Unusual Disappearance of Inferior Q Waves in an Elderly Man.

In a patient with an old inferior myocardial infarct, the Q waves disappear when he develops left anterior fascicular block.

Antiplatelet and anticoagulant therapies in acute coronary syndromes.

The combination of aspirin and clopidogrel is the mainstay antiplatelet therapy for acute coronary syndromes (ACS). However, the dosing of aspirin, the dosing of clopidogrel, the timing of clopidogrel initiation as well as the duration of clopidogrel therapy remain controversial matters. Clopidogrel resistance is an emerging concept with potential clinical implications. In the era of clopidogrel and bivalirudin, the role of glycoprotein IIb/IIIa antagonists is being challenged, yet they are still indicated in a select high-risk population. Concerning anticoagulant use in ACS, newer agents, bivalirudin and fondaparinux, have improved outcomes in comparison to heparin in patients managed with an invasive or conservative strategy, respectively. Combining multiple antiplatelet agents and an anticoagulant is the standard of care for ACS.

Left ventricular diastolic size in patients with normal ejection fraction and elevated left filling pressures.

OBJECTIVE: To evaluate the left-ventricular diastolic chamber size in patients with a normal ejection fraction and elevated left-sided filling pressures. BACKGROUND: The consensus view that patients with normal left ventricular ejection fraction (LVEF) and elevated left-sided filling pressures have a normal left ventricular diastolic size is a point of controversy. METHODS: We reviewed the coded database of echocardiographic studies performed at one institution between July 2007 and July 2008. We performed a retrospective descriptive study of 35 patients with normal ejection fraction (> or = 55%) and elevated left-sided filling pressures. We looked at their left ventricular internal diastolic diameter (LVIDD). RESULTS: Our population had a high prevalence of hypertension (100%), obesity (63%), diabetes (40%), chronic kidney disease (51%), coronary artery disease (25%), anemia (43%), and left ventricular hypertrophy (65%). Clinical diagnosis of heart failure was documented in 63% of the patients. LVIDD was mildly increased in comparison to a normal historical population: 4.85 + or - 0.5 cm for females, 5.3 + or - 0.5 cm for males, as compared to 4.6 + or - 0.3 cm for normal females (P = 0.045) and 5 + or - 0.4 cm for normal males (P < 0.001). However, the distribution of the indexed LVIDDs in these patients was comparable to the normal population (2.6 + or - 0.4 cm/m(2) for the study population, as compared to 2.7 + or - 0.2 cm/m(2) for the normal population, P = 0.16). CONCLUSION: In a population of patients with a normal LVEF and high left ventricular filling pressures, the indexed LV diastolic size is not increased in comparison to a normal population. (Echocardiography 2010;27:501-504).

Failure of Atrioventricular Conduction.

In a 27-year-old man the electrocardiogram suggests increased vagal tone, and not intrinsic atrioventricular nodal disease, as the cause of transient atrioventricular block.

New Onset Palpitations, Chest Pain, Dyspnea, and Diaphoresis in a 65-Year-Old Woman.

A woman with the new onset of cardiac symptoms was in atrial fibrillation with a wide QRS complex that was not typical of bundle branch block. After electrical cardioversion, a short PR interval and delta waves indicated the presence of an accessory atrioventricular pathway. This left lateral atrioventricular bypass tract was subsequently ablated.

Wide-QRS Tachycardia in an 89-Year-Old Woman With an ICD.

An elderly woman had ventricular tachycardia, and her defibrillator failed to discharge. Intravenously administered amiodarone returned her to sinus rhythm.

Electrocardiograms Recorded After Asystolic Cardiac Arrest.

A man with a history of drug abuse was found down at home and was asystolic. Following restoration of sinus rhythm, a hypothermia protocol brought his temperature to 32.5°C (90.5°F), and large Osborn waves appeared on his electrocardiogram. With rewarming the electrocardiographic signs of hypothermia diminished. Due to hypoxic brain injury during the arrest, the patient remained unresponsive and died on the fourth hospital day.

Bradycardia in a Man With Hypertension.

A man without cardiac symptoms was found to have a slow irregular pulse, and an electrocardiogram revealed sinus bradycardia with escape-capture bigeminy. He was taking verapamil, clonidine, and hydralazine for hypertension. The verapamil was discontinued; he returned to normal sinus rhythm and was discharged on the second hospital day.

