Intra-Individual Comparison of Sinus and Ectopic Beats Probing the Ventricular Gradient's Activation Dependence.

Wilson assumed that the ventricular gradient (VG) is independent of the ventricular activation order. This paradigm has often been refuted and was never convincingly corroborated. We sought to validate Wilson's concept by intra-individual comparison of the VG of sinus beats and ectopic beats, thus assessing the effects of both altered ventricular conduction (caused by the ectopic focus) and restitution (caused by ectopic prematurity). We studied standard diagnostic ECGs of 118 patients with accidental extrasystoles: normally conducted supraventricular ectopic beats (SN, N = 6) and aberrantly conducted supraventricular ectopic beats (SA, N = 20) or ventricular ectopic beats (V, N = 92). In each patient, we computed the VG vectors of the predominant beat, VGp→, of the ectopic beat, VGe→, and of the VG difference vector, ΔVGep→, and compared their sizes. VGe→ of the SA and V ectopic beats were significantly larger than VGp→ (53.7 ± 25.0 vs. 47.8 ± 24.6 mV∙ms, respectively; p < 0.001). ΔVGep→ were three times larger than the difference of VGe→ and VGp→ (19.94 ± 9.76 vs. 5.94 mV∙ms, respectively), demonstrating differences in the VGp→ and VGe→ spatial directions. The amount of ectopic prematurity was not correlated with ΔVGep→, although the larger VG difference vectors were observed for the more premature (<80%) extrasystoles. Electrical restitution properties and electrotonic interactions likely explain our findings. We conclude that the concept of a conduction-independent VG should be tested at equal heart rates and without including premature extrasystoles.

Prevalence of ECGs Exceeding Thresholds for ST-Segment-Elevation Myocardial Infarction in Apparently Healthy Individuals: The Role of Ethnicity.

Background Early prehospital recognition of critical conditions such as ST-segment-elevation myocardial infarction (STEMI) has prognostic relevance. Current international electrocardiographic STEMI thresholds are predominantly based on individuals of Western European descent. However, because of ethnic electrocardiographic variability both in health and disease, there is a need to reevaluate diagnostic ST-segment elevation thresholds for different populations. We hypothesized that fulfillment of ST-segment elevation thresholds of STEMI criteria (STE-ECGs) in apparently healthy individuals is ethnicity dependent. Methods and Results HELIUS (Healthy Life in an Urban Setting) is a multiethnic cohort study including 10 783 apparently healthy subjects of 6 different ethnicities (African Surinamese, Dutch, Ghanaian, Moroccan, South Asian Surinamese, and Turkish). Prevalence of STE-ECGs across ethnicities, sexes, and age groups was assessed with respect to the 2 international STEMI thresholds: sex and age specific versus sex specific. Mean prevalence of STE-ECGs was 2.8% to 3.4% (age/sex-specific and sex-specific thresholds, respectively), although with large ethnicity-dependent variability. Prevalences in Western European Dutch were 2.3% to 3.0%, but excessively higher in young (<40 years) Ghanaian males (21.7%-27.5%) and lowest in older (≥40 years) Turkish females (0.0%). Ethnicity (sub-Saharan African origin) and other variables (eg, younger age, male sex, high QRS voltages, or anterolateral early repolarization pattern) were positively associated with STE-ECG occurrence, resulting in subgroups with >45% STE-ECGs. Conclusions The accuracy of diagnostic tests partly relies on background prevalence in healthy individuals. In apparently healthy subjects, there is a highly variable ethnicity-dependent prevalence of ECGs with ST-segment elevations exceeding STEMI thresholds. This has potential consequences for STEMI evaluations in individuals who are not of Western European descent, putatively resulting in adverse outcomes with both over- and underdiagnosis of STEMI.

An initial exploration of subtraction electrocardiography to detect myocardial ischemia in the prehospital setting.

