Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects.

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

Distinct Features of Vascular Diseases in COVID-19.

The Coronavirus Disease 2019 (COVID-19) pandemic was declared in early 2020 after several unexplained pneumonia cases were first reported in Wuhan, China, and subsequently in other parts of the world. Commonly, the disease comprises several clinical features, including high temperature, dry cough, shortness of breath, and hypoxia, associated with findings of interstitial pneumonia on chest X-ray and computer tomography. Nevertheless, severe forms of acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) are not limited to the respiratory tract but also may be extended to other systems, including the cardiovascular system. The bi-directional relationship between atherosclerosis and COVID-19 is accompanied by poor prognosis. The immune response hyperactivation due to SARS-CoV-2 infection causes an increased secretion of cytokines, endothelial dysfunction, and arterial stiffness, which promotes the development of atherosclerosis. Also, due to the COVID-19 pandemic, access to healthcare amenities was reduced, resulting in increased morbidity and mortality in patients at risk. Furthermore, as lockdown measures were largely adopted worldwide, the sedentary lifestyle and the increased consumption of processed nutrients or unhealthy food increased, and in the consequence, we might observe even 70% of overweight and obese population. Altogether, with the relatively low ratio of vaccinated people in many countries, and important health debt appeared, which is now and will be for next decade a large healthcare challenge. However, the experience gained in the COVID-19 pandemic and the new methods of patients' approaching have helped the medical system to overcome this crisis and will hopefully help in the case of new possible epidemics.

Connection between Cardiac Fibrosis Biomarkers and Echocardiography Parameters in Advanced Chronic Kidney Disease Patients.

BACKGROUND: Myocardial fibrosis represents a mainstay pathway in the pathophysiology of uremic cardiomyopathy. This process leads to structural and functional changes in the heart, which can be detected by echocardiography. The purpose of our study was to determine the association between four echocardiographic parameters (ejection fraction (EF), global longitudinal strain (GLS), mean E/e' ratio, and left atrial volume indexed) and biomarkers associated with cardiac fibrosis, such as procollagen type I carboxy-terminal propeptide (PICP), procollagen type III N-terminal peptide (P3NP), and galectin-3 (Gal-3) in patients with end-stage renal disease (ESRD). METHODS: 140 patients with ESRD were enrolled and investigated by echocardiography and the serum levels of the aforementioned biomarkers were determined at baseline. RESULTS: The mean EF was 53.63 ± 8%, the mean GLS was -10.2 ± 5.3%, the mean E/e' ratio was 9.8 ± 4.3, and the mean left atrial volume indexed (LAVI) was 45.8 ± 14.2 mL/m2. The average levels for PICP, P3NP, and Gal-3 were 457.2 ± 240 µg/L, 242 ± 199.9 µg/L, and 10.7 ± 3.7 ng/mL, respectively. In regression analysis, PICP was strongly associated with all four echocardiographic parameters (EF: p = 0.0002, R2 = 0.69; GLS: p = 0.00001, R2 = 0.81; mean E/e': p = 0.00002; R2 = 0.89; LAVI: p = 0.003; R2 = 0.73). P3NP and Gal-3 were only associated with the EF (p = 0.01, R2 = 0.31 and p = 0.02; R2 = 0.35, respectively). CONCLUSION: Our study evidenced that PICP, a collagen-derived biomarker, is associated with important echocardiography parameters, suggesting that it can serve as an indicator of the presence of subclinical systolic and diastolic dysfunction in patients with advanced CKD.

Cardiac Resynchronization Therapy in Non-Ischemic Cardiomyopathy: Role of Multimodality Imaging.

Non-ischemic cardiomyopathy encompasses a heterogeneous group of diseases, with a generally unfavorable long-term prognosis. Cardiac resynchronization therapy (CRT) is a useful therapeutic option for patients with symptomatic heart failure, currently recommended by all available guidelines, with outstanding benefits, especially in non-ischemic dilated cardiomyopathy. Still, in spite of clear indications based on identifying a dyssynchronous pattern on the electrocardiogram (ECG,) a great proportion of patients are non-responders. The idea that multimodality cardiac imaging can play a role in refining the selection criteria and the implant technique and help with subsequent system optimization is promising. In this regard, predictors of CRT response, such as apical rocking and septal flash have been identified. Promising new data come from studies using cardiac magnetic resonance and nuclear imaging for showcasing myocardial dyssynchrony. Still, to date, no single imaging predictor has been included in the guidelines, probably due to lack of validation in large, multicenter cohorts. This review provides an up-to-date synthesis of the latest evidence of CRT use in non-ischemic cardiomyopathy and highlights the potential additional value of multimodality imaging for improving CRT response in this population. By incorporating all these findings into our clinical practice, we can aim toward obtaining a higher proportion of responders and improve the success rate of CRT.

