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PR prolongation (first-degree AV block) is defined primarily as delayed conduction through the atrioventricular (AV) node, but can also signify delayed electrical impulse propagation through any part of the specialized conduction system. The prevalence of PR prolongation ranges from 1-5% in patients younger than 50 years of age, with increasing prevalence, particularly after the sixth decade of life and in patients with organic heart disease. While classical studies suggest no adverse associations linked to PR prolongation, contemporary studies have documented increased risk of atrial arrhythmias, heart failure, and mortality in patients with PR prolongation. Future studies are needed to risk stratify elderly patients with PR prolongation who may be at increased risk of adverse outcomes and determine the optimal monitoring strategy for future follow-up.

BACKGROUND Dizziness is a common symptom in adults and usually due to peripheral causes affecting semicircular canal function or central causes affecting the pons, medulla, or cerebellum. Arrhythmia is a recognized cause of dizziness in people with structural or ischemic heart disease. We report a case of exercise-induced transient ventricular tachycardia and dizziness in a man with no evidence of organic heart disease. CASE SUMMARY A 42-year-old man presented with a 6 mo history of transient exercise-induced dizziness and prodromal palpitations. The patient was otherwise asymptomatic. Physical examination, otoscopy, vestibular tests, cerebellar tests, laboratory investigations, and imaging investigations were all unremarkable. Twenty-four hour Holter monitoring revealed four episodes of transient ventricular tachycardia during exercise. The patient was started on metoprolol and subsequently underwent radiofrequency catheter ablation. The patient reported a full recovery and no dizziness during daily activities. These results were maintained at the 6 mo follow-up. CONCLUSION Ventricular tachycardia is an uncommon but potentially serious cause of dizziness. The outcome of this case illustrates the benefits of careful clinical examination and communication with specialized centers. High clinical suspicion of arrhythmia in a patient with dizziness merits consultation with a cardiologist and referral to a specialized center to ensure timely diagnosis and treatment.

Fusobacterium necrophorum is a very rare cause of endocarditis. We herein report a case of F. necrophorum endocarditis with liver abscesses in a 51-year-old woman. This is the first reported case of monomicrobial F. necrophorum endocarditis to present in a patient over 50 years old. We also reviewed 10 reported cases, including the present case. Our review indicated that anaerobic bacteria, including Gram-negative anaerobic bacilli such as F. necrophorum, should be considered in the differential diagnosis of infective endocarditis, especially in patients without preexisting organic heart disease.

The aim of our study was to evaluate the influence of the main indicators of type 1 diabetes mellitus (T1DM) control on heart rate variability (HRV). We examined 62 patients at the age of 18-45 years with an average T1DM duration of 11.0 (5.0; 18.0) years. HRV in the time and frequency range was evaluated by analyzing a 24-hour Holter electrocardiogram (ECG). The following laboratory parameters were used as markers of course and compensation of T1DM: C-peptide, HbA1c, blood creatinine, albuminuria (AU), estimated glomerular filtration rate (eGFR) by CKD-EPI formula. In addition, the maximum and minimum blood glucose levels and the blood glucose range (maximum minus minimum blood glucose values) were conducted by continuous glucose monitoring system iPro2 (Medtronic MiniMed, USA). The daily monitoring of electrocardiogram (ECG) was made in parallel with long term monitoring of blood glucose. Echocardiography in all patients was performed to exclude organic heart disease and the possibility of its influence on HRV. Poor control of T1DM negatively influences HRV through decrease in both frequency and time characteristics. The blood glucose range can be an additional negative factor for cardiovascular system in T1DM patients, regardless of HbA1c, whereas it positively correlates with HRV- relative hypersympathicotonia markers: LF/HF 24-h, ρ=0.43 (p

Background Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection. Purpose We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF. Material and Methods we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF 80 ms; and GWI< 672 mmHg% to identify patients at risk of major arrhythmic events. Results During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF< 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF< 35%, and 0.77 (95%CI 0.68-0.86) for GWI 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)). Conclusions GWI< 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF

BACKGROUND New automated approaches for left heart chamber quantification based on adaptive analytics algorithms have been introduced for both two- (2DE) and three-dimensional (3DE) echocardiography. These algorithms measure a left ventricular ejection fraction (LVEF) and reduce the intra- and inter-observer variability associated with the conventional manual tracing of LV endocardial borders. However, the clinical utility of these algorithms in the sudden cardiac death (SCD) risk stratification of patients with organic heart disease remains to be clarified. PURPOSE We sought to test the feasibility and the accuracy of two automated algorithms that measure 2DE and 3DE LVEF in patients with impaired LV systolic function and to define the cut-off values for fully automated 2DE and 3DE LVEF that could predict major arrhythmic events (MAE). We wanted also to assess the feasibility of replacing manual 2DE and semi-automated (SA) 3DE LVEF with fully-automated (FA) 2DE and 3DE LVEF respectively, in the stratification of high arrhythmic risk patients. METHODS We prospectively enrolled 240 patients (63 ± 13 years, 81% men) with both ischemic and non-ischemic cardiomyopathy with 2DE LVEF < 50%, no previous MAE or coronary artery revascularization < 90 days, after at least 3 months of optimal medical therapy for heart failure. MAE were defined as SCD, resuscitated cardiac arrest (CA), ventricular fibrillation, sustained ventricular tachycardia and appropriate ICD shocks. The risk detection cut-off values for 2DE and 3DE FA LVEF were computed using the maximally selected rank statistics method. In order to predict the risk of MAE we created four different risk models, including both clinical characteristics (age, NYHA class, aetiology of the LV dysfunction) and imaging-derived data (2DE manual LVEF, 2DE FA LVEF, 3DE SA LVEF and 3DE FA LVEF), analyzed by a ROC curve. RESULTS During a 27 ± 25months follow-up period, 31 patients (13%) presented MAE including SCD (n= 22; 9%), resuscitated CA (n = 3; 1%) and appropriate ICD shocks (n = 6; 2%). Both 2DE and 3DE FA LVEF showed high feasibility (92% and 95%, respectively), and good agreement with conventional LVEF (2DE mean difference 4 ± 7%, and 3DE mean difference 4 ± 7%). We identified two FA LVEF cut-offs for the MAE detection: 2DE CONCLUSIONS Both 2DE and 3DE FA LVEF are feasible and accurate alternative to the conventional (manual) or SA endocardial border tracing. The use of specific FA 2DE LVEF cut-off values showed a comparable predictive power in the MAE risk stratification compared to the conventional one with the advantage of very low intra- and inter-observer variability.

The paper presents the special questionnaire «Quality of Life in Children with Arrhythmias» that reflects the subjective assessment of quality of life (QOL) in patients with cardiac arrhythmias and a procedure for the comprehensive assessment of QOL in children with arrhythmias on the basis of subjective and objective data. It gives the results of using the above procedures for assessing QOL in 151 children (71 girls and 80 boys) aged 6–18 years with various cardiac arrhythmias. Complaints were absent in 21,9±3,4% of the children with arrhythmia and were nonspecific, being rarely observed, in 29,8±3,7%, suggesting that there was no reduction in QOL according to their subjective assessments. Comprehensive assessment of QOL showed that its indicators were significantly lower (p