BACKGROUND: In the prehospital triage of patients presenting with symptoms suggestive of acute myocardial ischemia, reliable myocardial ischemia detection in the electrocardiogram (ECG) is pivotal. Due to large interindividual variability and overlap between ischemic and nonischemic ECG-patterns, incorporation of a previous elective (reference) ECG may improve accuracy. The aim of the current study was to explore the potential value of serial ECG analysis using subtraction electrocardiography. METHODS: SUBTRACT is a multicenter retrospective observational study, including patients who were prehospitally evaluated for acute myocardial ischemia. For each patient, an elective previously recorded reference ECG was subtracted from the ambulance ECG. Patients were classified as myocardial ischemia cases or controls, based on the in-hospital diagnosis. The diagnostic performance of subtraction electrocardiography was tested using logistic regression of 28 variables describing the differences between the reference and ambulance ECGs. The Uni-G ECG Analysis Program was used for state-of-the-art single-ECG interpretation of the ambulance ECG. RESULTS: In 1,229 patients, the mean area-under-the-curve of subtraction electrocardiography was 0.80 (95%CI: 0.77-0.82). The performance of our new method was comparable to single-ECG analysis using the Uni-G algorithm: sensitivities were 66% versus 67% (p-value > .05), respectively; specificities were 80% versus 81% (p-value > .05), respectively. CONCLUSIONS: In our initial exploration, the diagnostic performance of subtraction electrocardiography for the detection of acute myocardial ischemia proved equal to that of state-of-the-art automated single-ECG analysis by the Uni-G algorithm. Possibly, refinement of both algorithms, or even integration of the two, could surpass current electrocardiographic myocardial ischemia detection.

Mobile Health for Central Sleep Apnea Screening Among Patients With Stable Heart Failure: Single-Cohort, Open, Prospective Trial.

BACKGROUND: Polysomnography is the gold standard for detection of central sleep apnea in patients with stable heart failure. However, this procedure is costly, time consuming, and a burden to the patient and therefore unsuitable as a screening method. An electronic health (eHealth) app to measure overnight oximetry may be an acceptable screening alternative, as it can be automatically analyzed and is less burdensome to patients. OBJECTIVE: This study aimed to assess whether overnight pulse oximetry using a smartphone-compatible oximeter can be used to detect central sleep apnea in a population with stable heart failure. METHODS: A total of 26 patients with stable heart failure underwent one night of both a polygraph examination and overnight saturation using a smartphone-compatible oximeter. The primary endpoint was agreement between the oxygen desaturation index (ODI) above or below 15 on the smartphone-compatible oximeter and the diagnosis of the polygraph. RESULTS: The median age of patients was 66.4 (interquartile range, 62-71) years and 92% were men. The median body mass index was 27.1 (interquartile range, 24.4-30.8) kg/m2. Two patients were excluded due to incomplete data, and two other patients were excluded because they could not use a smartphone. Seven patients had central sleep apnea, and 6 patients had obstructive sleep apnea. Of the 7 (of 22, 32%) patients with central sleep apnea that were included in the analysis, 3 (13%) had an ODI≥15. Of all patients without central sleep apnea, 8 (36%) had an ODI<15. The McNemar test yielded a P value of .55. CONCLUSIONS: Oxygen desaturation measured by this smartphone-compatible oximeter is a weak predictor of central sleep apnea in patients with stable heart failure.

Electrocardiographic Detection of Left Ventricular Hypertrophy; Adding Body Mass Index and Spatial QRS-T Angle: A Cross-Sectional Study.

