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Abstract: To improve the correct diagnosis rate of coronary heart disease and to explore the guiding value of electrocardiogram (ECG) ST-T ischemic changes in the clinical diagnosis of coronary heart disease.A retrospective analysis was conducted on a total of 310 cases who underwent a conventional 12-lead ECG, 12-lead dynamic ECG (DECG, Holter) with ST-T ischemic changes, and then coronary angiography (CA) within 1 week in Qingdao Sttarr Heart Hospital from June 2015 to April 2020 in the study. Ischemic ST-T changes were evaluated using conventional diagnostic criteria, and Judkins diagnostic criteria were used in CA. The sensitivity and specificity of ECG were analyzed.The specificity of ST-T changes in conventional ECG for the diagnosis of coronary heart disease is 33.7% and the sensitivity is 66.0%. The specificity of ST-T changes in Holter in the diagnosis of coronary heart disease is 55.6% and the sensitivity is 32.2%. The sensitivity of conventional ECG for the diagnosis of coronary heart disease is better than Holter, but its specificity is inferior to Holter. The negative likelihood ratios of the 2 ECGs for the diagnosis of coronary heart disease were 1.0 and 1.22, both >0.1, and the positive likelihood ratios were 0.99 and 0.73, both <10. The positive results of ST-T in conventional ECG were 128 males (65.7%), 77 females (66.9%), (P < .05), 148 cases (74.7%) in the group ≥60 years old, and 75 cases in the group less than 60 years (67%), (P > .05). The positive results of ST-T change of DECG were 135 males (69.2%), 69 females (60.0%), (P < .05), 152 cases (78.7%) in the group ≥60 years, and 83 cases (70.9%) in the group less than 60 years, (P > .05). Coronary heart disease-related factors: symptoms, hypertension, diabetes, cancer, family history, smoking history as independent variables, and a binary multivariate logistic regression analysis was performed.The sensitivity of DECG in the diagnosis of myocardial ischemia in women and the elderly was slightly higher than that in men and young cases. ST-T ischemic changes in ECG are more significant for the diagnosis of coronary heart disease in male patients. Smoking, hypertension, diabetes, and family history are all high-risk factors for coronary heart disease., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Inverted T waves in the electrocardiogram (ECG) have been associated with coronary heart disease (CHD) and mortality. The pathophysiology and prognostic significance of T-wave inversion may differ between different anatomical lead groups, but scientific data related to this issue is scarce., Methods: A representative sample of Finnish subjects (n = 6,354) aged over 30 years underwent a health examination including a 12-lead ECG in the Health 2000 survey. ECGs with T-wave inversions were divided into three anatomical lead groups (anterior, lateral, and inferior) and were compared to ECGs with no pathological T-wave inversions in multivariable-adjusted Fine-Gray and Cox regression hazard models using CHD and mortality as endpoints., Results: The follow-up for both CHD and mortality lasted approximately fifteen years (median value with interquartile ranges between 14.9 and 15.3). In multivariate-adjusted models, anterior and lateral (but not inferior) T-wave inversions associated with increased risk of CHD (HR: 2.37 [95% confidence interval 1.20-4.68] and 1.65 [1.27-2.15], respectively). In multivariable analyses, only lateral T-wave inversions associated with increased risk of mortality in the entire study population (HR 1.51 [1.26-1.81]) as well as among individuals with no CHD at baseline (HR 1.59 [1.29-1.96])., Conclusions: The prognostic information of inverted T waves differs between anatomical lead groups. T-wave inversion in the anterior and lateral lead groups is independently associated with the risk of CHD, and lateral T-wave inversion is also associated with increased risk of mortality. Inverted T wave in the inferior lead group proved to be a benign phenomenon., (© 2020 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)