Background: Anaemia is one of the commonest clinical problems in our country. It affects various organs including the heart. Clinical manifestations of anaemia referable to cardiovascular system may closely simulate symptoms and signs of organic heart disease. It includes some electrocardiogram (ECG) changes also. ECG changes in anaemia show correlation to haemoglobin (Hb) concentration and the changes are reversible after correction of anaemia. In this study, the main objective was to study electrocardiographic changes in patients with severe anaemia and ECG reversibility after treatment of anaemia.Methods: 50 patients admitted in medicine wards of Shri B. M. Patil Medical College, Hospital and Research Center, Vijayapura for severe anaemia (Hb concentration less than or equal to 7 gm %) were studied for ECG changes. All patients were reassessed for reversibility of changes after treatment.Results: Out of 50 patients with severe anaemia, 20 patients were having Hb % of 3 to 5 gm %. Of which 16 patients were having ECG changes (10 were females and 6 were males). All ECG changes were reverted to normal after correction of anaemia, except one patient (showed pre-treatment T wave inversion and post-treatment flat T waves).Conclusions: ECG abnormalities in patients with severe anaemia are more common in females. ECG abnormalities in patients with severe anaemia (Hb 5 gm %) can get reverted to normal after correction of anaemia.

Patients with syncope and organic heart disease remain a small but important subset of those patients who experience transient loss of consciousness. These patients require thoughtful and complete evaluation in an attempt to better understand the mechanism of syncope and its relationship to the underlying disease, and to diagnose and treat both properly. The goal is to reduce the risk of further syncope, to improve long-term outcomes with respect to arrhythmic and total mortality, and to improve patients' quality of life.

Non-invasive left ventricular (LV) pressure-strain loop is a new method to quantify myocardial work. However, its prognostic value remains to be clarified and no threshold has been defined yet to distinguish patients at high or low risk of adverse events. We enrolled 216 patients with 2D LV

The effect of a number of repeated work tests on different electrocardiographic ST and T changes has been studied and the effect compared with that after an adrenergic beta-receptor blockade. In subjects with different ECG changes but without any apparent organic heart disease there was a normalization of the ST and T changes during the period of repeated work tests. The normalizing effect was almost identical to that after adrenergic blockade. Different patterns of ST and especially T depressions on the ECG at rest, in the standing position and during and after work are described. In patients with organic heart diseases the repeated work tests generally had no effect on the ECG patterns typical of coronary insufficiency and myocarditis. In one patient with signs of a vasoregulatory disturbance there seemed to be ST and T changes of different origin, probably both functional and organic. The effect of the adrenergic blockade was almost identical to that of the repeated work tests. The study gives support to the results of a previous investigation in which the possibility of using an adrenergic blockade for differentiating between ECG changes of functional and organic origin was pointed out. The normalization effect of 4–6 work tests over a period of 4–6 days on functional ST and T changes on the ECG is supposed to be due to a physical and psychic adaptation to the work tests and to the examination situation.

Sixteen young men with pre-excitation found at an enlistment medical examination of conscripts (giving an incidence of 1/1 000) have been compared with 112 randomly selected healthy men of the same age. None in the pre-excitation group had any signs of organic heart disease or history of tachycardial bouts. Those with pre-excitation were significantly shorter and had a slightly higher BP than the controls, but did not differ regarding physical work capacity (W170) or heart volume (HV). No difference was found in these respects between types A and B pre-excitation. W170 was. when adjusted for differences in HV, significantly higher in 8 subjects, whose ECG were totally or partially normalized during exercise, than in 8 subjects in whom no normalization occurred.

The effect of a new adrenergic β-receptor blocking agent H 56/28 has been studied in fourteen patients with nervous heart complaints, mainly palpitations. Organic heart disease and hyperthyroidism were excluded. The investigation was performed as a double blind test. During a first treatment period half of the patients received H 56/28 and the other half placebo-tablets; during the second period the treatment was reversed. The patients were also studied during repeated exercise tests. The heart rate during exercise was significantly reduced by H 56/28 and there was also a slight, though not significant, decrease of the systolic blood pressure. In addition to the immediate effect, H 56/28 treatment seemed to have a more prolonged lowering effect on the heart rate. No side effects of the drug worth mentioning were seen. All but three patients preferred H 56/28 to placebo. The β-blocker was especially effective in relieving palpitations. It is concluded that β-blocking agents might be of value in treating patients with nervous heart complaints.