INTRODUCTION: We investigated improvement of electrocardiographic LVH detection by adding measures of adiposity and/or novel electrocardiographic measures. Left ventricular hypertrophy (LVH) is an important risk factor for adverse cardiovascular outcomes. Improvement of electrocardiographic criteria for LVH is desirable, since electrocardiography is widely used. METHODS: We included 1091 participants of the Netherlands Epidemiology of Obesity Study (NEO) who underwent cardiac magnetic resonance imaging (MRI). Performance of Sokolow-Lyon and Cornell voltage and product criteria was assessed. Stepwise regression analysis was performed with each conventional electrocardiographic criterion and age, sex, body mass index (BMI), waist circumference, and waist:hip ratio (p-entry < 0.05, p-removal > 0.10). T-wave abnormalities or the spatial QRS-T angle (SA) were added to the improved models. RESULTS: The study population had a mean (SD) age of 56 (6) years, BMI of 26.1 (4.0) kg/m2 and 46% were men. MRI-LVH was present in 10% of participants. The c-statistic for Sokolow-Lyon voltage was 0.58, R2 was 0.02 and sensitivity at 90% specificity was 16%, for Sokolow-Lyon product this was 0.62, 0.02, and 21%, for Cornell voltage 0.65, 0.04, and 28% and for Cornell product 0.67, 0.04, and 25%. Best performing models were obtained by addition of both BMI and SA (Sokolow-Lyon voltage: c-statistic 0.74, R2 0.11, sensitivity of 41% at 90% specificity; Sokolow-Lyon product: 0.75, 0.12, 42%; Cornell voltage: c-statistic 0.70, R2 0.08, sensitivity of 38% at 90% specificity; Cornell product: c-statistic 0.72, R2 0.08, sensitivity of 44% at 90% specificity). CONCLUSIONS: Electrocardiographic detection of LVH improved by adding BMI and SA to a model with conventional electrocardiographic criteria. This approach would require little extra effort and application in clinical practice is feasible. However, results should first be replicated in high-risk populations.

Electrical remodeling after percutaneous atrial septal defect closure in pediatric and adult patients.

BACKGROUND: Several studies have reported changes in electrocardiographic variables after atrial septal defect (ASD) closure. However no temporal electro-and vectorcardiographic changes have been described from acute to long-term follow-up at different ages. We aimed to study electrical remodeling after percutaneous ASD closure in pediatric and adult patients. METHODS: ECGs of 69 children and 75 adults (median age 6 [IQR 4-11] years and 45 [IQR 33-54] years, respectively) were retrospectively selected before percutaneous ASD closure and at acute (1-7 days), intermediate (4-14 weeks) and late (6-18 months) follow-up. Apart from electrocardiographic variables, spatial QRS-T angle and ventricular gradient (VG) were derived from mathematically-synthesized vectorcardiograms. RESULTS: In both pediatric and adult patients, the heart rate decreased immediately post-closure, which persisted to late follow-up. The P-wave amplitude also decreased acutely post-closure, but remained unchanged at later follow-up. The PQ duration shortened immediately in children and at intermediate follow-up in adults. The QRS duration and QTc interval decreased at intermediate-term follow-up in both children and adults. In both groups the spatial QRS-T angle decreased at late follow-up. The VG magnitude increased at intermediate follow-up in children and at late follow-up in adults, after an initial decrease in children. CONCLUSION: In both pediatric and adult ASD patients, electrocardiographic changes mainly occurred directly after ASD closure except for shortening of QRS duration and QTc interval, which occurred at later follow-up. Adults also showed late changes in PQ duration. At 6-to-18 month post-closure, the spatial QRS-T angle decreased, reflecting increased electrocardiographic concordance. The initial acute decrease in VG in children, which was followed by a significant increase, may be the effect of action potential duration dynamics directly after percutaneous ASD closure.

Relation of Overall and Abdominal Adiposity With Electrocardiogram Parameters of Subclinical Cardiovascular Disease in Individuals Aged 45 to 65 Years (from the Netherlands Epidemiology of Obesity Study).

