Evaluation of cardiac autonomic functions in patients with systemic lupus erythematosus.

BACKGROUND: Cardiovascular involvement is one of the leading causes of death among patients with systemic lupus erythematosus (SLE). In this study, we aimed to investigate cardiac autonomic functions in SLE patients. METHODS: We enrolled 36 patients (25 female; mean age 34.2 ± 10.2 years) with SLE and 32 healthy subjects (23 female; mean age 35.0 ± 10.3 years). All participants underwent 24-h Holter recording. Heart rate recovery (HRR) indices were calculated by subtracting first, second, and third-minute heart rates from maximal heart rate. All patients underwent heart rate variability (HRV), heart rate turbulence (HRT) and QT dispersion analysis. The mean SLE duration was 8.4 ± 4.0 years. RESULTS: According to the baseline demographic characteristics, both groups were similar with regard to age, gender, body mass index and left ventricular ejection fraction. Mean HRR1 (32.6 ± 10.9 vs. 42.5 ± 6.5, p = 0.038), HRR2 (51.0 ± 16.9 vs. 61.0 ± 10.8, p = 0.01) and HRR3 (52.8 ± 17.5 vs. 65.8 ± 9.8, p < 0.001) values were significantly higher in control group. When HRV was considered, SDNN, SDANN, RMSSD, PNN50 and high frequency (HF) component were significantly decreased in patients with SLE compared with healthy controls, but low frequency (LF) component and LF/HF were significantly higher in SLE patients. In addition, HRT onset and HRT slope values were significantly less negative in SLE patients. QT dispersion was significantly greater in SLE patients than healthy subjects (81.3 ± 15.8 vs. 53.2 ± 13.1, p < 0.001). CONCLUSION: Our study results suggest that cardiac autonomic functions are impaired in SLE patients despite the absence of overt cardiac involvement and symptoms. Further studies are needed to elucidate the prognostic significance and clinical implications of impaired autonomic functions in patients with SLE.

Severe limb pain suppresses chest pain in a patient with anterior myocardial infarction.

Cardiac complications of chest trauma range from arrhythmias and valvular avulsions to myocardial contusion, rupture, and--rarely--myocardial infarction. Herein, we described a 44-year-old male patient who presented to the hospital after receiving a blow from a fist directly to the chest and fingertip amputation during a fight; anterior myocardial infarction without any chest pain was coincidentally detected. Our case illustrates the importance of electrocardiography in the initial evaluation of patients with chest trauma and suspected injury to the coronary arteries.

Myocardial infarction due to coronary thrombosis in a patient with Henoch-Schönlein purpura.

Henoch-Schönlein purpura (HSP) is characterized by vasculitic involvement of small-sized vessels and results in multisystem manifestations. Cardiac involvement is extremely rare and myocardial infarction with coronary thrombus formation in those patients has also rarely been reported. Herein, we report a 33-year-old man with acute myocardial infarction due to coronary thrombus formation and HSP.

The association between serum uric acid level and coronary artery disease.

OBJECTIVE: This study was designed to determine the relationship between serum uric acid level and the presence and severity of coronary artery disease (CAD). METHODS: A total of 1012 patients who underwent coronary angiography were included in this study. All patients were assessed for the presence of cardiovascular risk factors and ongoing medications. Serum uric acid and creatinine level, as well as a fasting lipid profile and fasting blood glucose, were measured in all patients before the procedure. The severity of CAD was assessed by the Gensini score. RESULTS: Of 1012 patients (mean age, 59.4 +/- 10.24 years), 680 were men (mean age, 58.7 +/- 10.5 years) and 332 were women (mean age, 61.0 +/- 9.51 years). Of the study patients, 703 (69%) were hypertensive, 292 (28.9%) were diabetic (DM), 304 (30%) had a smoking history, 306 (30%) had low high-density lipoprotein cholesterol levels and 350 (34%) had hypertriglyceridaemia. CAD was present in 689 (68%) patients who were assessed by coronary angiography. One-, two- and three-vessel disease was detected in 32.6%, 32.5% and 34.9% of the patients respectively; left main coronary artery lesion was detected in 15% of the patients. A statistically significant difference in the mean uric acid concentrations was found between the patients with or without CAD [380 +/- 121 micromol/l (6.39 +/- 2.04 mg/dl) vs. 323.5 +/- 83.2 micromol/l (5.44 +/- 1.40 mg/dl) p < 0.001]. Based on logistic regression analysis, the increased serum uric acid level was found to be associated with the presence of CAD in both men and women (p < 0.001). The increased serum uric acid level was also found to be associated with the severity of CAD in both men and women based on multivariate linear regression analysis (p < 0.001). CONCLUSION: In conclusion, serum uric acid level was found to be associated with the presence and severity of CAD.

