Partial Brain Tissue Oxygen Levels Predict Arrhythmia and Prognosis in Patients With Brain Injury.

The objective of this study was to examine the clinical determinants of incidence and prognosis of arrhythmias in the setting of acute brain injury. Acute brain injury is known to cause electrocardiographic abnormalities and cardiac arrhythmias. The relation between partial brain tissue oxygen (PBTO) and intracranial pressure (ICP) with arrhythmia incidence and prognosis remains unknown. Consecutive patients with acute brain injury and intracranial bleed admitted to the neurosurgical intensive care unit were enrolled in the study. Baseline characteristics [demographics, medical history, etiology of brain injury, Glasgow Coma Scale (GCS) score, blood pressure, and respiratory rate] were documented. Patient's telemetry recordings were reviewed for daily mean heart rates and arrhythmias. If arrhythmia was noted, PBTO levels at the beginning of arrhythmia, ICP, brain tissue temperature, and outcomes were recorded. A total of 106 subjects (53% men, age 39 ± 18 years, 65 traumatic and 41 nontraumatic brain injuries) were studied. Overall, 62% of subjects developed a total of 241 arrhythmia episodes. Ventricular arrhythmias were associated with significantly higher daily mean heart rates, low PBTO levels, and low GCS scores, whereas atrial arrhythmias were associated with lower daily mean heart rates, normal PBTO levels, and higher GCS and ICP. Three or more episodes of arrhythmia predicted worse outcomes, including mortality (P = 0.001). In patients with acute brain injury, poor PBTO levels are associated with higher incidence of ventricular tachyarrhythmias. In contrast, atrial tachyarrhythmias occur in patients with normal PBTO levels and higher ICP. Incidence of ventricular arrhythmia in those with poor PBTO is associated with increased mortality.

Elevated brain natriuretic peptide level in patients undergoing atrial fibrillation ablation: is it a predictor of failed ablation or a mere function of atrial rhythm and rate at a point in time?

BACKGROUND: Pre- and postablation atrial fibrillation (AF) brain natriuretic peptide (BNP) levels were shown to predict increased recurrence of AF following ablation. OBJECTIVE: Our objective was to assess whether elevated BNP levels merely represent the presence of AF at the time of measurement or indeed the true recurrence of AF. METHODS AND RESULTS: In a prospective study of 88 patients undergoing AF ablation, BNP levels were measured immediately before, after, 24 h, and 4-6 months postablation. BNP levels were stratified by presenting rhythm and ventricular rate at the time of measurement. Median BNP level preablation was higher in patients presenting in AF compared to sinus rhythm (SR) (54(44-79) pg/ml vs. 30(18-47) pg/ml, p < 0.001). Postablation restoration of SR in patients presenting in AF reduced median BNP levels from 54(44-79) pg/ml to 40(37-51) pg/ml, (p < 0.001). However, no change was noted in patients who presented in and maintained SR throughout the procedure (30(18-47) pg/ml to 27(16-40) pg/ml, p = 0.270). At 4-6 months, BNP measured in patients in SR was not significantly different from postablation BNP (35(22-53) pg/ml vs. 38(20-52) pg/ml, p = 0.656), although 35% of them had AF recurrence in 1-year follow-up. Median BNP level measured in five patients while in atrial arrhythmia was elevated compared to postablation BNP (464(421-464) pg/ml to 37(36-37) pg/ml, p = 0.043). BNP levels and ventricular rates are positively correlated at all times pre- and postablation. CONCLUSIONS: BNP level rises acutely during AF and with rapid ventricular rates. BNP level seems to be a function of atrial rhythm and ventricular rate rather than short- or long-term predictor of AF ablation success.

Clinical utility and prognostic significance of measuring troponin I levels in patients presenting to the emergency room with atrial fibrillation.