Introduction: The purpose of this study was to determine the effect of recommendations to limit troponin testing to patients with either chest pain or ischemic electrocardiographic changes., Methods: We included all adult patients hospitalized in a regional hospital in internal medicine, cardiology, and intensive care departments in 2014-2016 and in 2019 after recommending limiting troponin testing to patients with either chest pain or ischemic electrocardiographic changes., Results: After the intervention, testing decreased from 51.5% (11,634/22,581) to 34.6% (3417/9882). However, if only those with ischemia or chest pain were tested, the frequency would be 9.4% (924/9882) with a 95% confidence interval of 8.8%-9.9%. Variables increasing the odds of ordering a troponin test were older age, male sex, a discharge diagnosis of tachyarrhythmia, congestive heart failure, and dizziness or syncope as well as lower albumin and higher glucose, uric acid, and blood urea nitrogen test results. There were lower odds in those with nonspecific symptoms and infections of the skin, soft tissues, and the urinary tract. Auditing increased the effectiveness of the intervention in 1 internal medicine department (odds ratio 0.70, 95% confidence limit 0.60-0.82) after adjustment for other significant independent variables. The area under the curve was 0.713., Conclusion: We found that an educational program with clear recommendations decreased the proportion of patients with troponin testing in hospitalized internal medicine departments, but the intervention was only partially effective and did not include patients with congestive heart failure and other conditions in which expert recommendations for testing are discordant., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Aims: The diagnosis of LVH by ECG may particularly difficult in obese individuals. The aim of this study was to prospectively investigate whether the correction for body mass index (BMI) might improve the prognostic significance for cerebro and cardiovascular events of two electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH) in a large cohort of Italian adults., Methods and Results: In 18,330 adults (54 ± 11 years, 55% women) from the Moli-sani cohort, obesity was defined using the ATPIII criteria. The Sokolow-Lyon (SL) and Cornell Voltage (CV) criteria were used for ECG-LVH. In overweight and obese subjects, as compared with normal weight, the prevalence of ECG-LVH by the SL index was lower. During follow-up (median 4.3 yrs), 503 cerebro and cardiovascular events occurred. One standard deviation (1-SD) increment in uncorrected and in BMI-corrected SL index and CV was associated with an increased risk of events (HR 1.12, 95% CI 1.02-1.22 and HR 1.16, 95% CI 1.06-1.26 and HR 1.12, 95% CI 1.03-1.23 and HR 1.17, 95% CI 1.07-1.27, respectively for SL and CV). In obese subjects, 1-SD increment in uncorrected CV and in BMI-corrected CV was not associated to a significant risk of events (HR 1.05, 95% CI 0.910-1.22 and HR 1.08, 95% CI 0.95-1.23 respectively). Uncorrected SL index showed a significant association with events, which was marginally stronger with BMI-corrected SL voltage (HR 1.18, 95% CI 1.02-1.37 and HR 1.17, 95% CI 1.04-1.33 respectively, Akaike information criterion change from 3220 to 3218)., Conclusions: BMI correction of ECG LVH voltage criteria does not significantly improve the prediction of cerebro and cardiovascular events in obese patients in a large cohort at low cardiovascular risk., (Copyright © 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Backgound: Silent electrocardiographic ST change predicts future coronary heart disease (CHD) incidence and mortality, but the prognostic significance of painless ST-segment depression (STD) with respect to sudden cardiac death (SCD) in subjects without apparent CHD remain unclear. This study sought to test the association between non-ischemic resting STD and risk of SCD in the general population., Methods: A total of 14,935 middle-aged subjects from the prospective, population-based Atherosclerosis Risk in Communities (ARIC) study were included in this analysis. Cox models were used to estimate the hazard ratios (HRs) adjusted for possible confounding factors. STD was defined as ST-segment depression of ≥0.05 mV in two or more contiguous leads., Results: A total of 626 sudden cardiac death occurred during the mean follow-up of 20.4 years. Compared with those without STD, subjects with resting painless STD of at least 0.05 mV had a significantly increased risk of developing SCD (adjusted HR, 1.45; 95% CI, 1.20 to 1.76), and those with STD ≥ 0.1 mV had even higher risk of SCD (adjusted HR, 1.90; 95% CI, 1.25 to 2.88). Significant interactions were present between gender and STD (P = .03), and between race and STD (P = .01). STD was significantly predictive of SCD in males (adjusted HR, 1.57; 95% CI, 1.22-2.01) and in whites (adjusted HR, 1.65; 95% CI, 1.27-2.14). STD in lateral leads and global leads were strong predictors of SCD., Conclusions: Resting painless STD was an independent predictor of SCD in the middle-aged population without previously diagnosed CHD., (Copyright © 2019. Published by Elsevier B.V.)

Background: Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression., Methods: STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression., Results: Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001)., Conclusions: STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: ECG left ventricular hypertrophy (LVH) is a well-known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH ("ECG LVH trajectories") across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories., Methods and Results: We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1-9.3) years. ECG LVH was measured by Cornell voltage-duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively., Conclusions: ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background and Aims: The orientation of the frontal plane T-wave axis (T axis) is a reliable measure of ventricular repolarisation. We investigated the association between T-axis and the risk of coronary heart disease (CHD), heart failure (HF), atrial fibrillation (AF), stroke and cardiovascular (CVD) mortality., Methods: A sample of 21,287 Moli-sani participants randomly recruited from the general adult (≥35 y) Italian population, free of CVD disease, were followed for a median of 4.4 years. T-axis was measured from a standard 12-lead resting ECG., Results: After adjusting for CVD risk factors, subjects with abnormal T-axis showed an increase in the risk of both CHD (Hazard Ratio (HR) = 2.65; 95% CI = 1.67-4.21), HF (HR = 2.56; 1.80-3.63), AF (HR = 2.48; 1.56-3.94) and CVD mortality (HR = 2.83; 1.50-5.32). The association with CHD and HF, but not with AF or CVD death, remained significant after further adjustment for ECG abnormalities. Subjects with abnormal T-axis showed higher levels of subclinical inflammation, hs-troponin I and hs-NT-proBNP (p < 0.001 for all). However, further adjustment for troponin I and/or NT-proBNP determined a reduction of HRs ranging from 12.1 to 24.0% for CHD, while additional adjustment for inflammation markers did not change any association., Conclusions: An abnormal T-axis orientation is associated with an increased risk of both CHD and HF, independently of common CVD risk factors and other ECG abnormalities. This association was partially explained by increased hs-troponin I and hs-NT-proBNP levels., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Abnormal orientation of the T-wave axis and increased angle between the QRS complex (depolarization) and the T-wave (repolarization) have long been assumed to provide a global measure of repolarization abnormality, and have been used to assess ventricular repolarization. The ability of the T wave axis deviation and the QRS-T angle to predict incident coronary heart events was examined in several studies. However, conflicting results have led to significant controversy in the literature concerning their purported ability. Potential explanations involve true variation between study populations, non-standardized cut-off values, different baseline cardiovascular risk levels or different patterns of confounding by other concomitant cardiovascular risk factors. In the present article we will attempt to briefly present the rationale and pathophysiology behind these indices, summarize existing knowledge regarding their prognostic significance and their correlation with established cardiovascular disease risk factors. Further prospective studies are necessary to confirm or refute whether T-wave axis deviation, QRS-T angle and ventricular gradient may in the future serve as indicators of incident coronary heart events and mortality, both in populations with higher prevalence of subclinical advanced atherosclerotic heart disease and in apparently healthy subjects., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown., Objective: To measure the effect of use of the HEART score on patient outcomes and use of health care resources., Design: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846)., Setting: Emergency departments in 9 Dutch hospitals., Patients: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014., Intervention: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management., Measurements: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness., Results: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed., Limitation: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score., Conclusion: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations., Primary Funding Source: Netherlands Organisation for Health Research and Development.