Advanced age is associated with endothelial dysfunction in healthy elderly subjects.

BACKGROUND: Aging is associated with an increased risk for atherosclerosis in which endothelial dysfunction is an early marker. OBJECTIVE: The purpose of this study was to determine if endothelial function is altered with increasing age in healthy subjects. METHOD: The study population consisted of 30 elderly and 36 younger subjects free from major cardiovascular risk factors. Transthoracic echocardiography was performed for each subject to rule out structural heart disease. Endothelial function was evaluated by flow-mediated dilation (FMD) of the brachial artery via ultrasound. RESULTS: Baseline characteristics of the elderly and the younger group were similar, except for age (mean age: 71.3 +/- 5.8 vs. 26.5 +/- 7.2). Transthoracic echocardiography was normal in all subjects. FMD of the elderly group was significantly lower than the younger group (7.9 +/- 3.1 in the elderly, 10.8 +/- 1.9 in the younger group, p < 0.001). A negative relationship was found between FMD and age (r = -0.528, p < 0.001). CONCLUSION: It can be concluded that endothelial function detected by FMD declines with increasing age in healthy human subjects. Advanced age is a predictor of impaired endothelial function.

Determining the relationship between metabolic syndrome score and angiographic severity of coronary artery disease.

BACKGROUND: Cardiovascular disease is leading cause of mortality and morbidity in developed and developing countries. Metabolic syndrome (MS) is a risk factor for coronary artery disease (CAD). The effect of MS on angiographic severity of CAD is not well defined. The aim of this study was to examine the effect of MS on angiographic severity of CAD by using Gensini score. METHODS: The total number of 1003 patients who underwent elective coronary angiography in catheter laboratory were included in the study. MS score based on National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria which ranged between zero and five were calculated for each subject. Gensini scores were determined by examining coronary angiograms of the patients. RESULTS: The study population consisted of 634 (63%) male, and 369 (37%) female subjects. The mean age was 59 +/- 11. MS based on NCEP ATP III was present in 246 (25%) patients. CAD was present in 691 patients (69%). The median of Gensini score was five (0-192) in the total sample, 18 (1-192) in the patients with CAD and 25 (0-192) in the patients with MS. A positive correlation was found between MS score and Gensini score (r = 0.402, p < 0.001). CONCLUSIONS: In this study, it was determined that as the severity of MS increases, the angiographic severity of CAD increases as well. Besides, the most important factor on Gensini score was diabetes mellitus in male and hypertension in female subjects.

Dobutamine thallium-201 myocardial SPECT in patients with left bundle branch block and normal coronary arteries.

UNLABELLED: Dobutamine is a positive inotropic and chronotropic agent and is being widely used as a pharmacologic stress agent in patients unable to achieve maximal dynamic exercise test. The purpose of the current study was to document the dobutamine induced false-positive septal defect in terms of its frequency and extent on 201Tl myocardial SPECT in patient with left bundle branch block (LBBB). METHODS: Twenty-five symptomatic patients with LBBB underwent dobutamine and redistribution 201Tl myocardial SPECT studies. Coronary angiographies were also performed. Only those patients with normal coronaries (n = 19) were included in the study. For each study, tomograms were divided into 19 segments, and each segment was analyzed qualitatively as to presence and type of perfusion defect (reversible or fixed). In addition, septal perfusion was scored in each patient (1 = markedly, 2 = moderately reduced, 3 = normal uptake). RESULTS: Sixteen of 19 patients (84.21%) had false-positive septal reversible perfusion defect, and the remaining 3 had normal images. Perfusion defects were confined to only the septum in 5 of 16 patients (31.25%), whereas a greater proportion of patients had septal defect extending to the contiguous myocardial areas, mainly to the anterior wall. Five of 16 patients with false-positive defects had a septal perfusion score of 1, while the remaining 11 had a score of 2. CONCLUSION: Dobutamine myocardial scintigraphy in patients with LBBB was misleading for the diagnosis of coronary artery disease, since up to 84.21% of patients had false-positive septal perfusion defects.

