-like ventricular tachycardia/ventricular fibrillation (non- TdPs-like VT/VF) in low iCEB and Torsades de Pointes (TdPs) in high iCEB. We also investigated low voltage ECG among COVID-19 group. Methods and Results: This is a cross-sectional, single center study with a total of 53 newly diagnosed COVID-19 patients (confirmed with polymerase chain reaction (PCR) test) and 63 age and sex-matched control subjects were included in the study. Electrocardiographic marker of iCEB were calculated manually from 12-lead ECG. Low voltage ECG defined as peak-to-peak QRS voltage less than 5mm in all limb leads and less than 10mm in all precordial leads. Patients with COVID-19 more often had low iCEB, defined as iCEB below 3.24 compared to control group (56.6% vs 11.1%), (OR=10.435;95%CI 4.015 - 27.123;p=0.000). There were no significant association between COVID-19 and high iCEB, defined as iCEB above 5.24 (OR=1.041;95%CI 0.485 - 2.235;p=0.917). There were no significant difference of the number of low voltage ECG between COVID-19 and control groups (15.1% vs 6.3%), (OR=2.622;95%CI 0.743 - 9.257, p=0.123). Conclusion: In this study showed that patients with COVID-19 are more likely to have low iCEB, suggesting that patients with COVID-19 may be proarrhytmic (towards non- TdPs-like VT/VF event), due to the alleged myocardial involvement in SARS-CoV-2 infection.
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Background: Transthyretin cardiac amyloidosis (ATTR-CM) is important comorbidity associated with severe aortic stenosis (AS). Multiple studies have shown that ATTR-CM was present in 10-15% of all cases with severe AS. The purpose of this quality improvement project is to raise awareness of ATTR-CM in patients who underwent transcatheter aortic valve replacement (TAVR) for severe AS amongst the healthcare providers and patients. Methods: We retrospectively reviewed all TAVR cases performed at our institution in 2019 (Total cases 87). We screened for the presence of predefined high-risk features for ATTR-CM based on prior literature (Presence of diastolic dysfunction, left ventricular hypertrophy on echocardiogram, low voltage-mass ratio, low limb lead voltage on EKG, arrhythmia/bundle branch block, or systemic symptoms of amyloidosis). We subsequently contacted the patients to discuss our clinical suspicion of ATTR-CM and offered clinical referral to a cardiac amyloid specialist. Results: Of the total of 87 patients who underwent TAVR in 2019, 12 patients were deceased at chart review. We have identified 50 patients (66.7%) who had high-risk features of ATTR-CM. A total of 17 patients (34% of 50 patients) agreed to be referred to cardiac amyloid specialist. Six patients (12%) were tested with 99m Technetium Pyrophosphate imaging, and all were negative for ATTR-CM. Eleven patients (22%) are still pending testing. Six patients did not wish for referral due to personal reasons. We were not able to reach 15 patients via phone (30%). In addition, we have found additional 12 patients who were deceased (Total mortality count of 24, 27.5%) in two years. Conclusion: Our project has increased awareness within structural cardiologists as we have implemented a prospective screening process within our institution. While we expected to diagnose ATTR-CM in 10% of severe AS who underwent TAVR, we had multiple difficulties contacting them, coordinating referrals due to the COVID-19 pandemic and higher 2-year mortality. We are hypothesizing whether the higher 2-year mortality is secondary to undetected ATTR-CM. We are planning for screening and timely referral for patients who underwent TAVR more recently.
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Many factors and technical problems may alter the interpretation of electrocardiograms (ECGs). Infrequently, an artifact is considered to be the cause of ST-segment elevation, especially in asymptomatic patients. An important difference between true ST-segment elevation attributable to myocardial infarction and an artifact is that the baseline elevation in an artifact may begin before or after the onset of the QRS complex. When one encounters an abnormal ECG that exhibits suspicious wave contours and possibly only one completely normal limb lead, the diagnosis of arterial pulse artifact should be considered.
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BACKGROUND: We aimed to report the findings of the first Electrocardiography (ECG), before therapy initiation and receiving medication in COVID-19 patients, and to compare them with the ECG findings of healthy men. METHODS: A comprehensive and regular search was performed through the keywords ("Electrocardiographic" OR "ECG" OR; "COVID-19" OR "Coronavirus Disease 2019") without time and language restrictions in the Web of Science, Scopus, ProQuest, Cochrane Library, Science Direct, Medline, PubMed and Google Scholar. After evaluating the quality and reviewing the biases, 27 studies were finally enrolled. RESULTS: In 27 studies with a total number of 3994 COVID-19 patients, and mean age of 62.7 yr, 1993 subjects were male. The most common type of arrhythmia in them, especially in severe and critical cases, was 7% based on 10 studies (Atrial Fibrillation); while in 7 studies, QTc interval prolong (≥ 460 msec) was 15% and in 5 studies, QTc interval prolong (≥ 500 msec) was 18%. In COVID-19 patients at the time of admission and healthy men, HR (b per / min) was 85, 61.7 and PR interval (msec) was 285.4, 156 and QRS duration (msec) was 95, 94.3 and QT (msec) was 380. 384.1 and QTc (msec) (Bazett's formula) was 437, 387.1, respectively. In most cases, the variables were higher for COVID-19 patients. CONCLUSION: ECG abnormalities at the time of admission and prior to the initiation of medication that cause arrhythmic may have a clinically substantial effect on the course of the disease and confirm the effect of COVID-19 on increased cardiovascular risk in long-term.