Sudden cardiac death (SCD) causes a high burden of premature deaths in the population affecting subjects of all ages. The identification of subjects at high risk for SCD is of great importance as the prevention of many of these events would be possible with the treatment of underlying cardiac diseases and the use of implantable cardioverter-defibrillators (ICD). However, the current selection of patients for ICD therapy is based solely on left ventricular ejection fraction, and thus a substantial portion of patients at high risk does not qualify for the therapy. Role of the standard electrocardiogram (ECG) in SCD risk stratification has been under active research during the last decade and multiple abnormalities of depolarization and repolarization on the ECG associated with an increased risk of SCD have been identified. In this review, we describe the basic pathophysiological principles behind these changes. We also review the current knowledge of the prognostic significance of ECG predictors of SCD in the general population, and in patients with coronary heart disease (CHD), heart failure, cardiomyopathies, and in inheritable arrhythmia syndromes. Also, insights into the novel digital ECG signal processing techniques are provided.

Left ventricular hypertrophy (LVH) diagnosed by electrocardiography (ECG-LVH) and echocardiography (echo-LVH) are independently associated with an increased risk of cardiovascular disease (CVD) events. However, it is unknown if ECG-LVH retains its predictive properties independent of LV anatomy. We compared the risk of CVD associated with ECG-LVH and echo-LVH in 4,076 participants (41% men, 86% white) from the Cardiovascular Health Study, who were free of baseline CVD. ECG-LVH was defined with Minnesota ECG Classification criteria from baseline ECG data. Echo-LVH was defined by gender-specific LV mass values normalized to body surface area (male: >102 g/m(2); female: >88 g/m(2)). ECG-LVH was detected in 144 participants (3.5%) and echo-LVH in 430 participants (11%). Over a median follow-up of 10.6 years, 2,274 CVD events occurred. In a multivariate Cox regression analysis adjusted for common CVD risk factors, ECG-LVH (hazard ratio [HR] 1.84, 95% CI 1.51 to 2.24) and echo-LVH (HR 1.35, 95% CI 1.19 to 1.54) were associated with an increased risk for CVD events. The association between ECG-LVH and CVD events was not substantively altered with further adjustment for echo-LVH (HR 1.76, 95% CI 1.45 to 2.15). In conclusion, the association of ECG-LVH with CVD events is not dependent on echo-LVH. This finding provides support to the concept that ECG-LVH is an electrophysiological marker with predictive properties independent of LV anatomy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Electrical alternans (EA) has not been fully studied in the current percutaneous coronary intervention (PCI) procedure., Objective: The purpose of this study was to evaluate visible EA and the morphology of ST segment during PCI., Methods: The incidence of visible EA and ST-segment morphology were studied while the coronary artery was occluded for 20 seconds. When data were available, the relationship between EA and blood pressure was analyzed. The clinical and electrocardiographic data were compared with those of the age- and sex-matched controls., Results: During balloon inflation, visible EA was observed in 5 of 306 patients (1.6%) in the last 2 years. EA was limited to PCI in the proximal left anterior descending artery. The ST segment elevated to 10.1 ± 3.2 mm, followed by an alternating QRS complex with a lower ST segment (5.6 ± 1.9 mm; P = .0047) with characteristic ST-segment morphology, which is known as lambda pattern. The mean age of the 5 patients was 68 ± 20 years, and 4(80%). were men. After the release of inflation, the ST-segment level returned rapidly to baseline, followed by normalization of J point. Compared with controls, the maximal elevated ST segment was significantly higher in patients with EA (5.7 ± 2.7 mm; P = .0028). The occlusion of the proximal left anterior descending artery with more severe ischemia seemed to be a prerequisite for developing EA. A higher ST segment was associated with a lower blood pressure and vice versa., Conclusion: A short period of ischemia during PCI may induce visible EA and alternating QRS complexes with a characteristic ST-segment morphology. A higher ST segment was associated with a lower blood pressure and vice versa., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies., Methods: Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults., Results: Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise., High-Value Care Advice: Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

Background: Exercise electrocardiography in asymptomatic adults has been criticized because of relatively poor accuracy predicting future heart disease risk, but studies may have been too short. We investigated if integrated analysis of graded exercise tolerance tests (GXT) predicted long-term coronary heart disease (CHD) and all-cause mortalities among community-dwelling older adults., Methods and Results: From 1972 to 1974, 1789 adult residents of a predominantly Caucasian, middle- to upper-middle-class southern California community participated in a clinical evaluation that included a GXT; 52.4% (N=939) of those who had baseline GXT were followed up to 2010-up to 36years-for vital status, CHD and all-cause mortality. Multiply adjusted hazard ratios of an abnormal graded GXT were 1.65 (95% CI 0.78-3.49) and 1.56 (95% CI 1.15-2.11) for CHD and all-cause mortality, respectively. An integrated analysis hazard ratio was calculated based on the following GXT findings: significant ST change, inability to achieve target heart rate [THR], abnormal heart rate recovery [HRR], and chronotropic incompetency [ChI]. Compared to those with 0 or 1 abnormality, participants with 2 or more positive findings had significantly higher CHD (HR 2.18) and all-cause (HR 1.92) mortalities. Participants with 3 or more positive findings showed even higher hazard ratios-CHD (HR 6.16) and all-cause (HR 2.49) mortalities. When adjusted for any of 3 Framingham risk models, the integrated electrocardiographic model correlated well with CHD and all-cause mortalities., Conclusions: An integrated analysis of electrocardiographic and non-electrocardiographic measures of GXT is useful in predicting long-term CHD and all-cause mortalities in an asymptomatic middle-aged population., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Recent epidemiological studies documented that early repolarization may be associated with increased risk of serious cardiac events, including cardiac death. Little is known about the prognostic significance of this pattern in low risk surgical patients. This retrospective study included 3028 patients over 18 years of age and with ASA class I and II risk, undergoing noncardiac elective surgery. We followed the patients for one year. Early repolarization in preoperative ECG was found in 219 patients (7.2%) and patients with early repolarization were more likely to be male and younger. Newly observed cardiac events were significantly higher in the early repolarization group (1.37% versus 0.21%; P = 0.003). Multivariate regression analysis reveals that early repolarization (odds ratio: 6.019, P = 0.013) significantly increased newly observed cardiac events. Our retrospective study suggests that low risk surgical patients with early repolarization have statistically higher opportunity of newly observed cardiac events within one year after surgery.