cause of sudden cardiac death. The 5–10% rate of outof-hospital cardiac arrest is ascribed to VF in absence of organic heart disease [5, 12]. The trigger role of the ventricular premature beats (VPBs) arising from the distal Purkinje system has been identified by recent studies, which demonstrated the feasibility of eliminating or decreasing the incidence of idiopathic VF by catheter ablation of this trigger [3, 7–9, 15, 17]. However, multiple conditions like electrolyte imbalance, catecholamines, fever or drug use may facilitate induction of idiopathic VF [8, 11, 13, 14]. We report the case of a healthy woman who presented with a dramatic storm of more than 50 nonsustained and sustained VF episodes in the absence of a detectable underlying heart disease but with the presence of left bundle branch block. The morphology of initiating VBPs suggests the role of specific triggers arising from the distal Purkinje system. The concomitant presence of mild hypocalcemia without evident causes could have a possible and previously not described role in generating recurrent VF episodes.

Murmurs were described first by Laennec in 1819, after which the significance of a murmur became a matter of debate. By the late 19th century, many physicians regarded systolic murmurs as "organic," whereas others believed that they were often "functional." Samuel Levine became a central figure in separating functional from organic systolic murmurs. Freeman and Levine's 1933 study of 1,000 "noncardiac" subjects determined the frequency, cause, and significance of systolic murmurs. Murmurs were rated on a scale of 1 to 6 grades of intensity. Approximately 20% of their patients had grade 1 or 2 systolic murmurs. Hypertension, fever, tachycardia, and anemia were common factors, and the murmurs were considered functional because they would often disappear when these causes were controlled. Of 19 subjects with grade 3 or 4 murmurs, all were determined to have organic heart disease or anemia. Thus, louder systolic murmurs were found to be a significant finding, as were the cause, location, and effects of posture. They concluded that systolic murmurs often have an explanation and that their grade can be useful in the diagnosis and prognosis. They cautioned that a loud systolic murmur did not necessarily indicate a bad prognosis or even serious heart disease. Levine's system of grading a systolic murmur is valuable and persists into the 21st century.

Of 350 patients who had extensive non-invasive and invasive cardiological diagnostic tests, 56 had completely normal results. 24-hour ECG monitoring of the latter revealed the following ventricular arrhythmias-ventricular extrasystoles (VES): 36% without, 23% with rare ones (less than 30/h), 5.4% with more than 30/h, 25% with polytopic VES, 7.1% with paired VES and 3.6% with ventricular tachycardia. There was no preferential VES pattern. Mean duration of VES was 0.15 s. There were no VES with a prematurity index of less than 1. Extending ECG monitoring to 96 hours (10 persons without heart disease) did not reveal any more significant VES, but registering for less than 24 hours definitely underestimated the frequency of VES in persons without heart disease. In those without angiographic evidence of heart disease 36% had complex and 5.4% frequent VES. Complex arrhythmias, however, are rare in the individual subject and generally not accompanied by frequent VES. Frequent complex arrhythmias or both frequent and complex arrhythmias, as well as VES with a prematurity index less than 1, are suggestive of organic heart disease.

Arrhythmia profiles and heart rates, obtained by 24-hour ECG monitoring, were analysed in 48 patients with hyperthyroidism before (T3 level: 331 +/- 108 ng/100 ml, heart rate: 95 +/- 13/min), during (T3 level: 202 +/- 98 ng/100 ml, heart rate: 85 +/- 11/min) and after (T3 level: 149 +/- 41 ng/100 ml, heart rate: 79 +/- 9/min) antithyroid treatment. 50 persons in whom organic heart disease has been excluded by invasive and noninvasive tests served as controls. Only 6% of patients had repetitive ventricular arrhythmias (Lown group IV) before treatment (controls: 4%; P greater than 0.05). Supraventricular extrasystoles were common both before and after treatment (P less than 0.001), especially in elderly patients. The number of patients with supraventricular tachycardias decreased in the course of treatment from eleven to two. There was a clear correlation between the T3 level and nocturnal heart rate (r = 0.74; P less than 0.001). A day-night difference in heart rate (a ratio of greater than or equal to 1.10) was present in 43 patients and higher than in the controls (P less than 0.001). Thus with respect to ventricular arrhythmias hyperthyroid patients had a normal profile, but a marked tendency towards supraventricular arrhythmias which was partly age-related. Antithyroid treatment affected only the incidence of supraventricular tachycardias, while day-night differences in heart rate remained unchanged.