Diastolic dysfunction and increased serum homocysteine concentrations may contribute to increased cardiovascular risk in patients with polycystic ovary syndrome.

OBJECTIVE: To assess cardiac flow parameters in patients with polycystic ovary syndrome (PCOS). DESIGN: A prospective case-control study. SETTING: University-based hospital. PATIENT(S): Thirty consecutive patients with PCOS were enrolled. Thirty women with regular menstrual cycles served as the controls. INTERVENTION(S): Systolic and diastolic function parameters were assessed by standard two-dimensional and M-mode echocardiography. Insulin sensitivity was evaluated by a standard 75-g oral glucose tolerance test and area-under-curve insulin analysis. Serum hormones, lipid profile, homocysteine, vitamin B(12), folate, fibrinogen, uric acid, and plasminogen activator inhibitor-I concentrations were measured. MAIN OUTCOME MEASURE(S): Systolic and diastolic function parameters, insulin sensitivity and serum homocysteine levels. RESULT(S): The mean serum homocysteine and uric acid concentrations were significantly higher in the PCOS group. Patients with PCOS had significant hyperinsulinemia. All systolic function parameters were comparable between the two groups. However, patients with PCOS had significantly lower peak mitral flow velocity in early diastole and significantly lower ratio between the early and late peak mitral flow velocities and also had significantly longer isovolumic relaxation time, reflecting a trend for nonrestrictive-type diastolic dysfunction. The area-under-curve insulin correlated positively with peak mitral flow velocity in late diastole (r = 0.375). The mean cholesterol/high-density lipoprotein ratio correlated negatively with mean mitral flow velocity in early diastole (E) peak (r = -0.474). The mean fasting insulin level correlated negatively with mean E/A ratio (r = -0.387). CONCLUSION(S): Diastolic dysfunction and increased serum homocysteine concentrations may contribute to increased cardiovascular disease risk in patients with PCOS.

Left atrial appendage function in patients with cardioembolic stroke in sinus rhythm and atrial fibrillation.

The purpose of this study was to determine the left atrial appendage (LAA) function in patients with stroke. The study group consisted of 61 patients with stroke and 37 control subjects. Patients with stroke were divided into 2 groups on the basis of the presence of atrial fibrillation (group 1) or sinus rhythm (group 2). Group 1 showed a significant reduction of LAA flow velocities (13.2 +/- 6.4 cm/s versus 27.5 +/- 8 cm/s, P <.05) and significant increase in LAA areas (minimum area: 360.5 +/- 204 mm(2) versus 217.7 +/- 113.9 mm(2), P =.004). Group 2 showed a decrease in LAA flow velocities (17.7 +/- 8.2 cm/s versus 27.5 +/- 8 cm/s, P <.05), but no significant change was found in LAA areas. No significant difference was found in other parameters related to LAA. These findings show that a decreased LAA flow velocity is a risk factor for stroke in patients in sinus rhythm without LAA enlargement. Left atrial appendage area was increased in size only in patients with atrial fibrillation.

Angiotensin converting enzyme gene polymorphism and the risk and extent of ischemic heart disease among Turkish patients.

OBJECTIVE: To evaluate the effects of the angiotensin converting enzyme gene polymorphism on the presence and extent of coronary artery disease and myocardial infarction among Turkish patients. METHODS: In total 393 consecutive patients undergoing coronary angiography were evaluated for cardiac risk factors including the lipoprotein profile, lipoprotein (a), apoprotein B, and apoprotein A1 levels. The angiotensin converting enzyme genotype was determined by polymerase chain reaction. The extent of coronary atherosclerosis was determined from the angiograms using the Gensini and Leaman scores. RESULTS: The angiotensin converting enzyme genotype was found not to be associated either with coronary artery disease (odds ratio 0.81, P > 0.05) or with myocardial infarction (odds ratio 1.16, P > 0.05). Exclusion of high-risk individuals failed to reveal any association for these subgroups. Furthermore, there was no association between aneurysm formation and the genotype (P > 0.05). The lipid parameters were also not affected by the genotype (P > 0.05). However, the extent of coronary atherosclerosis determined by the Gensini score was related significantly to the genotype by multivariate analysis (P = 0.007). CONCLUSION: The DD genotype is not associated with coronary artery disease and myocardial infarction among these angiographically assessed Turkish patients, even when low-risk subgroups are analysed. Nonetheless, the extent of coronary atherosclerosis in patients with coronary artery disease is affected by their genotype.

