Electrocardiography – ABC CARDIOL

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ORIGINAL ARTICLE

Prognostic Value of QTc Interval and Other Ventricular Repolarization Parameters in Acute Stroke

Catarine Benta Lopes dos Santos et al. Sérgio Ferreira de Ferreira Filho Marcelo Angst Anderson Donelli da Silveira … Sheila Cristina Ouriques Martins Mauricio Pimentel

Abstract

Background:

The electrocardiogram (ECG) is routinely used in stroke evaluation, although interactions within the brain–heart axis remain incompletely understood. The prognostic relevance of the QTc interval and other ventricular repolarization markers has gained increasing interest in stroke populations.

Objectives:

To evaluate the association of QTc interval, QTc dispersion (QTc-d), Tpeak–end interval (Tp-e), and Tp-e/QTc ratio with neurological disability and in-hospital mortality in acute stroke.

Methods:

This retrospective cohort included patients admitted with acute stroke between January 2018 and April 2020. QTc was analyzed as both a continuous and categorical variable, using a cutoff of 480 ms. Functional disability was assessed using the modified Rankin Scale (mRS) and categorized as no disability (mRS ≤ 2) or disability (mRS > 2). Sample size calculation indicated a minimum of 482 patients (85% power; 5% significance), based on functional outcome differences between prolonged and normal QTc. A 5% significance level was used for all analyses.

Results:

A total of 565 patients were included (50.1% male; mean age 65 ± 13 years). Of these, 280 (49.6%) had mRS > 2, and 69 (12.5%) died during hospitalization. Higher QTc values were associated with worse neurological outcomes in univariable (HR 1.01; 95% CI, 1.00–1.01; p 480 ms was also associated with disability in univariable (HR 2.43) and multivariable models (HR 2.67). QTc was not associated with in-hospital mortality.

Conclusion:

QTc prolongation, particularly QTc > 480 ms, was independently associated with unfavorable neurological outcomes.

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Editorial

AI-Enhanced ECGs for the Diagnosis of HFpEF: A Promising Frontier, But Not Yet a Standalone Solution

Humberto Villacorta

Heart Failure with preserved Ejection Fraction (HFpEF) is among the most challenging syndromes in contemporary cardiology. Despite accounting for nearly half of all heart failure cases, HFpEF remains chronically underdiagnosed and is associated with significant morbidity and mortality.^, The diagnosis of HFpEF is challenging and relies on clinical history, natriuretic peptide measurements, and echocardiography. Diagnostic scores have been developed that integrate these three key elements.^, Echocardiography is indispensable for identifying structural and functional criteria, but its availability and cost make population-level screening impractical in many healthcare systems. In addition, in many places, a comprehensive echocardiogram is not performed. Likewise, natriuretic peptides are not always available. Therefore, new solutions to facilitate diagnosis are welcome.

In this context, the systematic review and meta-analysis presented in this issue of International Journal of Cardiovascular Sciences, provide important insights into an increasingly discussed alternative: Artificial Intelligence-enhanced Electrocardiography (AI-ECG). Drawing from more than 170,000 patients across three observational studies, the authors report a pooled sensitivity of 0.89, specificity of 0.80, and an AUC of 0.89 for AI-ECG in detecting HFpEF. These findings suggest that deep learning models can extract subtle electrical signatures associated with diastolic dysfunction – signals that may be visually imperceptible on standard ECGs. The appeal is clear: the ECG is universal, inexpensive, rapid, and deeply embedded in clinical workflows. If Artificial Intelligence could reliably identify patients requiring echocardiographic confirmation, screening strategies might be revolutionized.

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Original Article

Acute Coronary Syndrome Patient Profile in Emergency Department: A cross-sectional study

Riza Fikriana et al. Al Afik Randy Eka Prasetya

Abstract

Background:

Acute Coronary Syndrome (ACS) remains one of the leading causes of high morbidity and mortality worldwide. Psychological factors are considered important contributors to increasing recurrence rates in patients.

Objective:

This study aimed to analyze the association between stress, chest pain complaints, electrocardiographic changes, and cardiac enzyme levels.

Methods:

A cross-sectional design was employed. A sample of 105 ACS patients presenting to the hospital emergency department was selected using an accidental sampling technique. Variables measured included stress scores, chest pain, electrocardiographic findings, troponin, and CK-MB levels. Data were analyzed using the Spearman rank test and linear regression, with a significance level set at p < 0.05.

Results:

Stress scores were significantly associated with chest pain (p < 0.001), electrocardiographic changes (p < 0.001), troponin levels (p < 0.001), and CK-MB levels (p < 0.001). ECG findings showed that most STEMI patients (68.9%) experienced severe pain. Linear regression analysis indicated that troponin and CK-MB levels were significantly influenced by chest pain (p < 0.001).

Conclusions:

Stress is positively correlated with chest pain in ACS patients and is reflected in ECG changes and elevated cardiac enzymes (troponin and CK-MB).