BACKGROUND: The clinical significance of mildly elevated troponins in patients presenting to the emergency room (ER) with atrial fibrillation (AF) is not well understood. HYPOTHESIS: We hypothesized that mildly elevated troponin in these patients is associated with adverse cardiovascular outcomes. METHODS: In a multi-center, retrospective study, 662 patients with AF were divided into 3 groups based on troponin levels: group 1, mildly elevated; group 2, normal; and group 3, troponin not measured. Primary outcome was the combined endpoint of all-cause mortality and myocardial infarction (MI) at one year. RESULTS: Levels of TnI were measured in 503 (76%) patients. They were elevated in 220 patients (33%, group 1; mean, 0.56 ng/mL), normal in 283 patients (43%, group 2), and not measured in 159 patients (24%, group 3). Significantly more cardiac testing was done at index hospitalization in group 1 (50%) compared with groups 2 and 3 (28% and 29%, P ≤ 0.001) and in the following year (29%, vs 20% and 17%, P = 0.02). Group 1 had more positive tests (62%) compared with groups 2 and 3 (25% and 43%, P ≤ 0.001). Group 1 had a significantly higher occurrence of the primary endpoint (22%, vs 10% and 15%, P = 0.002), driven primarily by a higher incidence of MI in group 1 (7%, vs 1% and 2%, P = 0.001). CONCLUSIONS: Troponin levels are routinely checked in a majority of patients presenting to the emergency department with AF. Even mildly elevated TnI is associated with a greater incidence of coronary artery disease on diagnostic testing and a higher 1-year incidence of MI.

Atrial fibrillation ablation in patients with gastroesophageal reflux disease or irritable bowel syndrome-the heart to gut connection!

PURPOSE: An association between atrial fibrillation (AF) and gastroesophageal reflux disease (GERD) and/or irritable bowel syndrome (IBS) is increasingly being identified; yet the role of radiofrequency catheter ablation (RFA) of AF has not been systematically evaluated in these patient populations. METHODS: We performed a prospective matched case-control study of AF patients with GERD and/or IBS who underwent RFA for AF in two centers in North America. AF patients with GERD and/or IBS (gastrointestinal [GI] group) were matched by age, gender, and type of AF at each of the centers with an equal number of AF patients without GERD or IBS (non-GI group). RESULTS: Sixty patients were included in the study with 30 in each group. Mean age of the population was 45 years with 14 (47 %) males and 21 (87 %) patients with paroxysmal AF in each group. More patients in the GI group had identifiable GI triggers for AF episodes. During RFA, more patients in the GI group had a "vagal response" compared to non-GI group (60 vs 13 %; p < 0.001). Left atrial scar as identified by electroanatomical mapping was more common in patients in the non-GI group compared to the GI group (57 vs 27 %; p = 0.018). At 1-year follow-up, 56 (93 %) of the patients were free from AF with no difference between both groups. CONCLUSIONS: Majority of AF patients with GERD and/or IBS have triggered AF and a positive vagal response during RFA. RFA is equally effective in this patient population when compared to those without GERD or IBS.

Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: the YOGA My Heart Study.

OBJECTIVES: The purpose of this study was to examine the impact of yoga on atrial fibrillation (AF) burden, quality of life (QoL), depression, and anxiety scores. BACKGROUND: Yoga is known to have significant benefit on cardiovascular health. The effect of yoga in reducing AF burden is unknown. METHODS: This single-center, pre-post study enrolled patients with symptomatic paroxysmal AF with an initial 3-month noninterventional observation period followed by twice-weekly 60-min yoga training for next 3 months. AF episodes during the control and study periods as well as SF-36, Zung self-rated anxiety, and Zung self-rated depression scores at baseline, before, and after the study phase were assessed. RESULTS: Yoga training reduced symptomatic AF episodes (3.8 ± 3 vs. 2.1 ± 2.6, p < 0.001), symptomatic non-AF episodes (2.9 ± 3.4 vs. 1.4 ± 2.0; p < 0.001), asymptomatic AF episodes (0.12 ± 0.44 vs. 0.04 ± 0.20; p < 0.001), and depression and anxiety (p < 0.001), and improved the QoL parameters of physical functioning, general health, vitality, social functioning, and mental health domains on SF-36 (p = 0.017, p < 0.001, p < 0.001, p = 0.019, and p < 0.001, respectively). There was significant decrease in heart rate, and systolic and diastolic blood pressure before and after yoga (p < 0.001). CONCLUSIONS: In patients with paroxysmal AF, yoga improves symptoms, arrhythmia burden, heart rate, blood pressure, anxiety and depression scores, and several domains of QoL.