Measurement of right ventricular ejection fraction by contrast echocardiography.

We evaluated 20 healthy subjects with no cardiac disease (8 males, 12 females, age 49+/-12) to determine the accuracy of right ventricular ejection fraction measurement with contrast echocardiography performed with D-galactose (Echovist 300). All patients underwent two dimensional echocardiography where the right ventricular ejection fraction was calculated by the Simpson's rule first without contrast, then after the injection of 5 ml D-galactose in the same position and compared to the right ventricular ejection fraction measured by the first pass radionuclide angiography on the same day. Subjects had a normal left ventricular ejection fraction of 66+/-5 and a body mass index of 28.9+/-1.2. The correlation between echocardiographic and radionuclide derived right ventricular ejection fraction significantly increased when contrast was used (r=0.81 vs. r=0.6). The r value for interobserver variability also increased significantly with contrast use (r=0.98 vs. r=0.7). We conclude that D-galactose contrast injection significantly enhances border detection and improves the accuracy of right ventricular ejection fraction calculations with echocardiography making it a simple and reliable method.

Increased QT dispersion in the absence of QT prolongation in patients with Behcet's disease and ventricular arrhythmias.

In Behcet's disease, prominent clinical manifestations include involvement of mucocutaneous, ocular, gastrointestinal, respiratory, neurologic, urogenital, articular and cardiovascular systems. Patients with Behcet's disease have higher incidence of ventricular arrhythmia than healthy subjects. However there is a little information about the mechanism of ventricular arrhythmias in Behcet's disease. The aim of the study was to investigate whether dispersion of ventricular repolarisation was an arrhythmogenic mechanism. QT dispersion parameters were measured in 73 Behcet patients and QT dispersion was defined as the difference between the maximum and minimum QT interval in any of the 12 leads of surface electrocardiogram. Corrected QT dispersion for heart rate was calculated by Bazett's formula. The results were compared with the data from 51 matched controls without a history of cardiac disease. We found QT dispersion was greater in Behcet patients (58+/-12 vs. 37+/-8 ms, P=0.001) as was corrected QT dispersion (81+/-14 vs. 52+/-11 ms, P=0.001). There was no significant difference in minimum or maximum QT intervals between Behcet patients and controls (P>0.05). We found a correlation between QT dispersion and grade of premature ventricular complexes (r=0.7, P=0.002). Our findings suggest that increased dispersion of repolarisation may account for the development of ventricular arrhythmias in Behcet's disease.

No evidence of cardiac autonomic involvement in ankylosing spondylitis, as assessed by heart rate variability.

The aim of this study was to investigate the involvement of autonomic nervous system (ANS) function by using power spectral analysis of heart rate variability (HRV) method in patients with ankylosing spondylitis (AS). The study included 94 AS patients all fulfilling the New York criteria for AS, and 49 healthy volunteers. Recordings for HRV were obtained with a PC-based high-resolution electrocardiographic system and analysed using power spectral analysis. The peak around 0.04-0.15 Hz was defined as low-frequency peak (LF) and the other, around 0. 15-0.40 Hz, was defined as high-frequency peak (HF), representing mostly the sympathetic and the parasympathetic components of the ANS, respectively. The following variables were calculated and compared between groups: the LF in absolute and normalised units (LF nU); the HF in absolute and normalised units (HF nU); and LF/HF ratio. The AS group included 47 male and 47 female subjects with a mean age of 33 +/- 11 years (range 16-64). In the control group there were 23 male and 26 female healthy subjects (mean age 33 +/- 8; range 19-60). None of the patients or control subjects had any cardiac or neurological symptoms. Both groups were similar with respect to age and sex characteristics (p > 0.05). The HRV analysis indicated that the peaks of LF, LF nU, HF, HF nU and LF/HF ratio were similar in both groups. Groups also did not differ with respect to heart rate at the time of examination. Our data demonstrated no evidence of ANS involvement as assessed by HRV analysis in AS patients.

Transient cerebral ischemic attack and left atrial free-floating thrombus: a case report.