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Original Article

Diagnostic Performance of Artificial Intelligence-Driven Electrocardiogram Algorithms in Detecting Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Gustavo Barbosa David et al. Nicolas Ramos Ramon Huntermann Juan Peres de Oliveira … Maria Eduarda Molinari Caroline de Oliveira Fischer Bacca

Abstract

Background:

Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent syndrome associated with substantial morbidity and mortality. Accurate diagnosis is often challenging and costly. Recently, artificial intelligence-based electrocardiogram (AI-ECG) algorithms have emerged to make the diagnosis of HFpEF less expensive and more accessible. However, there is a lack of data regarding their accuracy.

Objective:

We aimed to conduct a systematic review and meta-analysis to evaluate the diagnostic performance of AI-ECG algorithms in detecting HFpEF.

Methods:

We searched PubMed, Embase, and Cochrane databases for studies evaluating AI-ECG algorithms in diagnosing HFpEF. We extracted true-positive, true-negative, false-positive, and false-negative events to estimate pooled sensitivity, specificity with 95% confidence intervals (CI), and area under the curve. Statistical analysis was performed using R under a random-effects model. Heterogeneity was assessed with I² statistics.

Results:

We included three studies comprising 171,073 patients (66.86% with HFpEF), in which an AI-ECG was evaluated alongside echocardiography, with a left ventricular ejection fraction of ≥ 50%. The patients’ mean age was 65.86 ± 4.5 years, and 48.12% were male. AI-ECG algorithms demonstrated a sensitivity of 0.89 (95% CI: 0.64 to 0.97), specificity of 0.80 (95% CI: 0.65 to 0.89), and an area under the receiver operating characteristic curve of 0.89 (95% CI: 0.85 to 0.92).

Conclusion:

AI-ECG algorithms demonstrate moderate to high sensitivity, specificity, and accuracy in diagnosing HFpEF, supporting their potential for routine screening and early detection.

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Brief Communication

S-Wave Amplitude in Lead V3 Identifies Other Electrocardiography Criteria of Left Ventricular Hypertrophy

Bernardo Augusto Silveira Corrêa et al. Gabriel Pinheiro Soares Alencar e Silva Felipe Campelo de Miranda Marcio Henrique de Jesus Oliveira … Gabriel Scarpioni Barbosa Victor Hudson de Lacerda Borges José Nunes de Alencar

Introduction

Electrocardiographic (ECG) criteria for detecting left ventricular hypertrophy (LVH) are integral to clinical decision-making. Although these methods are quick to apply, low cost, and widely available, their sensitivity is modest. Multiple voltage-based criteria exist, such as the Sokolow-Lyon, Cornell, and Peguero-Lo Presti criteria, but accurate use often requires familiarity with several indices and can be time-consuming for trainees. Simple, reliable markers could improve the efficiency and consistency with which ECGs are flagged as possibly indicating LVH.

The S-wave amplitude in lead V3 (SV3) is a plausible single-lead marker. It is a component of the Cornell criterion (SV3 + RaVL), and it is closely related to the Peguero-Lo Presti criterion (SV4 plus the deepest precordial S). Because the largest precordial S wave often occurs in V3, a single SV3 measurement could serve as a rapid screening tool to identify the presence of established LVH criteria, especially for those with less experience interpreting ECGs.

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Original Article

Left Ventricular Hypertrophy on Electrocardiography and Chronic Kidney Disease: A Case–Control Pilot Study

Nabil Hajar et al. Nabila Nuralya Joveazhari Shofa Chasani Zulfachmi Wahab … Galih Prakasa Adhyatma Indira Aura Balqis Zeidan Ahmad Fahdalhaq Bintang Adhiyoso Wicaksono

Abstract

Background:

Chronic kidney disease (CKD) is a condition characterized by abnormalities in kidney structure or function lasting more than 3 months. CKD is known to increase the risk of cardiovascular events, which may be predicted by electrocardiography (ECG) abnormalities, such as left ventricular hypertrophy (LVH). ECG is widely used in under-resourced health care settings due to its practicality and accessibility.

Objective:

This study aimed to analyze the relationship between LVH and CKD using ECG.

Methods:

This analytical observational study used a case–control design. The case group included patients diagnosed with CKD, while the control group consisted of patients presenting with signs and symptoms suggestive of CKD but without a confirmed diagnosis. Each group included 35 participants. Simple random sampling was used for the case group, and stratified random sampling for the control group. ECG examinations were performed, and measurements were taken using calipers in millimeters (mm). The Sokolow–Lyon criteria were applied to identify LVH. Data were analyzed using an independent t-test, with statistical significance set at p < 0.05.

Results:

The Sokolow–Lyon score was significantly higher in the case group than in the control group (p = 0.03).

Conclusion:

There is a significant association between LVH, as identified on ECG, and CKD. These findings may assist health professionals in resource-limited settings, where access to ECG is restricted.