Type I Second Degree Atrioventricular Block in a Woman With Remote Repair of a Ventricular Septal Defect.

In a 45-year-old woman with syncope, an electrocardiogram revealed intermittent asymptomatic type I second degree atrioventricular block, right bundle branch block and left anterior fascicular block. An echocardiogram documented concentric left ventricular hypertrophy and right ventricular dilatation and hypokinesia. Because the patient did not have second degree atrioventricular block at the time of an electrophysiological study, the atrioventricular node, the left posterior fascicle, and the His bundle all remain potential sites for the type I second degree atrioventricular block on her initial electrocardiogram.

An 18-Year-Old Woman Who Was Found Down.

An 18-year-old woman was found unresponsive by her mother. After the patient spontaneously regained consciousness, an electrocardiogram showed a markedly prolonged QT interval thought to be due to congenital long QT1. An implantable cardioverter defibrillator was placed. After being free of symptoms for 1 year, she spontaneously developed torsades de pointes that was successfully terminated by the defibrillator.

Repeat the Electrocardiogram!

A 71-year-old diabetic woman with intermittent chest pain and left bundle branch block was admitted to the hospital for further assessment. A repeat electrocardiogram showed new anterior T-wave inversions concordant with the QRS complexes. Thus, she had myocardial ischemia, and coronary arteriography revealed left main and triple vessel coronary disease. She went for urgent coronary artery bypass operation.

Hypotension and Left Bundle Branch Block.

A 69-year-old man with chronic kidney disease and no chest pain had the new onset of hypotension. An electrocardiogram revealed left bundle branch block and inferior ST-segment elevation concordant with the QRS complexes in leads II and aVF, a pattern diagnostic of acute inferior myocardial infarction. Coronary arteriography showed triple vessel disease with complete occlusion of the right. He was treated with an intraaortic balloon pump and percutaneous coronary intervention, followed by coronary artery bypass operation at a nearby hospital.

Painless Mini-Wellens Sign 5 Minutes After Exercise in a Man With Previously Undiagnosed Total Occlusion of the Left Anterior Descending and Right Coronary Arteries.

A 60-year-old man with no coronary artery history and a normal resting electrocardiogram came to the hospital with his second stroke and underwent a treadmill exercise test before carotid endarterectomy. He had no chest pain and stopped because of leg pain. Five minutes after exercise he developed terminal T-wave inversion in leads V3 and V4 that lasted 7 minutes. The T-wave pattern resembled the Wellens pattern that has usually been seen after intense preinfarction rest pain and has usually lasted hours, days, or even weeks. Coronary arteriography showed complete occlusion of the left anterior descending and right coronary arteries.

Angiosarcoma of the Heart Presenting as Subacute Pericarditis.

A young woman, who presented with what appeared to be subacute pericarditis, was found to have primary angiosarcoma of the heart, a condition that is nearly always fatal regardless of the therapy.

Narrow-QRS and Wide-QRS Tachycardias.

In a woman with rheumatic heart disease, atrial flutter with a rapid ventricular response, and congestive heart failure, treatment with digoxin slows conduction in the atrioventricular node and thus allows atrioventricular conduction to occur by way of a previously unrecognized accessory pathway.

Dizziness Playing the Saxophone Secondary to Hypertrophic Cardiomyopathy.

A decrease in left ventricular volume increases the severity of left ventricular outflow tract obstruction in patients with obstructive hypertrophic cardiomyopathy, formerly called idiopathic hypertrophic subaortic stenosis. Because of this, a musician with the condition develops dizziness playing his saxophone which requires repeated and prolonged Valsalva maneuvers.

Syncope and Dyspnea and Pulmonary Embolism.

Failure to recognize ECG features consistent with acute cor pulmonale in a man with new onset syncope and dyspnea resulted in death from undiagnosed pulmonary emboli.

Syncope on a Hot Summer Day.

In a 63-year-old man, episodes of ventricular tachycardia causing syncope and myocardial infarction are the first manifestations of triple vessel coronary disease in the absence of arteriographic evidence of a fresh occlusion.

The de Winter Electrocardiographic Pattern of Proximal Left Anterior Descending Coronary Artery Occlusion.

An example of the electrocardiographic pattern of acute anterior myocardial infarction described by deWinter et al is presented, and its implications is discussed.