Overall and abdominal obesity are well-established risk factors for cardiometabolic disease. However, associations of overall and abdominal adiposity with electrocardiographic (ECG) markers of subclinical cardiovascular disease (CVD) have not yet been fully elucidated. Therefore, we investigated these associations in a population without preexisting CVD. We performed cross-sectional analyses in the Netherlands Epidemiology of Obesity Study. Body mass index (BMI), total body fat, and waist circumference were assessed in all participants, and abdominal subcutaneous adipose tissue and visceral adipose tissue (by magnetic resonance imaging) were assessed in a random subgroup. ECG parameters were determined using 12-lead electrocardiograms. We performed linear regression analyses, adjusting for potential confounding factors and, when investigating abdominal adiposity, additionally for total body fat. After exclusion of participants with preexisting CVD (n = 654), 5,939 individuals (42% men) were analyzed, with a mean (SD) age of 55 (6) years and BMI of 26.3 (4.4) kg/m2. Measures of both overall and abdominal adiposity were associated with ECG parameters but none of these measures was more strongly associated than the others. For example, heart rate (beats/min) increased per SD higher BMI (2.2; 95% confidence interval 1.9,2.5), total body fat (2.9; 2.4,3.4), subcutaneous adipose tissue (2.3;1.7,2.9), waist circumference (2.1; 1.4,2.8), and visceral adipose tissue (1.7; 0.8,2.5). In subgroup analyses based on gender and cardiovascular risk factors, no consistent interactions were observed. In conclusion, in a middle-aged population without preexisting CVD, measures of both overall and abdominal adiposity were associated with ECG parameters. Future studies should evaluate the added value of adiposity measures in electrocardiography-based diagnoses and the prognostic value of adding adiposity measures to risk prediction tools.

Normal values of the ventricular gradient and QRS-T angle, derived from the pediatric electrocardiogram.

BACKGROUND: Normal values of the mathematically-synthesized vectorcardiogram (VCG) are lacking for children. Therefore, the objective of this study was to assess normal values of the pediatric synthesized VCG (spatial QRS-T angle [SA] and ventricular gradient [VG]). METHODS: Electrocardiograms (ECGs) of 1263 subjects (0-24 years) with a normal heart were retrospectively selected. VCGs were synthesized by the Kors matrix. Normal values (presented as 2nd and 98th percentiles) were assessed by quantile regression with smoothing by splines. RESULTS: Our results show that heart rate decreased over age, QRS duration increased and QTc interval remained constant. The SA initially decreased and increased again from the age of 8 years. The VG magnitude was relatively stable until the age of 2 years, after which it increased. CONCLUSION: Normal values of the pediatric ECG and VCG (VG and SA) were established. These normal values could be important for future studies using VG and SA for risk stratification in heart disease in children.

Mobile phones in cryptogenic strOke patients Bringing sIngle Lead ECGs for Atrial Fibrillation detection (MOBILE-AF): study protocol for a randomised controlled trial.

BACKGROUND: Recently published randomised clinical trials indicate that prolonged electrocardiom (ECG) monitoring might enhance the detection of paroxysmal atrial fibrillation (AF) in cryptogenic stroke or transient ischaemic attack (TIA) patients. A device that might be suitable for prolonged ECG monitoring is a smartphone-compatible ECG device (Kardia Mobile, Alivecor, San Francisco, CA, USA) that allows the patient to record a single-lead ECG without the presence of trained health care staff. The MOBILE-AF trial will investigate the effectiveness of the ECG device for AF detection in patients with cryptogenic stroke or TIA. In this paper, the rationale and design of the MOBILE-AF trial is presented. METHODS: For this international, multicentre trial, 200 patients with cryptogenic stroke or TIA will be randomised. One hundred patients will receive the ECG device and will be asked to record their ECG twice daily during a period of 1 year. One hundred patients will receive a 7-day Holter monitor. DISCUSSION: The primary outcome of this study is the percentage of patients in which AF is detected in the first year after the index ischaemic stroke or TIA. Secondary outcomes include markers for AF prediction, orally administered anticoagulation therapy changes, as well as the incidence of recurrent stroke and major bleeds. First results can be expected in mid-2019. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02507986 . Registered on 15 July 2015.

Association of metabolic syndrome and electrocardiographic markers of subclinical cardiovascular disease.