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Case Report

ECG's AVR ST elevation Analysis by Perfusion Scintilography in the Context of Myocardial Ischemia

Miriana Basso Gomes et al. Carolina Feijó Bombana Felipe C. Fuchs

Introduction

The presence of ST-segment elevation in two or more contiguous leads indicates a current subepicardial lesion that often requires early intervention, either by angioplasty or thrombolytic therapy.^, ST elevation, only in aVR, may also indicate the presence of an acute infarction. This finding was first made by Wellens et al. However, this is not always true, and physicians should be aware of the details surrounding changes in Right Vector amplification (aVR).

The medical literature has a wide range of articles reporting on the association between ST elevation in aVR during exercise testing and left main coronary artery injury.^– However, this concept began at a time when fewer imaging tests and catheterizations were performed. Altered stress tests are a common indication of myocardial scintigraphy, which is why the Nuclear Medicine laboratory is the perfect place to perform this type of analysis. There is now evidence that aVR elevation in this context may not indicate coronary lesions and may be present, for example, in patients with aortic stenosis, hypertrophy and hypoxia..^– Since these are stress tests, it is important to analyze the heart rate in which the aVR elevation occurs as well as the pattern of the other leads.

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Original Article

Electrocardiographic Analysis of Ventricular Repolarization in Patients With Psoriasis: A Cross-Sectional Study

Guilia Bevilacqua Schmitz et al. Raíssa Massaia Londero Chemello Marco Lumertz Saffi Luciane Prado de Vargas Diego Chemello

Abstract

Background

Psoriasis is a chronic inflammatory disease. Cardiovascular diseases, including arrhythmias, tend to occur more frequently in these patients.

Objective

This study aimed to investigate new electrocardiographic markers for assessing ventricular repolarization in outpatients with psoriasis in a tertiary center in Brazil.

Methods

This work is a cross-sectional study, which selected outpatients with psoriasis undergoing follow-up in a tertiary dermatology service in southern Brazil. The controls were selected from a private outpatient clinic. All the electrocardiogram (ECG) analyses were performed by one certified electrophysiologist. Comparative statistical tests and Spearman’s correlation analysis were used. Measures with statistically significant differences in the univariate analysis were taken to the multivariate analysis (Generalized Linear Model – Poisson Regression with age adjustment). A P<0.05 value was considered statistically significant for all analyses.

Results

A total of 130 individuals were evaluated, mean age of 53.1±15.1 years. The univariate analysis showed no difference in Corrected QT interval (QTc) between the groups, considering 411.2±21.2 ms in the psoriasis group (PG) versus 412.8±25.2 ms in the control group (CG) (p = 0.694). The median values of Corrected QT dispersion (QTdisc) were lower in the PG as compared to the CG, 15.7 ms (IQR 11.5–24.2 ms) versus 39.8 ms (Interquartile Range, IQR, 32.8–46.6 ms), respectively (p<0.001). For peak-to-end interval of the T wave (Tp-e) and Tp-e/QTc values, the mean values were also lower in patients with psoriasis. For Tp-e, the mean values in the PG were 91.7±11.6 ms versus 96.0±9.2 ms in the CG (p = 0.024). For The Tp-e/QTc, the mean values in the PG were 0.22±0.03 versus 0.23±0.03 in the CG (p = 0.024). The multivariate analysis, adjusted for age, QTdis, Qtdisc, Tp-e, and Tp-e/QTc, remained independently lower in patients with psoriasis.

Conclusion

The evaluation of ventricular repolarization parameters in a sample of outpatients with psoriasis in southern Brazil showed that ventricular repolarization values were generally lower when compared to controls. No significant correlation was found between disease activity and ventricular repolarization parameters.

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Review Article

Computer-Interpreted Electrocardiograms: Impact on Cardiology Practice

Shyla Gupta et al. Anthony H. Kashou Robert Herman Stephen Smith … Adam May Ana G. Múnera Echeverri Mildren Del Sueldo Ana C. Berni Juan Farina Sebastian Garcia-Zamora Adrian Baranchuk

Abstract

In the realm of modern cardiology, the integration of computer-interpreted electrocardiograms (CI-ECGs) has marked the beginning of a new era of diagnostic precision and efficiency. Contemporary electrocardiogram (ECG) integration systems, applying algorithms and artificial intelligence, have modernized the interpretation of heart rhythms and cardiac morphology. Due to their ability to rapidly analyze and interpret ECG recordings CI-ECGs have already profoundly impacted clinical practice. This review explores the evolution of computer interpreted ECG technology, evaluates the pros and cons of current automatic reporting systems, analyzes the growing role of artificial intelligence on ECG interpretation technologies, and discusses emerging applications that may have transformative effects on patient outcomes. Emphasis is placed on the role of ECGs in the automatic diagnosis of occlusion myocardial infarctions (OMI). AI models enhance accuracy and efficiency in ECG interpretation, offering insights into cardiac function and aiding timely detection of concerning patterns for accurate clinical diagnoses. The shift to AI-driven diagnostics has emphasized the importance of data in the realm of cardiology by improving patient care. The integration of novel AI models in ECG analysis has created a promising future for ECG diagnostics through a synergistic fusion of feature-based machine learning models, deep learning approaches, and clinical acumen. Overall, CI-ECGs have transformed cardiology practice, offering rapid, accurate, and standardized analyses. These systems reduce interpretation time significantly, allowing for quick identification of abnormalities. However, sole reliance on automated interpretations may overlook nuanced findings, risking diagnostic errors. Therefore, a balanced approach in integrating automated analysis with clinical judgment is necessary.