Exercise-induced ischemic preconditioning (IPC) can be assessed with the second exercise stress test during sequential testing. Exercise-induced IPC is defined as the time to 1 mm ST segment depression (STD), the rate-pressure product (RPP) at 1 mm STD, the maximal ST depression and the rate-pressure product at peak exercise. The purpose of this meta-analysis is to validate the parameters used to assess exercise-induced IPC in the scientific community. A literature search was performed using electronic database. The main key words were limited to human studies, which were (a) ischemic preconditioning, (b) warm-up phenomenon, and (c) exercise. Meta-analyses were performed on the study-specific mean difference between the clinical measures obtained in the two consecutive stress tests (second minus first test score). Random effect models were fitted with inverse variance weighting to provide greater weight to studies with larger sample size and more precise estimates. The search resulted in 309 articles of which 34 were included after revision (1053 patients). Results are: (a) time to 1 mm ST segment depression increased by 91 s (95% confidence interval (CI): 75-108), p < 0.001; (b) peak ST depression decreased by -0.38 mm (95% CI: -0.66 to -0.10), p < 0.01; and (c) rate-pressure product at 1 mm STD increased by 1.80 × 10(3)mmHg (95% CI: 1.0-2.0), p < 0.001. This is the first meta-analysis to set clinical parameters to assess the benefit of exercise-induced ischemic preconditioning in sequential stress testing. The results of this first meta-analysis on the sequential stress test confirm what is presented in the literature by independent studies on exercise-induced ischemic preconditioning. From now on, the results could be used in further research to set standardized parameters to assess the phenomenon., (© The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Coronary heart disease (CHD) places a major burden on the Australian health care system. Determining the likelihood of CHD in a patient presenting with chest pain can be particularly difficult in a remote setting where access to transportation and specialised investigations including myocardial stress studies and coronary angiography can be difficult and delayed. The objective is to develop a predictive model for determining the risk of CHD, including the value of high sensitivity C-reactive protein (hsCRP), in patients presenting with chest pain with a particular emphasis on resources and information likely to be available in a remote primary health care setting., Methods: A prospective, cross-sectional observational study of patients with no prior diagnosis of CHD presenting to a specialist chest pain assessment clinic at Cairns Hospital from November 2012 to May 2013., Results: Out of the 163 participants included in the study analyses, a total of 38 were classified as CHD likely (23.3% (95% CI 17.1-30.6)). Logistic regression modelling identified two factors that were independently associated with likely CHD, namely the presence of typical chest pain (OR 83.7 (95% CI 21.7-322.1)) and an abnormal baseline ECG (OR 12.8 (95% CI 1.9-86.0))., Conclusion: In this study, it was demonstrated that the presence of typical chest pain and an abnormal resting ECG, remain the cornerstone of predicting a subsequent diagnosis of CHD. This information is easily accessible in remote primary health care and should be utilised to expedite assessment in patients presenting with symptoms suggestive of CHD., (Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: We evaluated 25 repolarization-related ECG variables for the risk of coronary heart disease (CHD) death in 52 994 postmenopausal women from the Women's Health Initiative study., Methods and Results: Hazard ratios from Cox regression were computed for subgroups of women with and without cardiovascular disease (CVD). During the average follow-up of 16.9 years, 941 CHD deaths occurred. Based on electrophysiological considerations, 2 sets of ECG variables with low correlations were considered as candidates for independent predictors of CHD death: Set 1, Ѳ(Tp|Tref), the spatial angle between T peak (Tp) and normal T reference (Tref) vectors; Ѳ(Tinit|Tterm), the angle between the initial and terminal T vectors; STJ depression in V6 and rate-adjusted QTp interval (QTpa); and Set 2, TaVR and TV1 amplitudes, heart rate, and QRS duration. Strong independent predictors with over 2-fold increased risk for CHD death in women with and without CVD were Ѳ(Tp|Tref) >42° from Set 1 and TaVR amplitude >-100 μV from Set 2. The risk for these CHD death predictors remained significant after multivariable adjustment for demographic/clinical factors. Other significant predictors for CHD death in fully adjusted risk models were Ѳ(Tinit|Tterm) >30°, TV1 >175 μV, and QRS duration >100 ms., Conclusions: Ѳ(Tp|Tref) angle and TaVR amplitude are associated with CHD mortality in postmenopausal women. The use of these measures to identify high-risk women for further diagnostic evaluation or more intense preventive intervention warrants further study., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00000611., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Information about prognostic utility is limited for numerous electrocardiogram (ECG) abnormalities and is particularly scarce in women with coronary heart disease (CHD) or at increased risk of CHD occurrence., Design: This study used a prospectively planned observational post-hoc analysis of a negative randomised trial designed for other purposes., Methods: ECGs of 9789 postmenopausal women were analysed at a core laboratory. ECG abnormalities were determined and evaluated for mortality risk on top of established clinical risk factors and simultaneously with all other ECG abnormalities., Results: During a median follow-up of 5.6 years, 500 women sustained coronary death. Normal versus abnormal baseline ECGs were associated with an annual rate of 0.53% versus 1.28% coronary deaths. Ten clinically common ECG abnormalities, including left atrial abnormality, fragmented QRS, and Cornell voltage-only left ventricular hypertrophy, emerged as independent significant predictors of coronary death, eight of them also predicted all-cause mortality. Each ECG abnormality acted as a risk multiplier for a coexisting ECG abnormality. Two or three of any of the ECG abnormalities simultaneously present on the baseline ECG identified subsets with hazard ratios for coronary death of 3.3 or 5.5 respectively. Consideration of ECG abnormalities significantly improved risk stratification by common clinical parameters., Conclusion: The presence of ECG abnormalities provides independent risk information over and above that of established risk factors, both for women with CHD or at increased risk of occurrence of CHD. Normal ECG assures a low mortality risk regardless of whether CHD exists or not. The data derived could be applied to corresponding postmenopausal women in daily clinical practice., (© The European Society of Cardiology 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: This case report discusses an ethical communication dilemma in prehospital patient interaction, involving a patient who was about to board a plane at a busy airport. The article argues that the situation raised dilemmas about communication, patient autonomy and paternalism. Paramedics should be able to find good solutions to these dilemmas, but they have not received much attention in the literature on prehospital ambulance work., Case Presentation: The patient had chest pains that were consistent with serious heart disease, but she wanted to catch her plane and was unwilling to let paramedics assess her heart activity by means of an electrocardiogram (ECG). The paramedics had to decide, there and then, whether the patient's refusal to submit to an ECG should be respected, or whether they should set the patient's expressed wishes aside by exercising verbal power and persuasive communication techniques. The paramedics chose to do the latter. It later turned out that the patient was grateful that the paramedics had been very direct, almost brutal, in their communication. When the patient regained her autonomy, she saw clearly that taking time to obtain and monitor an ECG was the best option for her., Conclusion: Looking forward in time might be a good professional strategy for deciding whether ethical paternalism in communication is justified. If there is good reason to believe that patients who later regain their autonomy will agree that paternalistic verbal actions were in their best interests, and if acting in accordance with patients' preferences can have severe negative health consequences for them, then paramedics have good reason to believe that ethical paternalism is justified.

