ABSTRACT
AIMS: Grading of diastolic function can be useful, but indeterminate classifications are common. We aimed to invasively derive and validate a quantitative echocardiographic estimation of pulmonary artery wedge pressure (PAWP) and to compare its prognostic performance to diastolic dysfunction grading. METHODS AND RESULTS: Echocardiographic measures were used to derive an estimated PAWP (ePAWP) using multivariable linear regression in patients undergoing right heart catheterization (RHC). Prognostic associations were analysed in the National Echocardiography Database of Australia (NEDA). In patients who had undergone both RHC and echocardiography within 2â h (n = 90), ePAWP was derived using left atrial volume index, mitral peak early velocity (E), and pulmonary vein systolic velocity (S). In a separate external validation cohort (n = 53, simultaneous echocardiography and RHC), ePAWP showed good agreement with invasive PAWP (mean ± standard deviation difference 0.5 ± 5.0â mmHg) and good diagnostic accuracy for estimating PAWP >15â mmHg [area under the curve (95% confidence interval) 0.94 (0.88-1.00)]. Among patients in NEDA [n = 38,856, median (interquartile range) follow-up 4.8 (2.3-8.0) years, 2756 cardiovascular deaths], ePAWP was associated with cardiovascular death even after adjustment for age, sex, and diastolic dysfunction grading [hazard ratio (HR) 1.08 (1.07-1.09) per mmHg] and provided incremental prognostic information to diastolic dysfunction grading (improved C-statistic from 0.65 to 0.68, P < 0.001). Increased ePAWP was associated with worse prognosis across all grades of diastolic function [HR normal, 1.07 (1.06-1.09); indeterminate, 1.08 (1.07-1.09); abnormal, 1.08 (1.07-1.09), P < 0.001 for all]. CONCLUSION: Echocardiographic ePAWP is an easily acquired continuous variable with good accuracy that associates with prognosis beyond diastolic dysfunction grading.
Subject(s)
Echocardiography, Doppler , Echocardiography , Humans , Pulmonary Wedge Pressure , Prognosis , Echocardiography, Doppler/methods , Cardiac Catheterization/methods , Pulmonary ArteryABSTRACT
Objectives. Pericarditis, takotsubo cardiomyopathy and early repolarization syndrome (ERS) are well-known to mimic ST elevation myocardial infarction (STEMI). We aimed to study whether ECG findings of reciprocal ST depression, PR depression, ST-segment convexity or terminal QRS distortion can discriminate between ST elevation due to ischemia and non-ischemic conditions. Design. Eighty-five patients with STEMI and 94 patients with non-ischemic ST elevation were included. All patients had acute chest pain and at least 0.1 mV ST elevation. Presence of PR depression, ST-segment convexity, terminal QRS distortion or reciprocal ST depression was assessed in each ECG. Results. In anterior ST elevation, ST depression in lead II (≥0.025 mV) occurred in 40% of patients with STEMI but in none of the non-ischemic cases. In inferior ST elevation, ST depression in lead I (≥0.025 mV) was present in 83% of patients with STEMI but in none of the non-ischemic cases. Chest-lead PR depression was uncommon in STEMI (12%) compared to non-ischemic cases (38%; p < .001). Convex ST elevation occurred in 22% of STEMI cases and in 9% of non-ischemic cases (p = .01). Terminal QRS distortion was more prevalent in STEMI (40%) than in non-ischemic ST elevation (7%). In multivariable analysis, reciprocal ST depression was associated with an ischemic diagnosis, whereas ST depression in aVR and chest-lead PR depression were associated with a non-ischemic diagnosis. Conclusions. Identification of true STEMI among patients with different ST-elevation etiology may be improved by considering reciprocal ST depression, ST depression in aVR and chest-lead PR depression.
Subject(s)
Action Potentials , Arrhythmias, Cardiac/diagnosis , Electrocardiography , Heart Conduction System/physiopathology , Heart Rate , Pericarditis/diagnosis , Takotsubo Cardiomyopathy/diagnosis , Adult , Aged , Arrhythmias, Cardiac/physiopathology , Diagnosis, Differential , Female , Humans , Male , Middle Aged , Pericarditis/physiopathology , Predictive Value of Tests , Retrospective Studies , Takotsubo Cardiomyopathy/physiopathology , Time Factors , Young AdultABSTRACT
A long run of PVCs "sandwiched" in between the sinus beats resulting in an almost doubling of the heart rate-interpolated PVCs in bigeminy-is described. This case illustrates three interesting aspects of interpolated PVCs. Although they are not uncommon, long runs of interpolated PVCs in bigeminy are rare findings. In this case, the arrhythmia had a duration of 3 minutes. Second, it illustrates the "age-old wisdom" of partial retrograde conduction. Also, even though the arrhythmia resulted in an almost doubling of the heart rate, the patient remained asymptomatic.