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Editorial

Lessons Learned from Cardiac Complications of COVID-19 and the Value of the Electrocardiogram

Javier César Barcos et al. Ana G. Múnera Echeverri Adrian Baranchuk

Since the declaration of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, much has been learned about the epidemiology, pathophysiology, clinical characteristics, and predictors of poor prognosis. Furthermore, cardiovascular implications have emerged as significant contributors to morbi-mortality. In this sense, the recently published work of Galindes-Casanova et al. reinforces existing evidence on acute COVID-19 infection, cardiac complications, and electrocardiogram (ECG) manifestations.

By the end of 2023, COVID-19 had already caused more than 770 million confirmed cases and 7 million deaths worldwide. The disease is characterized by an acute phase that lasts up to 4 weeks. Symptoms and complications could occasionally extend up to several months, called post-acute COVID-19. The main clinical manifestations are fever and respiratory symptoms. Less commonly, extrapulmonary involvement can also occur, involving different organs and systems secondary to direct and indirect viral damage, the latter through the dysregulation of the immune system, a hyperinflammatory state, endothelial dysfunction, coagulopathy, a prothrombotic state, and an imbalance of the renin-angiotensin-aldosterone system. These complex mechanisms, added to the injury of different organs and the adverse effects of COVID-19 treatments, favor the development of cardiac complications ().

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Original Article

Evaluation of Symptomatic and Asymptomatic Outpatients in the Post-COVID-19 Period With Electrocardiographic Ventricular Depolarization and Repolarization Parameters

Muammer Karakayalı et al. Inanc Artac Dogan Ilis Timor Omar … Mehmet Altunova Ezgi Guzel İbrahim Rencüzoğulları Yavuz Karabağ

Abstract

Background

A recently identified viral illness called coronavirus disease 2019 (COVID-19) is spreading quickly. Numerous cardiovascular issues such as arrhythmias and electrocardiogram (ECG) alterations have been linked to COVID-19.

Objective

In this investigation, we compared ECG indicators of depolarization and repolarization heterogeneity between symptomatic individuals who complained of palpitations and chest discomfort following COVID-19 and those who did not.

Methods

In this prospective case-control study, 56 post-COVID-19 patients who did not have any symptoms of chest discomfort or palpitations were included in the control group and compared with a study group comprising 73 post-COVID-19 patients who presented at the outpatient clinic with complaints of chest pain and palpitation. Electrocardiographic (ECG) measures were used to assess depolarization and repolarization of the ventricles. These measures included the Tpeak-Tend (Tp-e) interval, QT dispersion (QTd), Tp-e/QT ratio, Tp-e/QTc ratio, frontal QRS-T (fQRS-T) angle, and fragmented QRS (FQRS). Two cardiologists recorded the patients’ ECG data. A statistically significant result was defined as a p value less than 0.05.

Results

The results of multivariate analysis including FQRS, Tp-e interval, Tp-e/QT, and Tp-e/cQT showed that presence of FQRS (OR: 6.707, 95% CI: 1.733-25.952; p = 0.006) was an independent predictor of symptomatic post-COVID -19 patients.

Conclusion

In our study, FQRS was found to be significantly higher in symptomatic post-COVID-19 patients than in non-symptomatic post-COVID-19 patients, while Tp-e interval was found to be lower.

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Original Article

Electrocardiographic Findings Among Asymptomatic Adults With Haemophilia

Ricardo Mesquita Camelo et al. Camila Caram-Deelder Carlos Guilherme Piscoya Roncal Bruna Pontes Duarte … Marilia Carolina Braga de Moura Neuza Cavalcanti de Moraes Costa Iris Maciel Costa Ana Maria Vanderlei Tania Maria Rocha Guimaraes Samantha Gouw Suely Meireles Rezende Johanna van der Bom

Abstract

Background:

People with haemophilia (PwH) are living longer. Therefore, they can develop atherosclerotic cardiovascular disease (ASCVD). Electrocardiogram (ECG) alterations may be a sign of initial ASCVD before the occurrence of symptoms.

Objective:

To describe the prevalence of resting ECG alterations among PwH adults asymptomatic for ASCVD.