The aVR is often neglected lead. It is an unipolar lead facing the right superior surface. As all the depolarisations are going away from lead aVR, all waves are negative in aVR (P, QRS, T) in normal sinus rhythm. In dextrocardia, (True and technical) the p is upright in aVR. The lead aVR is a very important lead in localisation of Coronary Artery Disease. In the presence of anterior ST elevation, ST elevation in lead aVR and V1 denotes proximal LAD obstruction where ST elevation is more in lead V1, than in aVR. In the presence of anterior ST depression, ST elevation in lead aVR indicates Left Main Coronary Artery (LMCA) Disease where ST elevation is more in aVR than in V1. In wide QRS tachycardia, tall R wave in aVR indicates Ventricular Tachycardia rather than SVT with aberrancy. In the presence of QS complexes in inferior leads, the lead aVR helps to differentiate between inferior wall MI (IWMI) and left anterior fascicular block (LAFB). Initial R in aVR is suggestive of IWMI and terminal R is suggestive of LAFB. In pericarditis, lead aVR is most often the only lead which shows reciprocal ST depression where as in Acute Infarction, usually a group of leads shows reciprocal depression. In the presence of persistent ST elevation in anterior chest leads, the R in aVR is suggestive of left ventricular aneurysm (Goldburger's sign). In acute pulmonary embolism, ST elevation in lead aVR is a bad prognostic sign. In Tricyclic antidepressant toxicity, R in aVR more than 3 mm is an adverse prognostic sign. So in variety of conditions, the aVR is proved to be a valuable lead not only in diagnosis but also in predicting the prognosis.

Background: The prognostic value of an isolated J-point depression, or rapidly upsloping ST-segment, on an exercise ECG has long been assumed to be a benign variant. However, little or no data supporting this assumption may be found in the literature. Our task was to examine if a rapidly upsloping ST-segment on an exercise ECG is associated with changes in risk of dying from CHD in 2014 healthy middle-aged men followed for 35 years., Methods: A group of healthy middle-aged men (n = 2014) participated in a cardiovascular survey. They underwent an examination programme including a symptom-limited ECG bicycle exercise test. Exercise induced ST-segments were categorised in three groups: normal ST-segment (n = 1383), rapidly upsloping (n = 401), and ST-depression (n = 230). Survival analyses were adjusted for smoking status, total cholesterol, systolic blood pressure, maximal heart rate, and physical fitness. The mean follow-up time was 35 years., Results: The rapidly upsloping group had a 30% decreased risk of CHD death (hazard ratio, HR, 0.70, 95% CI 0.51-0.95) compared to the normal ST-segment group. The risk of CVD-death was numerically lower in the rapidly upsloping group (HR 0.82, 95% CI 0.65-1.04) compared to the normal ST-segment group. The ST-depression group had a 1.45-fold (HR 1.45, 95% CI 1.09-1.90) increased risk of CHD death compared to the normal ST-segment group., Conclusions: The rapidly upsloping ST-segment was a common finding (20%) on exercise ECG among healthy middle-aged men and was associated with a 30% reduced risk of dying from CHD compared to individuals with normal ST-segment. A rapidly upsloping ST-segment on exercise ECG may represent the true healthy state.