BACKGROUND: The metabolic syndrome (MetS) and its components are well-established risk factors for cardiovascular diseases (CVD). It is inconclusive whether MetS and MetS score are associated with electrocardiographic markers of subclinical CVD, therefore we investigated this in a population without pre-existing CVD. METHODS: We performed a cross-sectional analysis in the Netherlands Epidemiology of Obesity study, a population-based cohort including 6671 participants aged 45-65. We excluded participants with pre-existing CVD (n = 499) or missing MetS components (n = 58). MetS was defined based on a modified definition of Adult Treatment Panel III. Subclinical CVD parameters were determined with 12-lead ECGs. MetS score was defined as number of abnormal MetS components and obesity as Body Mass Index (BMI) ≥30 kg/m2. We performed weighted adjusted linear regression analyses. RESULTS: Our study population (n = 6114) had a mean (SD) BMI of 26.3 (4.4) kg/m2 and MetS was present in 24% of participants. All ECG parameters differed between participants with and without MetS. Per additional MetS component, heart rate was 0.17 SD (95% CI 0.15, 0.19) higher, P wave duration, QRS complex duration and corrected QT interval were longer [0.07 SD (0.05, 0.10), 0.04 SD (0.01, 0.06) and 0.05 SD (0.02, 0.08) respectively], P wave axis, T wave axis and QRS axis were lower [-0.10 SD (-0.12, -0.07), -0.07 SD (-0.10, -0.05) and -0.19 SD (-0.22, -0.16)] and percentage small Q-waves also increased per additional MetS component. Associations were stronger in non-obese than obese participants. In joint modelling of all MetS components, increased waist circumference showed strongest associations with ECG parameters. CONCLUSIONS: Metabolic syndrome score and its individual components, in particular abdominal obesity, are associated with ECG markers of subclinical CVD, showing the importance of limiting the amount of MetS components in both obese and non-obese persons.

Effect of Aging on Left Atrial Compliance and Electromechanical Properties in Subjects Without Structural Heart Disease.

Aging is associated with changes in left atrial (LA) structure and function. The present study aimed at describing the effect of aging on LA properties in a large cohort of subjects without structural heart disease. We divided 386 subjects (mean age 58 years [range 16 to 91]; 188 men [49%]) clinically referred for echocardiography according to age groups. The P-wave dispersion (PWD), reflecting total atrial conduction time, was measured on a 12-lead surface electrocardiogram as the difference between maximum and minimum P-wave duration. The PA-TDI duration reflecting the total atrial conduction time was measured on tissue Doppler imaging (TDI) as the time between onset of P wave on surface electrocardiogram to peak A'-wave velocity. Two-dimensional speckle-tracking echocardiography was used to assess LA reservoir function, reflecting LA compliance. In the overall population, mean PWD, PA-TDI, and LA reservoir strain were 43 ± 12 ms, 129 ± 27 ms, and 36 ± 13%, respectively. Increasing age was independently associated with prolonged PWD (ß = 0.161; p <0.001), PA-TDI (ß = 0.476; p <0.001), and reduced LA reservoir strain (ß = -0.259; <0.001), suggesting age-related fibrotic changes of the LA myocardium. The association between age and LA reservoir strain was modulated by body mass index (ß = -0.582; p <0.001) and LA volume index (ß = -0.117; p = 0.014). In conclusion, aging is associated with longer PWD and PA-TDI duration along with a decrease in LA reservoir function. Obesity and larger LA volumes are independently associated with reduced LA compliance.

Detection of elevated pulmonary pressures by the ECG-derived ventricular gradient: A comparison of conversion matrices in patients with suspected pulmonary hypertension.