Methods:

PwH aged ≥ 30 years without previous ASCVD events were considered for the analysis. Resting ECG traces were analysed according to international reference values and the Brazilian Longitudinal Adult Health Study (ELSA-Brasil) results for asymptomatic Brazilian men. Based on the established normal values and using the QT index, we further described the altered ECGs as minor or major changes, according to the Minnesota Code. Differences between prevalences were evaluated by Pearson’s χ2 test. Differences between medians were evaluated by the Mann-Whitney U test. A p-value < 0.05 was accepted as statistically significant.

Results:

A total of 64 PwH were included in the study. Median age was 44 years (interquartile range 35-52). Most patients had haemophilia A (81%) and 47% were severe. The prevalence of obesity, systemic arterial hypertension (SAH), diabetes mellitus (DM), and dyslipidaemia were 16%, 56%, 14%, and 72%, respectively. All the PwH had sinus rhythm, except for one, who had an implanted pacemaker due to idiopathic third-degree atrioventricular block. Altered ECGs were found in 25% and 30% of PwH, according to established criteria and ELSA-Brasil criteria, respectively. Major changes were found in eight (13%) PwH according to the Minnesota Code, including two ECGs with ischaemia-like wall inactivity.

Conclusions:

The prevalence of altered ECG varied from 25% to 30% among asymptomatic PwH.

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Original Article

Frequent Cardiovascular Manifestations Associated With SARS Cov-2 Infection: Experience at a Tertiary Hospital In Cali, Colombia

Duvan Arley Galindes-Casanova et al. Edith Norela Benitez-Escobar Luis Álvaro Melo-Burbano Nelson Eduardo Murillo-Benitez … Juan Carlos Avila-Valencia Jorge Enrique Daza-Arana

Abstract

Background:

Coronavirus disease 2019 (COVID-19) mainly affects the respiratory system, while the most common extrapulmonary complication of COVID-19 is cardiovascular involvement.

Objective:

To identify the frequency of electrocardiographic changes and cardiac arrhythmias in patients hospitalized with COVID-19 infection.

Methods:

This was a cross-sectional study, including patients aged >18 years with diagnosis of severe acute respiratory syndrome coronavirus 2 infection in a high-complexity hospital in Santiago de Cali, Colombia, from March to September 2020. A descriptive analysis with an analytical component and multiple logistic regression analysis were performed; all estimates were established with a 95% confidence level (CI) and a 5% significance level.

Results:

This study included 183 individuals; of whom 160 were considered for electrocardiographic analysis, 63% of which evidenced significant findings, the most frequent being sinus tachycardia (29.4%). The frequency of myocardial injury was 21.9% and was more common among non-survivors than among survivors (41.7% vs. 12.2%, p < 0.001). Myocardial injury was also significantly more common in patients who presented electrocardiographic findings than those who did not (26.5% vs. 12.1%, p = 0.032) and in those who required intensive care admission (31.8% vs 10.5%, p < 0.001). The strongest mortality-associated factor was the need for mechanical ventilation — odds ratio (OR), 9.14; 95% confidence interval, 3.4–24.5.

Conclusions:

Electrocardiographic findings in patients with COVID 19 are frequent, including newly diagnosed arrhythmias, justifying the use of cost-effective tools for the initial approach and follow-up of this affected population. Worse outcomes depend on factors such as invasive mechanical ventilation, comorbidities, age, and superinfection.

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Original Article

Evaluation of Frontal QRS-T Angle in Patients with Coronary Artery Ectasia

Mehmet Zulkuf Karahan et al. Adem Aktan Tuncay Güzel Fethullah Kayan Serhat Günlü

Abstract

Background:

Coronary artery ectasia (CAE) is defined by focal enlargement of the coronary artery exceeding 1.5 times the adjacent normal segment. CAE can often cause arrhythmias, heart failure, sudden death, and myocardial ischemia. Ischemia due to microvascular dysfunction may be responsible for the ventricular heterogeneity in CAE.

Objectives:

The aim of our study was to evaluate the frontal QRS-T angle in patients with CAE.

Methods:

Our study included 55 patients with CAE and 50 individuals in the control group. Demographic characteristics and electrocardiographic parameters were compared between the two groups. Categorical variables were compared using the chi-square test. Continuous variables were compared using unpaired Student’s t-test. P values < 0.05 were considered statistically significant. The frontal QRS-T angle was calculated from 12-lead electrocardiograms (ECGs) using the automatic report from the electrocardiography machine.

Results:

The average age of patients with CAE was 63.2 ± 3.4 years, with 18 women among them. The control group had an average age of 61.1 ± 3.2 years, with 28 women included. There was no significant difference in demographic parameters between the two groups. Compared to the control group, patients with CAE had significantly wider frontal QRS-T angle (p < 0.001), as well as longer QTmax duration, p = 0.002; Tp-Te interval, p = 0.02; and QT dispersion (QTd), p = 0.04.

