The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?

Prompt and accurate identification of ST-elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult. The 2004 STEMI guideline recommended emergent reperfusion therapy to patients with suspected ischemia and new or presumably new LBBB. These recommendations have led to frequent false catheterization laboratory activation and inappropriate fibrinolytic therapy because most patients with suspected ischemia and new or presumably new LBBB do not have acute coronary artery occlusion on angiography. The new 2013 STEMI guideline makes a drastic change by removing previous recommendations. Therefore, patients with suspected ischemia and new or presumably new LBBB would no longer be treated as STEMI equivalent. The new guideline fails to recognize that some patients with suspected ischemia and LBBB do have STEMI, and denying reperfusion therapy could be fatal. The Sgarbossa electrocardiography criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥3 has a superb specificity (98%) and positive predictive value for acute myocardial infarction and angiography-confirmed acute coronary occlusion. Thus, we propose a diagnosis and triage algorithm incorporating the Sgarbossa criteria to quickly and accurately identify, among patients presenting with chest pain and new or presumably new LBBB, those with acute coronary artery occlusion. This is a high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guideline. Our algorithm will also significantly reduce false catheterization laboratory activation and inappropriate fibrinolytic therapy, the inevitable consequence of the 2004 STEMI guideline.

Postcardiac injury syndrome following transvenous pacer or defibrillator insertion: CT imaging and review of the literature.

Postcardiac injury syndrome (PCIS) is a frequent clinical entity developing as a complication of cardiac procedures. Some of these may be only minor procedures, such as the insertion of permanent pacer or defibrillator devices. The purpose of this article is to review and illustrate its common imaging findings. PCIS is expected to occur in approximately 1%-2% of patients after pacer or defibrillator device placement. The mechanism of pericarditis following implantation is unclear, but it may involve a direct irritation of the pericardium by minimally protruding electrodes, low-grade bleeding with hemorrhagic pericarditis, and a late autoimmune or inflammatory response to those insults. Radiologists may detect findings that in the appropriate clinical setting should raise the possibility of PCIS. On chest x-ray, the findings include the presence of a pericardial or pleural effusion or both. Computed tomography, in addition to having better characterization capabilities of the pericardial or pleural effusion or both, may also accomplish the diagnosis of lead perforation. Although typically rather benign, PCIS may result in significant morbidity and potential mortality due to arrhythmias, noncardiac pulmonary edema, and cardiac tamponade. Therefore, its early detection is of clinical importance.

Abdominal aortic aneurysm screening during transthoracic echocardiography: Cardiologist and vascular medicine specialist interpretation.

AIM: To study the interobserver variability between a cardiologist and vascular medicine specialist in the screening of the abdominal aorta during transthoracic echocardiography (TTE). METHODS: Consecutive patients, > 55 years of age, underwent abdominal aortic imaging following standard TTE. Two cardiologists and one vascular medicine specialist performed a blinded review of the images. Interobserver agreement of abdominal aortic size was determined by the correlation coefficient and paired t test. Interobserver reliability for each cardiologist was assessed using Bland-Altman plots. RESULTS: Ninety patients were studied. The mean age of patients was 72 ± 10 years and 48% were male. The mean aortic diameter was 2.31 ± 0.50 cm and 5 patients (5.5%) had an abdominal aortic aneurysm (AAA). The additional time required for the abdominal aortic images was 4.4 ± 0.9 min per patient. Interobserver agreement between the 2 cardiologist interpreters and the vascular medicine specialist was excellent (P > 0.05 for all comparisons). On Bland-Altman analysis of interobserver reliability, the 95% lower and upper limits for measurement by the cardiologists were 84% and 124% of that of the vascular specialist. CONCLUSION: The assessment of the abdominal aorta during a routine TTE performed by a cardiologist is accurate in comparison to that of a vascular medicine specialist. In selected patients undergoing TTE, the detection rate of AAA is significant. Additional time and effort required to perform imaging of the abdominal aorta after TTE is less than 5 min.

Cardiovascular emergencies in cruise ship passengers.