Objectives: The goal of this study was to evaluate the prevalence and clinical characteristics of mental stress-induced myocardial ischemia., Background: Mental stress-induced myocardial ischemia is prevalent and a risk factor for poor prognosis in patients with coronary heart disease, but past studies mainly studied patients with exercise-induced myocardial ischemia., Methods: Eligible patients with clinically stable coronary heart disease, regardless of exercise stress testing status, underwent a battery of 3 mental stress tests followed by a treadmill test. Stress-induced ischemia, assessed by echocardiography and electrocardiography, was defined as: 1) development or worsening of regional wall motion abnormality; 2) left ventricular ejection fraction reduction ≥ 8%; and/or 3) horizontal or downsloping ST-segment depression ≥ 1 mm in 2 or more leads lasting for ≥ 3 consecutive beats during at least 1 mental test or during the exercise test., Results: Mental stress-induced ischemia occurred in 43.45%, whereas exercise-induced ischemia occurred in 33.79% (p = 0.002) of the study population (N = 310). Women (odds ratio [OR]: 1.88), patients who were not married (OR: 1.99), and patients who lived alone (OR: 2.24) were more likely to have mental stress-induced ischemia (all p < 0.05). Multivariate analysis showed that compared with married men or men living with someone, unmarried men (OR: 2.57) and married women (OR: 3.18), or living alone (male OR: 2.25 and female OR: 2.72, respectively) had higher risk for mental stress-induced ischemia (all p < 0.05)., Conclusions: Mental stress-induced ischemia is more common than exercise-induced ischemia in patients with clinically stable coronary heart disease. Women, unmarried men, and individuals living alone are at higher risk for mental stress-induced ischemia. (Responses of Myocardial Ischemia to Escitalopram Treatment [REMIT]; NCT00574847)., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We assessed the clinical outcomes of symptomatic and asymptomatic coronary heart disease (CHD) with type 2 diabetic patients., Design: Population-based cohort study., Methods: The study sample consisted of 380 men and 546 women, aged ≥30 years. Silent CHD was defined using Minnesota coding criteria on baseline electrocardiogram (ECG), in the absence of a history of CHD and symptoms of angina. Participants were categorized into four groups: group 1, participants with no CHD symptoms and with normal ECG; group 2, silent CHD; group 3, participants with symptomatic CHD but with normal ECG; group 4, participants with symptomatic CHD and ECG-determined CHD. Cox regression analysis was used to estimate the hazard ratios (HRs) of cardiovascular disease (CVD) and CHD events for these groups, with group 1 as the reference., Results: During median follow up of 9.2 years, we ascertained 226 CVD events (202 CHD). In the multivariable-adjusted model, among men, HRs (95% CI) of CVD events were 2.32 (1.29-4.16), 2.56 (1.47-4.46), and 3.97 (2.24-7.02) for groups 2, 3, and 4, respectively; the corresponding figures among women were 1.19 (0.65-2.18), 1.90 (1.24-2.92), and 1.92 (1.02-3.62) respectively. Similar results were achieved for CHD events., Conclusion: In both sexes, symptomatic CHD was an independent predictor of recurrent CVD/CHD, regardless of ECG results. In diabetic men with asymptomatic CHD, ECG could be of prognostic value for incident CVD/CHD. The present study provides evidence-based support only in men for the ADA recommendation of 'further cardiac testing for diabetic patients with an abnormal resting ECG'.

Aims: To compare the value of serial electrocardiographic (ECG) changes by the two most widely used ECG classification systems-the Minnesota Code (MC) and Novacode (Nova) for the prediction of subsequent coronary heart disease (CHD) and total mortality., Methods and Results: We studied 12-lead ECGs from 12,477 participants (average age 54 years at baseline; 58% women; 76% non-Hispanic white) in the Atherosclerosis Risk in Communities (ARIC) Study, who were free of CHD at baseline in 1987, had both good-quality ECGs at baseline and at first study-scheduled follow-up visit, and had ECG QRS duration <120 ms. A total 2119 participants died (17%), including 280 CHD deaths during an average 17-year follow up. Cox regression models assessed outcome associated with significant serial ECG changes by MC and Nova separately. For CHD death the hazard ratio was 6.8 (95% CI 3.5-13.3) for incident Nova myocardial infarction (MI), and 5.7 (95% CI 2.7-11.9) for MC-MI in a multivariable model adjusted for clinical and demographic characteristics, and ECG left ventricular hypertrophy. The increased risk for total mortality doubled for both Nova and MC serial ECG MI. Major evolving ST-T wave abnormalities alone were associated with a ≥132% increased risk for CHD death and a 50% increased risk for total mortality by either Nova or MC., Conclusion: ECG serial change by both MC and Nova are equally valuable predictors for future fatal cardiac events and total mortality and hence equally useful prognostic indicators in clinical trials and epidemiological studies.

An increasing number of elderly people and diabetes patients with myocardial infarction go unrecognized because of painless ischemia and regression of major Q-waves over time. An increased awareness of diagnostic electrocardiogram (ECG) abnormalities other than Q-waves should allow physicians to optimize patient management. Particularly emphasized is the R-peak delay in V6, i.e. the R-peak in V6 being later than the S-peak in V2, as a sign of masked anterior myocardial infarction and ECG findings if infarcts are masked by left ventricular hemiblocks and left bundle branch block (LBBB). In left anterior hemiblocks dramatically decreased R-waves in leads II, III and AVF in conjunction with disappearance of Q-waves in leads I and aVL help to identify posterodiaphragmatic infarction. The left posterior hemiblock is itself a potent indicator of underlying posterodiaphragmatic infarction not recognized by Q-waves. In LBBB Cabrera's sign, RSR' morphology in the left-sided or inferior leads, inverse R-progression from V1 to V3 and primary repolarization abnormalities overlying the secondary T-wave changes are specific indicators of myocardial infarction. QRS-prolongation greater than 150 ms independently identifies ventricular function impairment in chronic coronary heart disease.