Radiofrequency ablation of premature ventricular ectopy improves the efficacy of cardiac resynchronization therapy in nonresponders.

OBJECTIVES: This study sought to examine whether suppressing premature ventricular contractions (PVC) using radiofrequency ablation improves effectiveness of the cardiac resynchronization therapy (CRT) in nonresponders. BACKGROUND: CRT is an effective strategy for drug refractory congestive heart failure. However, one-third of patients with CRT do not respond clinically, and the causes for nonresponse are poorly understood. Whether frequent PVC contribute to CRT nonresponse remains unknown. METHODS: In this multicenter study, CRT nonresponders with >10,000 PVC in 24 h who underwent PVC ablation were enrolled from a prospective database. RESULTS: Sixty-five subjects (age 66.6 ± 12.4 years, 78% men, QRS duration of 155 ± 18 ms) had radiofrequency ablation of PVC from 76 foci. Acute and long-term success rates of ablation were 91% and 88% in 12 ± 4 months of follow-up. There was significant improvement in left ventricular (LV) ejection fraction (26.2 ± 5.5% to 32.7 ± 6.7 %, p < 0.001), LV end-systolic diameter (5.93 ± 0.55 cm to 5.62 ± 0.32 cm, p < 0.001), LV end-diastolic diameter (6.83 ± 0.83 cm to 6.51 ± 0.91 cm, p < 0.001), LV end-systolic volume (178 ± 72 to 145 ± 23 ml, p < 0.001), LV end-diastolic volume (242 ± 85 ml to 212 ± 63 ml, p < 0.001), and median New York Heart Association functional class (3.0 to 2.0, p < 0.001). Modeling of pre-ablation PVC burden revealed an improvement in ejection fraction when the pre-ablation PVC burden was >22% in 24 h. CONCLUSIONS: Frequent PVC is an uncommon yet significant cause of CRT nonresponse. Radiofrequency ablation of PVC foci improves LV function and New York Heart Association class and promotes reverse remodeling in CRT nonresponders. PVC ablation may be used to enhance CRT efficacy in nonresponders with significant PVC burden.

Should 25-hydroxyvitamin D and bone density using DXA be tested in adolescents with lumbar stress fractures of the pars interarticularis?

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine if 25-hydroxyvitamin D (25[OH]D) level measurement and bone mineral density (BMD) using dual-energy x-ray absorptiometry (DXA) are indicated in children with a history of stress fracture of the pars interarticularis. SUMMARY OF BACKGROUND DATA: Healing rates of 4%-25% for bilateral and unilateral pars fractures, respectively, have previously been reported. Factors that may contribute to osteomalacia, rickets, and poor bone healing include low (25[OH]D) and low BMD. METHODS: Patients were seen at the Nebraska Spine Center between 2008 and 2010. Selection criteria included a diagnosis of pars fracture with DXA Z-score values (lumbar and hip) and pretreatment serum (25[OH]D) level measurement. Twenty-four patients were included. Vitamin D was defined as sufficient when ≥ 32 ng/mL, insufficient when 20 to < 32 ng/mL, and deficient when < 20 ng/mL. BMD was interpreted from DXA Z-scores using reference intervals defined in the literature. A Z-score <-2.0 was considered low for chronological age. RESULTS: The mean (± SD) vitamin D level was 29.9 ng/mL ± 10.8 (range, 9-56 ng/mL). Values were ≤ 10 ng/mL in 1 patient (4%), 11-20 ng/mL in 4 patients (17%), 21-30 ng/mL in 8 patients (33%), 31-50 ng/mL in 10 patients (42%), and > 50 ng/mL in 1 patient (4%). This correlated to 3 (13%) patients with deficient vitamin D (≤ 15 ng/mL), 12 (50%) patients with insufficient levels, and 9 (38%) with sufficient levels of vitamin D. The mean Z-scores were 0.43 ± 0.93 (lumbar, range, -1.3 to 2.8) and 1.0 ± 1.11 (hip, range, -0.5 to 3.0). All scores were consistent with normal bony mineralization for age. CONCLUSIONS: On the basis of these data, we recommend routine vitamin D testing and do not recommend routine DXA in adolescents with lumbar stress fractures of the pars interarticularis.