A patient with rheumatic mitral stenosis was found to have a free-floating thrombus in the left atrium during echocardiography. Subsequently, the patient underwent surgical treatment. At surgery, a free thrombus was found within the left atrium. The postoperative course of the patient was satisfactory.

Plasma big-endothelin levels, cardiac autonomic neuropathy, and cardiac functions in patients with insulin-dependent diabetes mellitus.

BACKGROUND: The alteration of endothelin (ET) levels in diabetic patients with cardiac autonomic neuropathy (CAN) has not been studied extensively and its correlation with cardiac function parameters has not been discussed. HYPOTHESIS: The aim of the present study was to discuss the correlation between the degree of cardiac autonomic neuropathy, plasma big-ET levels, and cardiac functions in diabetic patients who were clinically free of cardiovascular disease. METHODS: Twenty subjects (32.1 +/- 7.8 years, 11 men, 9 women) with insulin-dependent diabetes mellitus (IDDM) were studied to evaluate the relationship between circulating big-endothelin (big-ET1) levels, CAN, and cardiac functions. The severity of CAN was scored according to Ewing's criteria. Cardiac functions were assessed using Doppler echocardiography. RESULTS: Left ventricular systolic function in the patient group was within normal limits and comparable with the values of the control group (n = 10). The mean E/A values of diabetics with CAN (1.15 +/- 0.33, p = 0.004) and without CAN (1.34 +/- 0.17) were significantly lower than those of controls (1.57 +/- 0.27). Diabetics with CAN had significantly higher big-ET1 values (81.1 +/- 94 pg/ml) compared with others (12.4 +/- 5.9 and 21.1 +/- 17.7 pg/ml, p = 0.04). Circulating big-ET1 levels showed a significant correlation with E/A values in the control group (p = 0.01, r = -0.7) and with peak A values (p = 0.003, r = 0.64) in diabetics. The CAN score correlated negatively with E/A values (p = 0.01, r = 0.54). CONCLUSIONS: High big-ET levels might have an important role in the pathogenesis or consequences of diastolic dysfunction in diabetics with CAN. Their role in cardiac autonomic neuropathy and diastolic dysfunction should be investigated further.

Is ventricular repolarization heterogeneity a cause of serious ventricular tachyarrhythmias in aortic valve stenosis?

BACKGROUND: It is well known that there is a close relation between sudden cardiac death and serious ventricular tachyarrhythmias in patients with aortic valve stenosis (AS). QT dispersion (QTd) reflects the ventricular repolarization heterogeneity and has been proposed as an indicator for ventricular arrhythmias. HYPOTHESIS: This study investigated the QTd and its relevance to the clinical and echocardiographic variables. METHODS: In all, 51 patients (33 men, 18 women, mean age 56 +/- 12) with isolated AS and 51 age- and gender-matched healthy controls comprised the study group. Left ventricular mass index (LVMI) was calculated by the Devereux formula, and we used continuous-wave Doppler (n = 15) and cardiac catheterization (n = 36) for the determination of the maximum aortic valve pressure gradient (PG). RESULTS: Corrected QTd (QTcd) (89 +/- 39 vs. 49 +/- 15 ms, p < 0.001) and LVMI (176 +/- 69 g/m2 vs. 101 +/- 28 g/m2, p < 0.001) in patients with AS were significantly different from those in the control group. The group of 21 patients had a significantly greater number of 24-h mean ventricular premature beats (VPB) and mean number of couplet VT episodes than did the control group (p < 0.05). QTcd also correlated significantly well with LVMI (r = 0.58, p < 0.001), PG (r = 0.41, p = 0.003), and number of 24-h VPB (r = 0.56, p = 0.008). With respect to symptoms (e.g., angina, syncope, and dyspnea) patients without symptoms (n = 19) displayed less QTcd (71 +/- 31 vs. 100 +/- 39 ms, p = 0.007) and less LVMI (144 +/- 80 g/m2 vs. 195 +/- 57 g/m2, p = 0.01) than patients with symptoms. Statistical analysis was similar for all variables with uncorrected QTd values. CONCLUSION: We found that ventricular repolarization heterogeneity was greater in patients with AS than in controls. Our findings also showed that QTd in the patient group correlates well with LVMI, severity of AS, and PG. The present results suggest that serious ventricular arrhythmias in patients with AS may be due to spatial ventricular repolarization abnormality.