More than 10 million people, many elderly and likely to harbor cardiovascular (CV) disease, embark on cruise ship travel worldwide every year. The clinical presentation and outcome of CV emergencies presenting during cruise ship travel remain largely unknown. Our department provides contracted cardiology consultations to several large cruise lines. We prospectively maintained a registry of all such consultations during a 2-year period. One hundred consecutive patients were identified (age 66 +/- 14 years, range 18 to 90, 76% men). The most common symptom was chest pain (50%). The most common diagnosis was acute coronary syndrome (58%; ST elevation in 21% and non-ST elevation in 37%). On-board mortality was 3%. Overall, 73% of patients required hospital triage. Of the 25 patients triaged to our institution, 17 underwent a revascularization procedure. One patient died. Ten percent of patients had cardiac symptoms in the days or weeks before boarding; all required hospital triage. Access to a baseline electrocardiogram would have been clinically useful in 23% of cases. In conclusion, CV emergencies, such as acute coronary syndrome and heart failure, are not uncommon on cruise ships. They are often serious, requiring hospital triage and coronary revascularization. A pretravel medical evaluation is recommended for passengers with a cardiac history or a high-risk profile. Passengers should be encouraged to bring a copy of their electrocardiogram on board if abnormal. Cruise lines should establish mechanisms for prompt consultation and triage.

Meta-analysis comparing reported frequency of atrial fibrillation after acute coronary syndromes in Asians versus whites.

The development of atrial fibrillation (AF) in cardiac patients is multifactorial, including not well defined genetic factors. To determine if Asian ethnicity is associated with the development of AF in patients with coronary disease, a meta-analysis was conducted of patient-level data from 7 prospective randomized clinical trials that prospectively collected information on the development of AF: 3 trials in patients with ST-elevation myocardial infarction (Global Use of Strategies to Open Occluded Coronary Arteries [GUSTO] I, GUSTO III, and GUSTO V), 3 trials in patients with non-ST-elevation acute coronary syndromes (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy [PURSUIT], Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis-II [IMPACT II], and Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network [PARAGON A]), and 1 trial in patients with both conditions (GUSTO IIb). A total of 94,785 patients were identified (93,050 white, 1,735 Asian). At baseline, Asian patients were younger; had lower body mass indexes; had a lower prevalence of female gender, previous angioplasty, and previous coronary artery bypass grafting; and had a greater prevalence of diabetes compared with white patients. The development of AF was lower in Asian than in white patients (4.7% vs 7.6%, p <0.001), while rates of ventricular tachycardia and fibrillation were similar in the 2 groups. In multivariate logistic regression analysis, Asian ethnicity was associated with significantly lower rates of AF (odds ratio 0.65, 95% confidence interval 0.50 to 0.84, p = 0.001) compared with white ethnicity. In conclusion, similar to previous studies showing a lower incidence of AF in non-Caucasian populations, Asians experiencing acute ischemic syndromes have a significantly lower frequency of AF compared with whites. Further study is needed to investigate the mechanisms and potential genetic underpinnings behind this association.

Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week.

BACKGROUND: The use of the prehospital electrocardiogram (ECG) to identify patients with ST-segment elevation myocardial infarction (STEMI), coupled with a centralised system to alert the cardiac catheterisation team in preparation for prompt intervention, has been shown to reduce door-to-balloon times (DBT) effectively. A confounding variable in prolonging the recommended 90 min DBT is the time of day or day of the week of patient presentation. We postulated that use of the prehospital ECG, coupled with an emergency department initiated "Cath Alert" system, could neutralise DBT delays related to time of day or day of week. METHODS: A prospective study was conducted on 167 consecutive patients presenting to our emergency department with acute STEMI. All patients were treated with primary percutaneous coronary intervention. Patients were grouped according to time of presentation: during regular hours (Monday to Friday 08:00 to 17:00) vs off hours (after 17:00 on weekdays and all hours on weekends). Baseline recorded variables included mode of presentation, transmission of prehospital ECG, and activation of Cath Alert system. RESULTS: Overall, the mean (SD) DBT was 69 (35) mins, with the majority of patients (n = 131, 78%) achieving the recommended DBT of 90 mins. The shortest DBT occurred in patients who arrived by emergency medical services with use of the prehospital ECG and Cath Alert system (53 (21) min), while those who arrived as a walk-in without use of emergency medical services had the longest DBT (105 (38) min; p<0.001). Compared to regular hours, presentation during off hours prolonged DBT in patients presenting via emergency medical services (75 (16) vs 53 (18) min, p = 0.03). With transmission of the prehospital ECG, the delay in DBT was improved among those presenting off hours, nullifying the adverse effect of off hour presentation (54 (21) vs 49 (22) min; p = 0.26). CONCLUSION: Variables such as time of day and mode of presentation have an impact on achieving currently recommended DBT in patients with STEMI. With the addition of each prehospital variable in succession-that is, arrival by emergency medical services, Cath Alert system, and the prehospital ECG-the DBT can be progressively shortened and the adverse "off hour effect" nullified.