Background: Several risk scores are available for prognostic purpose in patients presenting with chest pain., Aim: The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting., Methods: Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged. End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up., Results: Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001)., Conclusions: The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The prognostic relevance of quantitative an intracoronary occlusive electrocardiographic (ECG) ST-segment shift and its determinants have not been investigated in humans. In 765 patients with chronic stable coronary artery disease, the following simultaneous quantitative measurements were obtained during a 1-minute coronary balloon occlusion: intracoronary ECG ST-segment shift (recorded by angioplasty guidewire), mean aortic pressure, mean distal coronary pressure, and mean central venous pressure (CVP). Collateral flow index (CFI) was calculated as follows: (mean distal coronary pressure minus CVP)/(mean aortic pressure minus CVP). During an average follow-up duration of 50 ± 34 months, the cumulative mortality rate from all causes was significantly lower in the group with an ST-segment shift <0.1 mV (n = 89) than in the group with an ST-segment shift ≥0.1 mV (n = 676, p = 0.0211). Factors independently related to intracoronary occlusive ECG ST-segment shift <0.1 mV (r(2) = 0.189, p <0.0001) were high CFI (p <0.0001), intracoronary occlusive RR interval (p = 0.0467), right coronary artery as the ischemic region (p <0.0001), and absence of arterial hypertension (p = 0.0132). "High" CFI according to receiver operating characteristics analysis was ≥0.217 (area under receiver operating characteristics curve 0.647, p <0.0001). In conclusion, absence of ECG ST-segment shift during brief coronary occlusion in patients with chronic coronary artery disease conveys a decreased mortality and is directly influenced by a well-developed collateral supply to the right versus left coronary ischemic region and by the absence of systemic hypertension in a patient's history., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To examine the added value of electrocardiogram (ECG) abnormalities beyond the Framingham risk score (FRS) in risk stratification for coronary heart disease (CHD) in a population of Middle Eastern women., Methods: The study population consisted of 2568 women aged ≥30 years, free from CHD symptoms and with no major Q or QS wave or complete left-bundle branch block in their baseline ECG. ECG abnormalities included ST depression (Minnesota codes 4.1-4.2), or T-wave items (Minnesota codes 5.1-5.2). Participants were categorized into 3 groups, according to their FRS. Cox regression analysis was used to estimate the hazard ratios (HR) of CHD events for ECG abnormalities among each FRS group. Net Reclassification Index (NRI) was used as the measure of predictive ability added to the FRS by ECG abnormalities., Results: During 9.3 years, 127 CHD events occurred. In the FRS adjusted analysis, the HRs (95%CI) of CHD events were 3.69 (0.87-15.68), 3.82 (2.01-7.23) and 1.39 (0.47-4.16) for ECG abnormalities in each FRS category (i.e. 0-4.9%, 5-19.9 and ≥20%, respectively). Addition of ECG abnormalities to FRS did not significantly increase the C-statistics (0.838), but improved the predictive ability of the FRS by 20.8 (95% CIs 5.0-38.9) using the cut point free NRI., Conclusion: Among women, only in the intermediate risk group, ECG abnormalities were independently associated with increased risk of developing CHD. Addition of the ECG abnormalities to the FRS improved the classification of coronary heart disease risk, especially in this group., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Although clockwise rotation and counterclockwise rotation are distinct findings of the ECG, their prognostic significance is rarely studied., Methods and Results: We studied prognostic values of clockwise and counterclockwise rotation on total, cardiovascular disease (CVD), and subtype mortality using the National Integrated Project for Prospective Observation of Noncommunicable Disease and Its Trends in the Aged, 1980-2004 (NIPPON DATA80) database with a 24-year follow-up. At baseline in 1980, data were collected on study participants aged ≥30 years from randomly selected areas in Japan. We followed 9067 participants (44% men; mean age, 51 years). During the 24-year follow-up, mortality was as follows: 2581 total, 887 CVD, 179 coronary heart disease, 173 heart failure, and 411 stroke. The multivariate-adjusted hazard ratio (HR) with the use of the Cox model including biochemical and other ECG variables revealed that clockwise rotation was significantly positively associated with heart failure in men and women combined (HR=1.79; 95% confidence interval [CI], 1.13-2.83; P=0.013), CVD in men and in men and women combined (HR=1.49; 95% CI, 1.12-1.98; P=0.007 in men; HR=1.28; 95% CI, 1.02-1.59; P=0.030 in combined), and total mortality in men and in men and women combined (HR=1.19; 95% CI, 1.00-1.49; P=0.0496 in men; HR=1.15; 95% CI, 1.00-1.32; P=0.045 in combined). Counterclockwise rotation was significantly inversely associated stroke in men and women combined (HR=0.77; 95% CI, 0.62-0.96; P=0.017), CVD in men and in men and women combined (HR=0.74; 95% CI, 0.59-0.94; P=0.011 in men; HR=0.81; 95% CI, 0.70-0.94; P=0.006 in combined), and total mortality in women (HR=0.87; 95% CI, 0.77-0.98; P=0.023)., Conclusions: We found a significant positive association of clockwise rotation and a significant inverse association of counterclockwise rotation with CVD mortality in men and in men and women combined, independent of confounding factors including other ECG changes.

Significant advances in medical treatment, medical technology, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, coronary artery disease (CAD) is the leading cause of cardiovascular death of women in the Western world. In the past 2 decades, the focused research on women at risk for CAD has helped to clarify our understanding of some of the sex-specific factors that are important in the detection of CAD. In women, the detection and evaluation of physiologically significant CAD can be challenging. Many of the traditional tests that are designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients, who have a greater burden of symptoms, higher atherosclerotic burden, and lower prevalence of obstructive coronary disease. In this article, we review the available evidence on the role of contemporary noninvasive diagnostic techniques in the evaluation of women with symptoms of CAD. The authors have no funding, financial relationships, or conflicts of interest to disclose., (© 2012 Wiley Periodicals, Inc.)

Objective: To identify specific ECG and clinical predictors that separate atherosclerotic sudden cardiac death (SCD) from incident coronary heart disease (CHD) (non-fatal events and non-sudden death) in the combined cohorts of the Atherosclerosis Risk in Communities study and the Cardiovascular Health Study., Methods: This analysis included 18,497 participants (58% females, 24% black individuals, mean age 58 years) who were initially free of clinical CHD. A competing risk analysis was conducted to examine the prognostic significance of baseline clinical characteristics and an extensive electronic database of ECG measurements for prediction of 229 cases of SCD as a first event versus 2297 incident CHD cases (2122 non-fatal events and 175 non-sudden death) that occurred during a median follow-up time of 13 years in the Cardiovascular Health Study and 14 years in the Atherosclerosis Risk in Communities study., Results: After adjusting for common CHD risk factors, a number of clinical characteristics and ECG measurements were independently predictive of SCD and CHD. However, the risk of SCD versus incident CHD was significantly different for race/ethnicity, hypertension, body mass index (BMI), heart rate, QTc, abnormally inverted T wave in any ECG lead group and level of ST elevation in V2. Black race/ethnicity (compared to non-black) was predictive of high SCD risk but less risk of incident CHD (p value for differences in the risk (HR) for SCD versus CHD <0.0001). Hypertension, increased heart rate, prolongation of QTc and abnormally inverted T wave were stronger predictors of high SCD risk compared to CHD (p value=0.0460, 0.0398, 0.0158 and 0.0265, respectively). BMI was not predictive of incident CHD but was predictive of high SCD risk in a quadratic fashion (p value=0.0220). On the other hand, elevated ST height as measured at the J point and that measured at 60 ms after the J point in V2 were not predictive of SCD but were predictive of high incident CHD risk (p value=0.0251 and 0.0155, respectively)., Conclusions: SCD and CHD have many risk factors in common. Hypertension, race/ethnicity, BMI, heart rate, QTc, abnormally inverted T wave in any ECG lead group and level of ST elevation in V2 have the potential to separate between the risks of SCD and CHD. These results need to be validated in another cohort.