Impact of a comprehensive safety program on radiation exposure during catheter ablation of atrial fibrillation: a prospective study.

BACKGROUND: Pulmonary vein antral isolation (PVAI) is an effective treatment for atrial fibrillation and involves prolonged procedure and fluoroscopy times. This study assesses the impact of a comprehensive radiation safety program on patient and operator radiation exposure during PVAI. METHODS AND RESULTS: We evaluated a comprehensive radiation safety program including: (1) verbal reinforcement of previous fluoroscopy times (2) effective collimation (3) minimizing source-intensifier distance and (4) effective lead shield use. Exposure doses in 41 consecutive patients without (group-I, n = 21) and with (group-II, n = 20) the use of radiation safety program were assessed. PVAI was done using intracardiac echo (ICE) guided roving circular mapping catheter. A 3-dimensional mapping system was used in 27% cases for additional guidance. Operator and patient exposure was measured during the PVAI. The age, gender, body mass index and AF duration were similar in both of the groups. The total procedure (166 +/- 56 vs 178 +/- 38 min, p = 0.54) and fluoroscopy times (74 +/- 24 vs 70 +/- 20 min, p = 0.72) were comparable. Group-II had significantly lower dose area product (234 +/- 120 vs 548 +/- 363 Gy cm(2), p = 0.03) compared to group-I. The mean operator exposure was reduced by half and mean patient peak skin dose by three to ten times with comprehensive radiation safety program. None of the patients were noted to have radiation related skin injuries. Additional lifetime cancer risk was significantly lower in group-II patients (0.08 vs 0.2%, p < 0.001) than group-I. CONCLUSIONS: Implementation of a comprehensive radiation safety program described above significantly decreases the radiation exposure to the patient as well as the operator.

Cardiac effects of electrical stun guns: does position of barbs contact make a difference?