Maternal cardiac arrhythmias are frequently observed during pregnancy and they can range from benign, clinically-irrelevant isolated premature beats to debilitating supraventricular and ventricular tachycardia. However, malignant ventricular tachyarrhythmias, such as sustained ventricular tachycardia, ventricular flutter and ventricular fibrillation, are relatively rare particularly in women without the presence of an organic heart disease.

This study evaluated the effects of heart rate (HR) on brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABI). Thirty-two patients without significant organic heart disease underwent elective cardiac catheterization or electrophysiologic study, and were then enrolled in right atrial pacing (RAP; 11 men, 9 women; aged 48 ∓15 years) or right ventricular pacing (RVP; 6 men, 6 women, aged 45 ∓13 years) studies. Three different HR levels (90, 100, and 110 beats per minute) were paced in random order. By stepwise, multiple linear regression analysis, age, systolic blood pressure (SBP), and pulse pressure (PP) correlated positively with baseline baPWV. In the RAP group, as HR increased, baPWV and left brachial diastolic blood pressure increased significantly (p ≤0.015), while ABI, left ankle SBP, left brachial PP, and left ankle PP decreased significantly (p ≤0.013). In the RVP group, as HR increased, baPWV also increased significantly (p=0.001), while ABI, left ankle SBP, and PP decreased significantly (p ≤ 0.034). Values of baPWV and ABI may be influenced by HR in young and middle-aged patients without significant organic heart disease. When these values are used to evaluate and follow up cardiovascular risk in patients, HR changes should be considered.

Currently, the transmitral flow (TMF) pattern is routinely recorded as the first step in the assessment of left ventricular diastolic function. In young, healthy subjects, it is known that the early diastolic flow (E wave) of TMF is larger than the late diastolic flow (A wave). The E/A ratio then gradually decreases with age. This change in the pattern of TMF can be expected to occur earlier in patients with systemic hypertension than in healthy subjects. However, data pertaining to this matter are limited for Japanese patients. The purpose of this study was to investigate the changing pattern of TMF with age in Japanese patients with systemic hypertension. A database of echocardiographic examination reports was surveyed. A total of 553 patients with systemic hypertension (HT group) and 394 patients without hypertension or organic heart disease (control group) were included in this study. The patients were subdivided according to age, after which the E/A ratio was compared for different patient categories and age groups. The E/A ratio gradually decreased with age in the control group, and the mean value of E/A was

A 12-year-old girl with occasional symptoms of chest discomfort was diagnosed with ventricular tachycardia on cardiac evaluation. No evidence of organic heart disease was apparent, but a laboratory evaluation revealed hypomagnesemia. Ventricular tachycardia disappeared after treatment with 200 mg/day of oral magnesium hydroxide, and no further chest discomfort was reported. In addition to routine cardiac evaluation for arrhythmia, serum magnesium levels should be checked in patients with suspected idiopathic benign ventricular tachycardia. Treatment with oral magnesium is a physiologic therapy and should be considered for patients with ventricular tachycardia due to hypomagnesemia.