BACKGROUND: The aim was to assess the diagnostic value of the Inverse Dower (INVD)-derived vectorcardiogram (VCG) and the Kors-derived VCG to detect elevated systolic pulmonary artery pressure (SPAP) in suspected pulmonary hypertension (PH). METHODS: In 132 patients, morphologic variables were evaluated by comparing the VCG parameters synthesized by INVD and Kors matrix. Comparison of the diagnostic accuracy of detecting SPAP ≥50mmHg between the matrices was performed by ROC curve analysis and logistic regression analysis. RESULTS: Most VCG parameters differed significantly between INVD and Kors. ROC analysis for detection of SPAP ≥50mmHg by VG projected on the X-axis demonstrated no difference (p=0.99) between INVD (AUC=0.80) and Kors (AUC=0.80). Both the INVD- and Kors-derived VCG provided significant diagnostic information on the presence of SPAP ≥50mmHg (INVD, OR 1.05, 95%CI 1.03-1.07; P<0.001; Kors, OR 1.05, 95%CI 1.03-1.08; P<0.001). CONCLUSION: Although there were significant differences in measures of vector morphology, both INVD- and Kors-derived VCG demonstrated equal clinical performance in case of elevated SPAP.

Position of ST-deviation measurements relative to the J-point: Impact for ischemia detection.

BACKGROUND: There is no consensus about the time instant relative to the J point where ST deviation has to be measured for detection of acute ischemia in the ECG. METHODS: We analyzed 53 ECGs, recorded preceding emergency catheterization of acute coronary syndrome patients with a completely occluded culprit artery (cases), and 88 control ECGs recorded in the cardiology outpatient clinic. ECG-amplitude measurements were made every 10 ms, between 20 ms before till 80 ms after the J point. STEMI-detection algorithms varied from the traditional STEMI criterion (elevations in at least two adjacent ECG leads), via the STEMI equivalent criterion (depressions in V2 and V3), to the most liberal STEMI-detection algorithm in which elevations as well as depressions in two adjacent leads were considered as signs of ischemia. RESULTS: Diagnostic accuracy was highest (93.6%) for the most liberal STEMI-detection algorithm at 10 ms after the J point; sensitivity was 94.3% and specificity was 93.2%. CONCLUSION: The results of our study suggest that STEMI detection close to the J point is optimal.

Comparative Analysis of the Equivital EQ02 Lifemonitor with Holter Ambulatory ECG Device for Continuous Measurement of ECG, Heart Rate, and Heart Rate Variability: A Validation Study for Precision and Accuracy.

Background: The Equivital (EQ02) is a multi-parameter telemetric device offering both real-time and/or retrospective, synchronized monitoring of ECG, HR, and HRV, respiration, activity, and temperature. Unlike the Holter, which is the gold standard for continuous ECG measurement, EQO2 continuously monitors ECG via electrodes interwoven in the textile of a wearable belt. Objective: To compare EQ02 with the Holter for continuous home measurement of ECG, heart rate (HR), and heart rate variability (HRV). Methods: Eighteen healthy participants wore, simultaneously for 24 h, the Holter and EQ02 monitors. Per participant, averaged HR, and HRV per 5 min from the two devices were compared using Pearson correlation, paired T-test, and Bland-Altman analyses. Accuracy and precision metrics included mean absolute relative difference (MARD). Results: Artifact content of EQ02 data varied widely between (range 1.93-56.45%) and within (range 0.75-9.61%) participants. Comparing the EQ02 to the Holter, the Pearson correlations were respectively 0.724, 0.955, and 0.997 for datasets containing all data and data with < 50 or < 20% artifacts respectively. For datasets containing respectively all data, data with < 50, or < 20% artifacts, bias estimated by Bland-Altman analysis was -2.8, -1.0, and -0.8 beats per minute and 24 h MARD was 7.08, 3.01, and 1.5. After selecting a 3-h stretch of data containing 1.15% artifacts, Pearson correlation was 0.786 for HRV measured as standard deviation of NN intervals (SDNN). Conclusions: Although the EQ02 can accurately measure ECG and HRV, its accuracy and precision is highly dependent on artifact content. This is a limitation for clinical use in individual patients. However, the advantages of the EQ02 (ability to simultaneously monitor several physiologic parameters) may outweigh its disadvantages (higher artifact load) for research purposes and/ or for home monitoring in larger groups of study participants. Further studies can be aimed at minimizing the artifacts.