Conclusion:

The frontal QRS-T angle can be calculated easily and time-efficiently using surface electrocardiography. In this study, we showed for the first time that the frontal QRS-T angle was significantly increased in patients with CAE.

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Original Article

Implementation of a Telecardiology Service in a Health Unit in the City of Porto Alegre, Brazil: A Pilot Study

Francieli Giachini Esmerio et al. Silvia Goldmeier Eduardo Costa Duarte Barbosa Luis Marcelo Segredo … Rodolfo Silva Maria Claudia Irigoyen Bruna Eibel Patricia Oliveira Dias

Abstract

Background:

The implementation of Telecardiology in primary care in the city of Porto Alegre, Brazil, is a viable and promising strategy. It would decrease the distance between patient and specialized professional services by reducing unnecessary referrals and improving the quality of primary care and satisfaction of patients and health professionals.

Objective:

To implement a Telecardiology service and assess user satisfaction using the CARDIOSATIS scale.

Methods:

This was a pilot study developed by a partnership between the Institute of Cardiology and the Telehealth Center of Rio Grande do Sul. The study was carried out at Eri Flores-Vila Vargas health center in the city of Porto Alegre, from May to October 2019, and included 21 patients attending the health center. The descriptive analysis of data was performed using the SPSS program (Statistical Package for the Sciences) version 23. Data normality was checked using the Kolmogorov-Smirnov test. Statistical significance was set at 10%.

Results:

Mean age of participants was 43.8 ± 16.1 years. The most common risk factors in the sample were physical inactivity (81%) and smoking (43%). Most patients had normal electrocardiogram (ECG) readings. The time elapsed from the performance of the ECG test, transmission of the ECG traces to Telehealth, and return of the final ECG report to the health center was 0-7 days. The CARDIOSATIS scale revealed a high prevalence of “very satisfied” users for the general satisfaction domain, and only 14.3% of patients were dissatisfied with their health.

Conclusions:

Telecardiology reduced the distance between patient and the specialized professional, with a high level of patient and health professional satisfaction. Our study can serve as a basis for the implementation of a telecardiology network in the city of Porto Alegre in the future.

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Case Report

ST-Elevation in a Patient with Acute Chagas Disease

Guilherme Dantas Campos Pinto et al. José Henrique Martins Pimentel Maria das Neves Dantas da Silveira Barros Carolina de Araújo Medeiros … Cristina de Fátima Velloso Carrazzone Silvia Marinho Matins Wilson Alves de Oliveira Júnior

Introduction

Chagas disease (CD) is classically reported as a neglected disease of vectorial transmission and is endemic in 21 Latin America countries. While it has long been stigmatized as a mere tropical pathology, CD has recently gained prominence, since new means of infection have become more common, including blood transmission and consumption of food contaminated with feces from a given vector. Taking immigration into account, the disease is currently spreading beyond the limits of endemic areas and has become a global issue.

Many acute CD (ACD) outbreaks have been reported since 1965, by oral accidental routes, in Brazil and in other Latin American countries.^, That phase of the disease is, in general, asymptomatic or presents unspecific symptoms, such as fever, fatigue, myalgia, facial and lower limb edema, abdominal pain, diarrhea, vomiting, and dyspnea. One to five percent of the patients develop severe disease, most commonly perimyocarditis, acute heart failure, and/or meningoencephalitis, with a mortality rate of around 5%.^,

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Original Article

The Association between Tp-e interval, Tp-e/QT , and Tp-e/QTc Ratios and Coronary Artery Disease Spectrum and Syntax Score

Serkan Kahraman et al. Ali Dogan Gokhan Demirci Arda Guler … Ali Kemal Kalkan Fatih Uzun Nuri Kurtoglu Mehmet Erturk Mehmet Emin Kalkan

Abstract

Background

Coronary artery disease (CAD) causes electrical heterogeneity on ventricular myocardium and ventricular arrhythmia due to myocardial ischemia linked to ventricular repolarization abnormalities.

Objective

Our aim is to investigate the impact of increased level of CAD spectrum and severity on ventricular repolarization via Tp-e interval, Tp-e/QT and Tp-e/QTc ratios.

Methods

127 patients with normal coronary artery (group 1), 129 patients with stable CAD (group 2) and 121 patients with acute coronary syndrome (group 3) were enrolled. Tp-e interval, Tp-e/QT and Tp-e/QTc ratios were evaluated as well as baseline demographic and clinical parameters. Kruskal-Wallis one-way ANOVA test was used for comparing quantitative variables with abnormal distribution while One-Way ANOVA test was used for comparing the means between groups with normal distribution. Tukey HSD and Welch tests were used for subgroups analyses with normal distribution. Spearman analysis was used to evaluate the correlation between clinical variables and repolarization markers. A p-value < 0.05 was considered statistically significant.