Role of collagen turnover biomarkers in the noninvasive assessment of myocardial fibrosis: an update.

The pro-fibrotic milieu, as the result of the extracellular matrix remodeling, is a central feature in the pathophysiology of heart disease and contributes to its high morbidity and mortality. Fibrosis is a recognized risk factor for development of heart failure and arrythmias and is usually detected by cardiac magnetic resonance or endomyocardial biopsy. Collagen type I and type III are major components of the collagen network, and the assessment of their derived biomarkers could serve as estimate of the myocardial fibrotic content. This review summarizes data from numerous studies in which these biomarkers have proven their diagnostic and prognostic utility, setting the stage for further randomized clinical trials that might translate into early implementation of antifibrotic therapies.

In search of lost time - a case of myocardial perforation in a patient with arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is particularly hard to diagnose and manage. We present the case of a 49-year-old, a former professional football player, with a history of cardiac arrest in 2011 by ventricular tachycardia (VT) (normal coronary arteries). Between 2011 and 2019 the patient didn't present for reevaluation and resumed endurance sports activity. In 2019 he was directed to our clinic for a syncope followed by constrictive anterior chest pain and palpitations, the clinical expression of a VT for which cardioversion was required. Upon admission, the patient was at sinus rhythm with negative T waves in V1-V2. Echocardiography showed significant dilatation and dysfunction of the RV (TAPSE 16 mm, FAC 20%, S' 8.6 cm/s). To confirm the diagnosis of ARVC, cardiac MRI was performed, confirming fat infiltration in the RV free wall with biventricular involvement. Given the high arrhythmic risk, a two-chamber ICD was implanted. In the second postprocedural day, the patient presented important epigastric pain, with ECG signs of sensing and pacing malfunction and ventricular probe displacement on the radioscopy. Emergency surgery was performed, with successful extraction of the electrode. Postoperative progression was favorable under treatment with beta-blocker and amiodarone. In conclusion, this case is a particular one since we've documented two distinct phases in the evolution of the ARVC (electrical phase - 2011 and structural phase - 2019). Moreover, by resuming endurance sports activity and in concordance with the literature data, we can only assume that the progression of the disease was accelerated, with a greater arrhythmic risk.

Programming an optimal atrioventricular interval in a dual chamber pacemaker regional population.

BACKGROUND: Since the introduction of the dual chamber pacemaker (DDDR) in the early 1980s, researchers have repeatedly discussed and attempted to optimize the atrioventricular (AV) interval, in order to increase the cardiac performance of pacemaker patients. Nominal AV delay in a DDDR is not, by hemodynamics, the best option for the majority of patients with AV conduction disorders. Our research is suggesting a simplified approach to define an optimal AV delay in a DDDR pacemaker population on the use of the programming electrocardiogram (ECG) at follow-up. METHODS: The study enrolled 55 consecutive patients (67.28 ± 1.03 years, 36 male) with an initial dual chamber pacemaker implanted for complete and second degree AV block between 2005-2010. Optimal AV delay was achieved by programming an additional delay of 95 ms, to the medium value of the interval between atrial pacing spike to the end of P wave or to the width of intrinsic P wave, on the ECG of the programming device. At discharge, shortly after the implant procedure, the patients were examined by Doppler echocardiography, during nominal and optimal AV delay pacing measuring systolic and diastolic left ventricular function parameters. RESULTS: Compared with the nominal AV delay settings, the left ventricular end diastolic volume did not changed (from 112.3 ± 2.3 ml to 112.9 ± 2.3 ml), the end systolic volume decreased (from 59.8 ± 1.7 ml to 50.9 ± 1.3 ml, p<0.01) after adjusted the AV delay, followed by an increased left ventricle ejection fraction (from 61.07 ± 0.18 % to 65.46 ± 0.13 %, p<0.001) and isovolumic relaxation time decreased (from 102.7 ± 1.9 ms to 97 ± 2 ms, p<0.05). E wave velocity, A wave velocity and E/A ratio were not significantly changed. CONCLUSION: AV delay adjusted by programmer ECG in a follow-up session of an implantable device is a simple and useful method used in our laboratory as a resource for ventricular pacing optimization and hemodynamic improvement in patients with a dual chamber pacemaker (DDDR).