Heart rate turbulence (HRT) has been described as a predictor of high-risk patients with cardiac diseases. The purpose of this study is to determine how the degree of prematurity of a ventricular premature beat (VPB%) and retrograde ventriculoatrial (VA) conduction of VPBs affect HRT. We studied 30 patients without organic heart disease. We calculated turbulent slope (TS) and turbulent onset (TO) from VPBs induced by programmed stimulation from the right ventricular apex. TS was inversely and TO was positively correlated to VPB%. Without retrograde VA conduction of VPBs, TS was inversely and TO was positively correlated to VPB%. In VPBs with retrograde VA conduction, there were no significant correlations between TO and TS with VPB%. In conclusion, TS and TO calculated from VPBs with different degrees of prematurity varied widely. Both VPB% and characteristics of retrograde VA conduction may affect HRT.

Catecholamine-induced polymorphic ventricular tachycardia (CPVT), a rare disease that occurs in subjects without obvious organic heart disease, is characterized by episodes of syncope, seizures, or sudden death in response to physiologic or emotional stress. This report reviews evidence that a missense mutation in the CASQ2 gene is associated with autosomal-recessive CPVT.

The comparative usefulness of 10 min of beat-to-beat 12-lead QT dispersion (QTd) and QT interval variability index (QTVI) analysis for identifying patients with organic heart disease (OHD) at risk for ventricular arrhythmias was assessed in 86 subjects: 54 had OHD without a history of ventricular arrhythmias, 15 had OHD with documented ventricular tachycardia, and there were 17 controls. The following parameters were analyzed among the groups: (1) the average QTd (mean QTd), (2) the difference between the maximum and minimum QTd observed over the recording time (QTd variation), (3) the maximum difference of QTd between consecutive beats (QTd maximum), (4) the QTd standard deviation (QTd variability), and (5) QTVI, calculated in lead I or II according to an established formula: log 10 [(QTv/QTm2) / (HRv/HRm2)]. All the analyzed parameters were significantly increased in the patients with and without ventricular tachycardia when compared with the controls. QTd variation, QTd maximum and QTd variability were the only variables that remained significantly increased in the group of patients with documented ventricular tachycardia, compared with those without arrhythmia. Thus, beat-to-beat fluctuations of both the QT interval and QTd may be markers of temporal electrical instability in patients with OHD. (Circ J 2003; 67: 125 - 128)

Activations in Permanent Atrial Fibrillation.Introduction: Activation patterns during permanent atrial fibrillation (AF) in patients with organic heart diseases are unclear. Methods and Results: We studied six patients with permanent AF and organic heart diseases undergoing surgery. The duration of AF averaged 4.9 ± 7.6 years. Computerized epicardial mappings of the right atrial (RA) free wall and the left atrial (LA) posterior wall were simultaneously performed with 224 bipolar electrodes at 3-mm spatial resolution. In the RA, large wavefronts and conduction blocks were frequently observed. The lines of block correlated with the crista terminalis and large pectinate muscles. In contrast, the LA had rapid repetitive activities originated from corners of the electrode plaque, near the four pulmonary veins (PVs). On average, 2.8 ± 1.2 sites of rapid repetitive activities were identified per patient. They activated continuously, intermittently, or alternately during AF. The mean activation cycle length in the RA (196 ± 22 msec) was significantly longer than that in the LA (179 ± 26 msec; P = 0.004). The maximum dominant frequency in the LA was higher than that in the RA (6.41 ± 1.18 Hz vs 5.66 ± 0.55 Hz; P = 0.049). The maximum dominant frequency was consistently located in areas with rapid repetitive activations near the PVs. Conclusion: During human permanent AF associated with organic heart diseases, the activation cycle length was shorter in the LA posterior wall than in the RA free wall. Rapid repetitive activities are consistently observed in the LA posterior wall, at or near the PVs.

This case report presents a 27-year-old man with paroxysmal tachycardia, which could not be provoked by a submaximal but only by a maximal exercise test. The provoked tachycardia was diagnosed as ventricular on the basis of fusion beats. During a follow-up period of 5 years the patient has not had any more attacks of dizziness or syncope, and he still is without signs of organic heart disease.