Circadian variations of QTc dispersion: is it a clue to morning increase of sudden cardiac death?

BACKGROUND: Several studies related to cardiac events including sudden death have shown a peak incidence in the early morning hours. It has also been known that acute ischemia is a potent stimulus to increased dispersion of repolarization and development of malignant arrhythmias. HYPOTHESIS: The purpose of the present study was to investigate diurnal variations of corrected QT dispersion (QTcD) in patients with coronary artery disease (CAD) (Group 1) compared with controls with normal coronary angiograms (Group 2). METHODS: We investigated a total of 110 patients who had been referred for coronary angiography, of whom 62 (42 men, 20 women; age 55 +/- 7 years) had double- or triple-vessel disease, and of whom 48 (31 men, 17 women; age 54 +/- 9 years) had normal coronary angiograms. QTcD measurements were calculated from a 12-lead resting electrocardiogram (ECG) during sinus rhythm. These ECGs were obtained for each patient in the morning, at noon, in the evening, and at night on the day after performance of coronary angiography. QTcD was significantly greater in patients with abnormal coronary angiograms (Group 1) than in patients with angiographically documented normal coronary arteries (Group 2). This difference appeared to be more prominent in the morning hours (p < 0.001) than at other times. QTcD in the evening and night hours was not statistically different (p > 0.05) between both groups. We also compared intragroup QTcD values: QTcD values were significantly increased in the morning hours and were more prominent in Group 1 than in Group 2. CONCLUSIONS: Our data suggest that QTcD has a circadian variation with an increase in the morning hours, especially in patients with coronary artery disease. This finding was thought to be an explanation for the role played by sympathetic nervous system in the occurrence of acute cardiac events and sudden death during these hours.

Hormone replacement therapy to improve left ventricular diastolic functions in healthy postmenopausal women.

OBJECTIVES: To investigate the effects of estrogen and estrogen plus progesterone replacement therapy on left ventricular systolic and diastolic function parameters in healthy postmenopausal women. METHODS: Forty-six healthy consecutive postmenopausal women were prospectively enrolled. Hormone replacement therapy (HRT), which was either 0.625 mg/day conjugated equine estrogen (CEE) alone, or with 2.5 mg/day medroxyprogesterone acetate (MPA) was administered depending on the hysterectomy status. Left ventricular systolic and diastolic function parameters were evaluated with echocardiography before and after 6 months of HRT. The paired t-test was used for statistical analysis. RESULTS: Estrogen or estrogen plus progesterone did not significantly alter the left ventricular dimensions and systolic function parameters. However, significant improvements were noted in several diastolic function parameters including late diastolic mitral flow velocity, ratio of early to late mitral flow velocity and isovolumic relaxation time (P=0.003, P=0.001 and P=0.005, respectively, for the CEE group; all P<0.001 for the CEE+MPA group). CONCLUSIONS: Estrogen or estrogen plus progesterone replacement therapy may significantly improve left ventricular diastolic functions in healthy postmenopausal women.

Left ventricular septal aneurysm in association with bicuspid aortic valve--a case report.

Diverticula of the left ventricle are rare cardiac anomalies. Most cases arise from the apex of the left ventricle and are usually found in children. Only a few cases have been documented in adults. The authors report a case of a 38-year-old woman who presented with dyspnea and chest pain. She was found to have a septal left ventricular diverticulum associated with bicuspid aortic valve, aortic stenosis, and aortic regurgitation. The aortic valve was replaced with the resection of the diverticulum. Pathologic examination confirmed the diagnosis of fibrous diverticulum.

Inappropriate shocks diagnosed by stored electrograms of implantable cardioverter defibrillators--two case reports.

An implantable cardioverter defibrillator is an important therapeutic option for patients with high risk of life-threatening ventricular arrhythmias. However, their use is also associated with several complications including inappropriate shock. Although the most frequent cause of inappropriate shock is supraventricular tachyarrhythmias, lead fracture can also be associated with inappropriate shock. Diagnosis of lead fracture can be made by chest x-ray radiography, fluoroscopic examination, interrogation of the device, and intracardiac electrograms. In this report, the authors present two cases of inappropriate shock due to lead fractures in the costoclavicular region that could only be diagnosed by the help of stored intracardiac electrograms. Methods for diagnosis of lead fractures and modalities to avoid recurrences are also discussed.