BACKGROUND: The use of electrical stun guns has been rising among law enforcement authorities for subduing violent subjects. Multiple reports have raised concerns over their safety. The cardiovascular safety profile of these devices in relationship to the position of delivery on the torso has not been well studied. METHODS: We tested 13 adult pigs using a custom device built to deliver neuromuscular incapacitating (NMI) discharge of increasing intensity that matched the waveform of a commercially available stun gun (TASER(R) X-26, TASER International, Scottsdale, AZ, USA). Discharges with increasing multiples of output capacitances were applied in a step-up and step-down fashion, using two-tethered barbs at five locations: (1) Sternal notch to cardiac apex (position-1), (2) sternal notch to supraumbilical area (position-2), (3) sternal notch to infraumbilical area (position-3), (4) side to side on the chest (position-4), and (5) upper to lower mid-posterior torso (position-5). Endpoints included determination of maximum safe multiple (MaxSM), ventricular fibrillation threshold (VFT), and minimum ventricular fibrillation induction multiple (MinVFIM). RESULTS: Standard TASER discharges repeated three times did not cause ventricular fibrillation (VF) at any of the five locations. When the barbs were applied in the axis of the heart (position-1), MaxSM and MinVFIM were significantly lower than when applied away from the heart, on the dorsum (position-5) (4.31 +/- 1.11 vs 40.77 +/- 9.54, P< 0.001 and 8.31 +/- 2.69 vs 50.77 +/- 9.54, P< 0.001, respectively). The values of these endpoints at position-2, position-3, and position-4 were progressively higher and ranged in between those of position-1 and position-5. Presence of ventricular capture at a 2:1 ratio to the delivered TASER impulses correlated with induction of VF. No significant metabolic changes were seen after standard NMI TASER discharge. There was no evidence of myocardial damage based on serum cardiac markers, electrocardiography, echocardiography, and histopathologic findings confirming the absence of significant cardiac effects. CONCLUSIONS: Standard TASER discharges did not cause VF at any of the positions. Induction of VF at higher output multiples appear to be sensitive to electrode distance from the heart, giving highest ventricular fibrillation safety margin when the electrodes are placed on the dorsum. Rapid ventricular capture appears to be a likely mechanism of VF induction by higher output TASER discharges.

Success of Radiofrequency Catheter Ablation of Atrial Fibrillation: Does Obesity Influence the Outcomes?

Background: Catheter ablation of atrial fibrillation (AF) is an increasingly popular therapeutic option for symptomatic patients who have failed multiple antiarrhythmic drugs (AADs). Patients of higher body mass index often fail direct current cardioversion. The role of body mass index (BMI) on the success of AF ablation is not well understood. Methods: We prospectively studied 511 patients who underwent AF ablation at the Cleveland Clinic Foundation between 2002 and 2005. Patients were divided into four classes based on their BMI: Class I ( 25); Class II (25.1-30); Class III (30.1-35) and Class IV (>35). These groups were compared for baseline demographic and clinical characteristics. Any recurrence of AF after 3 months of ablation was considered as failure. All classes were followed for at least 12 months and rates of failure were compared. Results: Based on their BMI, 25% of patients were assigned to class I, 37% in class II, 21% in class III and 16% in class IV. Patients of higher classification (class III or IV) were more likely to be male (p<0.001), diabetic (p<0.001), smokers (p=0.002), with coronary artery disease (=0.018), left atrial enlargement (p=0.015) and longstanding AF (p=0.007). Severity of obesity as measured by BMI had a direct correlation to early (p=0.05) and late (p=0.01) recurrence of AF. Conclusion: Obesity is significantly associated with long-term AF recurrence after catheter ablation. Higher incidence of smoking & left atrial enlargement may possibly contribute to higher failure rates in this sub-group of patients.

Effects of cocaine intoxication on the threshold for stun gun induction of ventricular fibrillation.

OBJECTIVES: This study sought to assess cocaine's effects on Taser-induced ventricular fibrillation (VF) threshold in a pig model. BACKGROUND: Stun guns are increasingly used by law enforcement officials to restrain violent subjects, who are frequently intoxicated with cocaine and other drugs of abuse. The interaction of cocaine and the stun gun on VF induction is unknown. METHODS: We tested five adult pigs using a custom device built to deliver multiples of standard neuromuscular incapacitating (NMI) discharge that matched the waveform of a commercially available electrical stun gun (Taser X-26, Taser International, Scottsdale, Arizona). The NMI discharges were applied in a step-up and step-down fashion at 5 body locations. End points included determination of maximum safe multiple, minimum VF-inducing multiple, and ventricular fibrillation threshold (VFT) before and after cocaine infusion. RESULTS: Standard NMI discharges (x1) did not cause VF at any of the 5 locations before or after cocaine infusion. The maximum safe multiple, minimum VF-inducing multiple, and VFT of NMI application increased with increasing electrode distance from the heart. There was a 1.5- to 2-fold increase in these values at each position after cocaine infusion, suggesting decreased cardiac vulnerability for VF. Cocaine increased the required strength of NMI discharge that caused 2:1 or 3:1 ventricular capture ratios at all of the positions. No significant changes in creatine kinase-MB and troponin-I were seen. CONCLUSIONS: Cocaine increased the VFT of NMI discharges at all dart locations tested and reduced cardiac vulnerability to VF. The application of cocaine increased the safety margin by 50% to 100% above the baseline safety margin.