Subtraction electrocardiography: Detection of ischemia-induced ST displacement without the need to identify the J point.

BACKGROUND: When triaging a patient with acute chest pain at first medical contact, an electrocardiogram (ECG) is routinely made and inspected for signs of myocardial ischemia. The guidelines recommend comparison of the acute and an earlier-made ECG, when available. No concrete recommendations for this comparison exist, neither is known how to handle J-point identification difficulties. Here we present a J-point independent method for such a comparison. METHODS: After conversion to vectorcardiograms, baseline and acute ischemic ECGs after 3minutes of balloon occlusion during elective PCI were compared in 81 patients of the STAFF III ECG database. Baseline vectorcardiograms were subtracted from ischemic vectorcardiograms using either the QRS onsets or the J points as synchronization instants, yielding vector magnitude difference signals, ΔH. Output variables for the J-point synchronized differences were ΔH at the actual J point and at 20, 40, 60 and 80ms thereafter. Output variables for the onset-QRS synchronized differences were the ΔH at 80, 100, 120, 140 and 160ms after onset QRS. Finally, linear regressions of all combinations of ΔHJ+… versus ΔHQRS+… were made, and the best combination was identified. RESULTS: The highest correlation, 0.93 (p<0.01), was found between ΔH 40ms after the J point and 160ms after the onset of the QRS complex. With a ΔH ischemia threshold of 0.05mV, 66/81 (J-point synchronized differences) and 68/81 (onset-QRS synchronized differences) subjects were above the ischemia threshold, corresponding to sensitivities of 81% and 84%, respectively. CONCLUSION: Our current study opens an alternative way to detect cardiac ischemia without the need for human expertise for determination of the J point by measuring the difference vector magnitude at 160ms after the onset of the QRS complex.

Ischemic QRS prolongation as a biomarker of severe myocardial ischemia.

BACKGROUND: Previous studies have shown that QRS prolongation is a sign of depressed collateral flow and increased rate of myocardial cell death during coronary occlusion. The aims of this study were to evaluate ischemic QRS prolongation as a biomarker of severe ischemia by establishing the relationship between prolongation and collateral flow experimentally in a dog model, and test if the same pattern of ischemic QRS prolongation occurs in man. METHODS: Degree of ischemic QRS prolongation was measured using a novel method in dogs (n=23) and patients (n=52) during coronary occlusion for 5min. Collateral arterial flow was assessed in the dogs. RESULTS: There was a significant correlation between QRS prolongation and collateral flow in dogs (r=0.61, p=0.008). Magnitude and temporal evolution of prolongation during ischemia were similar for dogs and humans (p=0.202 and p=0.911). CONCLUSION: Quantification of ischemic QRS prolongation could potentially be used as a biomarker for severe myocardial ischemia.

Vectorcardiographic diagnostic & prognostic information derived from the 12-lead electrocardiogram: Historical review and clinical perspective.

In the course of time, electrocardiography has assumed several modalities with varying electrode numbers, electrode positions and lead systems. 12-lead electrocardiography and 3-lead vectorcardiography have become particularly popular. These modalities developed in parallel through the mid-twentieth century. In the same time interval, the physical concepts underlying electrocardiography were defined and worked out. In particular, the vector concept (heart vector, lead vector, volume conductor) appeared to be essential to understanding the manifestations of electrical heart activity, both in the 12-lead electrocardiogram (ECG) and in the 3-lead vectorcardiogram (VCG). Not universally appreciated in the clinic, the vectorcardiogram, and with it the vector concept, went out of use. A revival of vectorcardiography started in the 90's, when VCGs were mathematically synthesized from standard 12-lead ECGs. This facilitated combined electrocardiography and vectorcardiography without the need for a special recording system. This paper gives an overview of these historical developments, elaborates on the vector concept and seeks to define where VCG analysis/interpretation can add diagnostic/prognostic value to conventional 12-lead ECG analysis.