Spondyloarthropathy-associated aortitis and massive thickening of the aortic-mitral curtain: diagnosis by echocardiography.

Cardiac involvement in reactive arthritis is well-recognized, and usually results in aortic regurgitation, proximal aortitis, and conduction system abnormalities. Aortitis is usually recognized in conjunction with aortic regurgitation, but can be diagnosed in isolation as aortic root thickening and subaortic fibrous ridging. We report a case of spondyloarthropathy-associated aortitis diagnosed by transesophageal echocardiography. The case illustrates the aortic root pathology and highlights the unique morphologic echocardiographic feature of this condition, prominent thickening of the aortic-mitral curtain.

Cardiac pacing: the state of the art.

Permanent cardiac pacing remains the only effective treatment for chronic, symptomatic bradycardia. In recent years, the role of implantable pacing devices has expanded substantially. At the beginning of the 21st century, exciting developments in technology seem to happen at an exponential rate. Major advances have extended the use of pacing beyond the arrhythmia horizon. Such developments include dual-chamber pacers, rate-response algorithms, improved functionality of implantable cardioverter defibrillators, combinations of sensors for optimum physiological response, and advances in lead placement and extraction. Cardiac pacing is poised to help millions of patients worldwide to live better electrically. We review pacing studies of sick-sinus syndrome, neurocardiogenic syncope, hypertrophic obstructive cardiomyopathy, and cardiac resynchronisation therapy, which are common or controversial indications for cardiac pacing. We also look at the benefits and complications of implantation in specific arrhythmias, suitability of different pacing modes, and the role of permanent pacing in the management of patients with heart failure.

Twelve-lead electrocardiogram: the advantages of an orderly frontal lead display including lead -aVR.

BACKGROUND: It is possible that efforts in ECG review by both young experienced clinicians are currently discouraged-and risk to be completely dismissed-by the conventional (ie, disorderly) display of the frontal plane leads, with lead aVR at -150 degrees. METHODS: We reviewed studies on the usefulness of leads aVR and -aVR as well as on the history of the frontal leads in electrocardiography. RESULTS: Lead aVR and particularly, lead -aVR, provide useful information when systematically analyzed. In addition, if lead -aVR is examined in its anatomically logical sequence, ie, aVL, I, -aVR, II, aVF, and III, the frontal plane of the 12-lead ECG is more easily understood. This "panoramic" or "orderly" display is in common use in countries such as Sweden, but it is rarely seen in the United States. CONCLUSIONS: ECG interpretation would be enhanced by displaying the limb leads in an orderly arrangement that starts with lead aVL and ends with lead III, and many ECG changes would be ideally displayed by a lead -aVR at 30 degrees.

What is the minimal pacing rate that prevents torsades de pointes? Insights from patients with permanent pacemakers.

In the acquired long QT syndrome, torsades de pointes (TP) is invariably preceded by pauses or bradycardia. Thus, it has been proposed that out-of-hospital initiation of drugs that prolong repolarization should be safe in patients with permanent pacemakers. However, a minimal protective pacing rate has not been identified. The authors reviewed published reports of acquired TP in patients with permanent pacing. Those providing documentation of tachycardia onset and pacemaker programming were included in the analysis. Events occurring < or = 1 month after AV nodal ablation were excluded. Eighteen cases were identified (age 74 +/- 5; 10 women). QT prolonging drugs were present in 15 patients (quinidine 5, sotalol 3, disopyramide 3, amytriptiline, chloroquine, cisapride + haloperidol, and monopride + flecainide 1 each). Hypokalemia was present in eight patients. At the time of TP, the programmed lower rate was 63 +/- 13 beats/min. However, the effective pacing rate was lower (55 +/- 11 beats/min) due to invocation of pause-promoting features (hysteresis [4 patients]; + PVARP extension on PVC [1 patient]) or ventricular oversensing (2 patients). No patient developed TP with an effective pacing rate > 70 beats/min. TP is possible in the presence of a functional permanent pacemaker. Programmed lower rates < or = 70 beats/min are not protective. At programmed lower rates > 70 beats/min, TP may occur only when facilitated by programmable pause-promoting features or oversensing. It remains to be seen if rate smoothing algorithms can prevent TP when the baseline rate is programmed < or = 70 beats/min.