Safety and efficacy of radiofrequency energy catheter ablation of atrial fibrillation in patients with pacemakers and implantable cardiac defibrillators.

BACKGROUND: Catheter ablation has significantly transformed the clinical management of atrial fibrillation (AF). The safety and efficacy of this procedure are not well understood in patients with pacemakers and defibrillators. OBJECTIVES: The purpose of this study was to study the impact of radiofrequency catheter ablation of AF in patients with pacemakers and implantable cardiac defibrillators. METHODS: We studied 86 patients with pacemakers and defibrillators (group I) and a similar number of age- and gender-matched controls (group II) who underwent AF ablation between 1999 and 2004. Clinical and procedural variables were compared between the two groups. In group I, various generator and lead parameters were compared before and after the procedure. Resurgence of clinical AF after 2 months was considered recurrence. RESULTS: Both groups were similar with regard to age, gender, body mass index, and type of AF. Group I had a higher incidence of diabetes (17% vs 6%, P = .03), coronary artery disease (25% vs 13%, P = .05), less prolonged AF (31 +/- 21 vs 45 +/- 30 months, P <.001), lower left ventricular ejection fraction (49 +/- 13% vs 52 +/- 9%, P = .03), and left ventricular end-diastolic dimensions (4.97 +/- 0.81 vs 4.72 +/- 0.67, P = .03). No changes in the sensing and pacing thresholds, impedance of atrial and ventricular leads, or defibrillator coil impedance after AF ablation were observed in group I. Atrial lead dislodgment was seen in two patients. Transient abnormal but "expected" pulse generator behavior was seen in 25% of patients without permanent malfunction. Stroke (1% vs 1%, P = 1.000), pulmonary vein stenosis (2% vs 1%, P = .77), and AF recurrence rates at 12 months were similar between groups I and II, respectively (19% vs 21%, P = .73). CONCLUSION: AF ablation is safe and efficacious in patients with pacemakers and defibrillators.

Prognostic value of the Duke Treadmill Score in diabetic patients.

BACKGROUND: The Duke Treadmill Score (DTS) is an established clinical tool for risk stratification of coronary artery disease. We sought to assess the prognostic value of the DTS in diabetics compared with nondiabetics in this study. METHODS: We studied 100 diabetics and 202 age- and sex-matched nondiabetic controls without known coronary artery disease risk stratified by DTS and followed for a median duration of 6.6 years. The association between DTS and primary, secondary outcomes, composite events, and rate of coronary angiography was tested. RESULTS: Survival free from cardiac death, nonfatal myocardial infarction, congestive heart failure, or early and late revascularization was 89%, 54%, and 13%, respectively, in the low-, intermediate-, and high-risk categories of diabetic group (P < .0001), and 91%, 57%, and 17%, respectively, in the low- to high-risk groups of nondiabetics (P < .0001). During follow-up, diabetics had more secondary events (P = .011) and coronary angiography (P < .001) compared with nondiabetics. The DTS was a strong independent predictor of composite events in both diabetics (P < .001) and nondiabetics (P < .001). A significant number of diabetics were classified as intermediate risk and had a significantly higher incidence of coronary angiography (87.5% vs 70.8%, P = .032) and late revascularizations (35.4% vs 15.3%, P = .011) within this risk group compared with nondiabetics. Survival free from major adverse cardiac events differed significantly across the 3 Duke risk groups for diabetics (P = .002) but not for controls (P = .07). Survival free from composite events differed significantly across the 3 Duke risk groups for both diabetics and nondiabetics (P < .0001). Overall, diabetics had higher rates of major adverse cardiac events, composite events (P = .011), and coronary angiography (P < .001) than nondiabetics. The DTS is a strong predictor of survival free of composite events in both groups by multivariate analysis. CONCLUSIONS: The DTS predicted survival free from MACE and composite events equally well in patients with and without diabetes.