Performance of ST and ventricular gradient difference vectors in electrocardiographic detection of acute myocardial ischemia.

INTRODUCTION: Serial analysis could improve ECG diagnosis of myocardial ischemia caused by acute coronary occlusion. METHODS: We analyzed ECG pairs of 84 cases and 398 controls. In case-patients, who underwent elective percutaneous coronary intervention, ischemic ECGs during balloon occlusion were compared with preceding non-ischemic ECGs. In control-patients, two elective non-ischemic ECGs were compared. In each ECG the ST vector at the J point and the ventricular gradient (VG) vector was computed, after which difference vectors ΔST and ΔVG were computed within patients. Finally, receiver operating characteristic analysis was done. RESULTS: Areas under the curve were 0.906 (P<0.001; CI 0.862-0.949; SE 0.022) for ΔST and 0.880 (P<0.001; CI 0.833-0.926; SE 0.024) for ΔVG. Sensitivity and specificity of conventional ST-elevation myocardial infarction (STEMI) criteria were 70.2% and 89.1%, respectively. At matched serial analysis specificity and STEMI specificity, serial analysis sensitivity was 78.6% for ΔST and 71.4% for ΔVG (not significantly different from STEMI sensitivity). At matched serial analysis sensitivity and STEMI sensitivity, serial analysis specificity was 96.5% for ΔST and 89.3% for ΔVG; ΔST and STEMI specificities differed significantly (P<0.001). CONCLUSION: Detection of acute myocardial ischemia by serial ECG analysis of ST and VG vectors has equal or even superior performance than the STEMI criteria. This concept should be further evaluated in triage ECGs of patients suspected from having acute myocardial ischemia.

Intra-individual ECG changes over 25 years: How long can elective ECGs be used as reference for acute ischemia detection?

BACKGROUND: The guidelines advocate, in patients with chest pain, comparison of the acute ECG with a previously made, non-ischemic ECG that serves as a reference, to corroborate the working diagnosis of acute coronary syndrome (ACS). Our approach of this serial comparison is to compute the differences between the ST vectors at the J point and 60 ms thereafter (∆ST(J+0), ∆ST(J+60)) and between the ventricular gradient (VG) vectors (∆VG). In the current study, we investigate if reference ECGs remain valid in time. METHODS: We studied 6 elective non-ischemic ECGs (ECG0, ECG1, …, ECG5), 5 years apart, in 88 patients. Within each patient, serial comparisons were done 1) between all successive ECGs, and 2) between each of ECG1, ECG2, …, ECG5 and ECG0, computing, in addition to ∆ST(J+0), ∆ST(J+60) and ∆VG, the difference in heart rates, ∆HR. Additionally, relevant clinical events and the diagnoses associated with each ECG were collected. Linear regression was used to assess trends in ∆ST(J+0), ∆ST(J+60) and ∆VG; multiple linear regression was used to assess the influence of the clinical events and diagnoses on ∆ST(J+0), ∆ST(J+60) and ∆VG. RESULTS: There were no trends in the differences between successive ECGs. Positive trends were seen with increasing time lapses between ECGs: ∆ST(J+0), ∆ST(J+60) and ∆VG increased per year by 0.65 µV, 1.45 µV and 3.69 mV∙ms, respectively. Extrapolation to a time lapse of 0 yielded 50.92 µV, 36.63 µV and 20.91 mV∙ms for the short-term reproducibility of ∆ST(J+0), ∆ST(J+60) and ∆VG, respectively. Multiple linear regression revealed that clinical variables could explain only 10%, 17% and 13% of the variability in ∆ST(J+0), ∆ST(J+60) and ∆VG, respectively. CONCLUSION: With a view on ischemia detection thresholds in the order of magnitude of 58 µV for ∆ST and 26 mV·ms for ∆VG, our study suggests that it is important to have a recent ECG available for the detection of myocardial ischemia, as an "aged" ECG may have lost its validity as a reference.