Background: Coronary heart disease is the leading cause of death in adults. Screening for abnormalities by using resting or exercise electrocardiography (ECG) might help identify persons who would benefit from interventions to reduce cardiovascular risk., Purpose: To update the 2004 U.S. Preventive Services Task Force evidence review on screening for resting or exercise ECG abnormalities in asymptomatic adults., Data Sources: MEDLINE (2002 through January 2011), the Cochrane Library database (through the fourth quarter of 2010), and reference lists., Study Selection: Randomized, controlled trials and prospective cohort studies., Data Extraction: Investigators abstracted details about the study population, study design, data analysis, follow-up, and results and assessed quality by using predefined criteria., Data Synthesis: No study evaluated clinical outcomes or use of risk-reducing therapies after screening versus no screening. No study estimated how accurately resting or exercise electrocardiography classified participants into high-, intermediate-, or low-risk groups, compared with traditional risk factor assessment alone. Sixty-three prospective cohort studies evaluated abnormalities on resting or exercise ECG as predictors of cardiovascular events after adjustment for traditional risk factors. Abnormalities on resting ECG (ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation) or exercise ECG (ST-segment depression with exercise, chronotropic incompetence, abnormal heart rate recovery, or decreased exercise capacity) were associated with increased risk (pooled hazard ratio estimates, 1.4 to 2.1). Evidence on harms was limited, but direct harms seemed minimal (for resting ECG) or small (for exercise ECG). No study estimated harms from subsequent testing or interventions, although rates of angiography after exercise ECG ranged from 0.6% to 2.9%., Limitations: Only English-language studies were included. Statistical heterogeneity was present in several of the pooled analyses., Conclusion: Abnormalities on resting or exercise ECG are associated with an increased risk for subsequent cardiovascular events after adjustment for traditional risk factors, but the clinical implications of these findings are unclear.

A 51-year-old female undergoing an outpatient stress echocardiogram to evaluate atypical chest pain developed acute ST elevation in the anterior precordial leads on electrocardiogram following exercise. Echocardiography revealed a severe rise in pulmonary artery systolic pressure (PASP) with marked right ventricular (RV) enlargement and interventricular septum flattening. Subsequently, cardiac catherization confirmed an exercise-induced elevation in PASP and diagnosed pulmonary arterial hypertension without evidence of coronary artery disease. This case suggests that an acute elevation in pulmonary artery pressure with RV dilation may be a potential cause of acute ST elevation during stress testing.

There are large numbers of people suffering from simultaneous coronary heart disease and ischaemic heart disease who remain under home palliative care. When concentrating on oencological palliative treatment, there exists sometimes a tendency to forget about the possibility of deterioration in the general condition of a patient with cardio-vascular system dysfunctions. Deterioration in the patient's condition and persistent somatic complaints are frequently interpreted as progress in neoplastic disease or side effects of the employed therapy. It frequently leads to unnecessary discontinuation of palliative oencological treatment. Severe general condition of most patients limits the possibility of ischaemic heart disease diagnosis. It is also impossible to perform stress tests. Resting ECG is a simple and relatively inexpensive diagnostic method, possible to be performed at home by the patient's bed. Basing on a medical survey and an analysis of ECG record, diagnosis of deterioration in CHNS is very successful. The management of a patient with advanced neoplastic disease coexistent with ischaemic heart disease demands careful oencological and cardiologic treatment. ECG examinations carried in the patient's bed constitutes a crucial element of diagnostics in deteriorating coronary heart disease and in heart rate disregulations in patients under home palliative care.

Little is known about electrocardiographic (ECG) characteristics of menopausal women with or at increased risk of coronary heart disease (CHD). Data from 10,101 participants in the Raloxifene Use for The Heart (RUTH) trial were used to correlate baseline ECG abnormalities with clinical characteristics. Baseline characteristics that were statistically significantly associated (p ≤ 0.05) with ECG findings in univariate analyses were used to derive multivariate model selection. Of 59% normal electrocardiograms, 50% were from women with CHD and 69% from women at increased risk of CHD. In the women with CHD, 59% reported a previous myocardial infarction (MI); 43% had a normal electrocardiogram, and 49% had a definite ECG Q-wave MI. Women in the increased-risk group had not reported a previous MI, yet 11% had a definite ECG Q-wave MI. Of women reporting hypertension, 35% had ECG evidence of left ventricular hypertrophy, but 58% did not have an abnormal electrocardiogram. Significantly more women with diabetes in the increased-risk and documented CHD cohorts had abnormal electrocardiograms (p < 0.01 for the 2 cohorts). Percent abnormal electrocardiograms increased with increasing age (55 to 64, 65 to 74, and ≥ 75 years, p < 0.01) in all cohorts. Angina and coronary artery bypass graft surgery, but not percutaneous coronary intervention, predicted an abnormal electrocardiogram. In conclusion, there were high percentages of normal electrocardiograms in the increased-risk and documented CHD groups of RUTH participants, with substantial discrepancy between MI history and ECG MI documentation, and increasing age was the predominant correlate with an abnormal electrocardiogram in all 3 cohorts., (Copyright © 2010 Elsevier Inc. All rights reserved.)