Results

Tp-e interval [66(50-83), 71(59-82) and 76(64-86); group 1,2 and 3 respectively, p<0.001], Tp-e/QT (0.170.02, 0.180.01 and 0,190.01; group 1,2 and 3 respectively, p<0.001) and Tp-e/QTc (0.150.02, 0.160.02 and 0.170.02; group 1,2 and 3 respectively, p<0.001) ratios were found to be associated with increased level of CAD spectrum. Syntax score was positively correlated with Tp-e interval (r=0.514, p<0.001), Tp-e/QT (r=0.407, p<0.001), and Tp-e/QTc ratios (r=0.240, p<0.001).

Conclusion

Prolonged Tp-e interval and increased Tp-e/QT and Tp-e/QTc ratios were detected in the presence of CAD and especially in patients with acute ischemic syndromes. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Case Report

Sgarbossa Criteria in Left Bundle Branch Block in a Hypertensive Emergency, a Case Report

Yaser Mohammed Hassanain El Sayed

Abstract

Left bundle branch block and hypertensive emergency are very common conditions in clinical cardiovascular and emergency practice. Hypertensive emergency encompasses a spectrum of clinical presentations in which uncontrolled blood pressure leads to progressive end-organ dysfunction. Suspected acute myocardial infarction in the setting of a left bundle branch block presents a unique diagnostic and therapeutic challenge to the clinician. The diagnosis is especially difficult due to electrocardiographic changes caused by altered ventricular depolarization. However, reports on the use of the Sgarbossa’s criteria during the management of hypertensive emergency are rare. My current case is a hypertensive emergency patient with acute chest pain and left bundle branch block. Sgarbossa’s criteria were initially very weak and, over time, became highly suggestive of acute ST-segment elevation myocardial infarction. Interestingly, chest pain increased as the Sgarbossa’s diagnostic criteria were met. Here, we present a case of developing ST-segment elevation myocardial infarction with left bundle branch block that is indicating for thrombolytic therapy. Thrombolytic therapy was strongly indicated because of a higher developing of Sgarbossa criteria scoring. Thus, the higher Sgarbossa criteria scoring in the case was the only indication for thrombolytic. Therefore, how did Sgarbossa criteria developing during the course of the case to indicating the need for thrombolytic therapy?

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Case Report

Brugada Pattern, Brugada Phenocopy, What to Think?

José Luis Martins et al. Raquel Ferreira Jesus Viana José Santos

Introduction

Propafenone is a class 1 anti-arrhythmic medication with beta-adrenergic and calcium channel blocker properties.

Brugada syndrome (BrS) has a typical electrocardiographic pattern characterized by increased propensity for malignant ventricular arrhythmias and sudden death in patients with no structural heart disease.

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Original Article

Atrial activation during sinus rhythm in patients with rheumatic and non-rheumatic paroxysmal atrial fibrillation. Frequency-domain analysis using signal-averaged electrocardiography

Rogério Carregoza Dantas et al. Eduardo Corrêa Barbosa P. R. Benchimol-Barbosa Alfredo de Souza Bomfim Paulo Ginefra

OBJECTIVE: Using P-wave signal-averaged electrocardiography, we assessed the patterns of atrial electrical activation in patients with idiopathic atrial fibrillation as compared with patterns in patients with atrial fibrillation associated with structural heart disease. METHODS: Eighty patients with recurrent paroxysmal atrial fibrillation were divided into 3 groups as follows: group I – 40 patients with atrial fibrillation associated with non-rheumatic heart disease; group II – 25 patients with rheumatic atrial fibrillation; and group III – 15 patients with idiopathic atrial fibrillation. All patients underwent P-wave signal-averaged electrocardiography for frequency-domain analysis using spectrotemporal mapping and statistical techniques for detecting and quantifying intraatrial conduction disturbances. RESULTS: We observed an important fragmentation in atrial electrical conduction in 27% of the patients in group I, 64% of the patients in group II, and 67% of the patients in group III (p=0.003). CONCLUSION: Idiopathic atrial fibrillation has important intraatrial conduction disturbances. These alterations are similar to those observed in individuals with rheumatic atrial fibrillation, suggesting the existence of some degree of structural involvement of the atrial myocardium that cannot be detected with conventional electrocardiography and echocardiography.

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Original Article

Electrocardiographic abnormalities in neurological diseases

Rui Póvoa et al. Luciano Cavichio Ana Lúcia de Almeida Danielle Viotti … Celso Ferreira Luciane Galvão João Pimenta

OBJECTIVE: To evaluate electrocardiographic abnormalities in patients with neurologic diseases. METHODS: We studied 161 patients with neurologic disorders by analyzing the 12-lead electrocardiogram during the pathological process. An expert who did not know anything about the patients evaluated the traces. RESULTS: Neurological process included brain tumor (41%), stroke (27.3%), cerebral aneurysm (15.5%), subarachnoid hemorrhage (6.8%), subdural hemorrhage (5%), and head injury (4.4%). Electrocardiograms were normal in 61% of cases, and the most frequent abnormality was ventricular repolarization (23.7%). The presence of T waves (4.6%) and prolonged QT intervals (8.8%) was the most characteristic of brain injuries. CONCLUSION: We observed a lower incidence of electrocardiographic abnormalities than that described in the literature.