The impact of povidone-iodine pocket irrigation use on pacemaker and defibrillator infections.

BACKGROUND: Infection is a devastating complication of permanent pacemakers (PMs) implantable cardioverter defibrillators (ICDs). Many implanting physicians commonly use povidone-iodine solution to irrigate the device pocket before implanting the device. We sought to assess if such a measure would alter the rate of infection. METHODS: A total of 2,564 consecutive patients who received implantable PM or ICD devices between 1994 and 2002 were studied. Povidone-iodine was used for pocket irrigation in 53% and saline in 47%. A total of 18 (0.7%) patients developed pocket infections with 0.7% (10/1,359) in povidone-iodine (group I) and 0.6% (8/1,205) in saline (group II) pocket irrigation (p = ns). Groups I and II were studied for various clinical and demographic variables described in the results section. RESULTS: There was no statistical difference in the baseline demographic and clinical characteristics between groups I and II, respectively. ICDs were most frequently infected than PMs (56% vs 44%). Most (83%) of the devices were dual chamber. Reopening of the pocket for either lead or generator replacement had a higher incidence of infection than new implants (61% vs 39%). There was no difference in the use of preimplantation antibiotic prophylaxis. Late (61%) and deep pocket infections (78%) were more common than early (39%) and superficial infections (22%). Blood cultures were positive in 67% and Staphylococcus aureus was the common most pathogen (50%). The mean duration of antibiotics use after the diagnosis of device infection was 35 +/- 23 days with 72% requiring device explantation. The device was reimplanted on the contralateral side in 56% cases. One patient in each group died due to device infection and related complications. No significant allergy to iodine was seen in either group. CONCLUSION: Povidone-iodine irrigation of the subcutaneous pocket did not alter the rates of pocket infection after pacemaker/defibrillator implantation.

Gender significance of ST-segment deviation detected by ambulatory (Holter) monitoring.

OBJECTIVE: To evaluate the gender influence in diagnostic and prognostic value of Holter-detected ST-segment deviation. METHODS: Two-hundred seventy-seven consecutive patients (196 men) who underwent coronary angiography for evaluation of chest pain were studied with 24-h Holter monitoring within 72 h of coronary angiography, and were followed up for 65+/-21 months. RESULTS: Men had a higher prevalence of coronary artery disease (169 of 196, 86%) compared to that of women (54 of 81, 67%), p<0.00025. Thirty-three (17%) men and 15 (19%) women had ST-segment deviation during 24-h recording. The sensitivity, specificity and positive predictive values of ST-segment deviation (elevation, depression, or both) for the detection of significant coronary artery disease were similar in men and women. The negative predictive values were significantly higher in women than men for ST-segment deviation (36% vs. 15%, p<0.001), ST-segment elevation (35% vs. 14%, p<0.001), and ST-segment depression (34% vs. 15%, p<0.001). Similarly, the diagnostic accuracies were significantly higher in women than men for ST-segment deviation (44% vs. 29%, p<0.025), ST-segment elevation (38% vs. 19%, p<0.001), and ST-segment depression (40% vs. 24%, p<0.025). There was no significant difference in composite end-point of events (mortality, nonfatal myocardial infarction, unstable angina, and coronary revascularization) in men versus women with ST-segment deviation (elevation, depression, or both). CONCLUSION: Holter-detected ST-segment deviation has a higher negative predictive value and diagnostic accuracy for detection of significant coronary artery disease in women than in men, although the prognostic values are not significantly different between men and women.