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Original Article

QRS Voltage-Duration Product in the Identification of Left Ventricular Hypertrophy in Spontaneously Hypertensive Rats

Ljuba Bacharova et al. Jan Kyselovic Jan Klimas

OBJECTIVE – Evaluation of the performance of the QRS voltage-duration product (VDP) for detection of left ventricular hypertrophy (LVH) in spontaneously hypertensive rats (SHR). METHODS – Orthogonal electrocardiograms (ECG) were recorded in male SHR at the age of 12 and 20 weeks, when systolic blood pressure (sBP) reached the average values of 165±3 mmHg and 195±12 mmHg, respectively. Age- and sex- matched normotensive Wistar Kyoto (WKY) rats were used as controls. VDP was calculated as a product of maximum QRS spatial vector magnitude and QRS duration. Left ventricular mass (LVM) was weighed after rats were sacrificed. RESULTS – LVM in SHR at 12 and 20 weeks of age (0.86±0.05 g and 1.05±0.07 g, respectively) was significantly higher as compared with that in WKY (0.65±0.07 g and 0.70±0.02 g). The increase in LVM closely correlated with the sBP increase. VDP did not reflect the increase in LVM in SHR. VDP was lower in SHR as compared with that in WKY, and the difference was significant at the age of 20 weeks (18.2mVms compared with 10.7mVms, p<0.01). On the contrary, a significant increase in the VDP was observed in the control WKY at the age of 20 weeks without changes in LVM. The changes in VDP were influenced mainly by the changes in QRSmax. CONCLUSION – LVM was not the major determinant of QRS voltage changes and consequently of the VDP. These data point to the importance of the nonspatial determinants of the recorded QRS voltage in terms of the solid angle theory.

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Original Article

Electrocardiographic Alterations in Patients Hospitalized with Leptospirosis in the Brazilian City of Salvador

Edilson Sacramento et al. Antonio Alberto Lopes Everaldo Costa Olaivio Lima Passos … Yara Aragão Costa Eliana Dias Matos

OBJECTIVE: To report the frequency and types of electrocardiographic alterations in patients with leptospirosis in the first 24 hours of hospitalization. METHODS: We analyzed the electrocardiograms of 157 patients admitted to the Hospital Couto Maia in the city of Salvador, in the State of Bahia, Brazil, from March 1998 to June 1999. The electrocardiograms were performed in the first 24 hours after hospital admission, independent of the clinical manifestations of the patients. RESULTS: The mean ± SD for patients’ age was 35.5± 13.7 (median = 32) years, and jaundice was present in 95.5% of them. Alterations in the electrocardiogram were detected in 68.2% (107/157) of the patients (95% confidence interval = 60.6% – 75.1%). Atrial fibrillation was the most frequent arrhythmia, occurring in 10.8% (17/157) of the patients. Other frequent findings were alterations in ventricular repolarization detected in 38.9% (61/157) of patients and first-degree atrioventricular block in 10.2% (16/157). The patients with atrial fibrillation were older and had higher levels of creatinine and aminotransferases. CONCLUSION: In this sample, approximately 2/3 of the patients had electrocardiographic alterations after hospital admission. Of the major arrhythmias, atrial fibrillation was the most frequent, and the patients with this arrhythmia had evidence of more severe disease. The relation between the presence and type of electrocardiographic alteration and the prognosis of leptospirosis is yet to be assessed.

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Original Article

Effects of propranolol on the QT dispersion in congestive heart failure

Evandro Tinoco Mesquita et al. Flávia Cristina Carvalho de Deus Cassia Regina Guedes Eduardo Reis Maia … César Gerson Pereira Subieta Humberto Villacorta Patrice Alessandra dos Santos Helena Cramer Valeria Battistella Amado dos Santos Luis José Martins Romeo

OBJECTIVE – Studies have shown that therapy with beta-blockers reduces mortality in patients with heart failure. However, there are no studies describing the effects of propranolol on the QT dispersion in this population. The objective of this study was to assess the electrophysiological profile, mainly QT dispersion, of patients with heart failure regularly using propranolol. METHODS – Fifteen patients with heart failure and using propranolol were assessed over a period of 12 months. Twelve-lead electrocardiograms (ECG) were recorded prior to the onset of beta-blocker therapy and after 3 months of drug use. RESULTS – A significant reduction in heart rate, in QT dispersion and in QTc dispersion was observed, as was also an increase in the PR interval and in the QT interval, after the use of propranolol in an average dosage of 100 mg/day. CONCLUSION – Reduction in QT dispersion in patients with heart failure using propranolol may explain the reduction in the risk of sudden cardiac death with beta-blocker therapy, in this specific group of patients.

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