Circulation
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Twenty-one patients without evidence of hypertrophy by M-mode echocardiography were studied by wide-angle two-dimensional echocardiography to determine if they had a form of hypertrophic cardiomyopathy that could not be detected by conventional M-mode echocardiography. Each patient was suspected clinically of having hypertrophic cardiomyopathy because of a distinctly abnormal ECG and either a family history of hypertrophic cardiomyopathy or cardiac symptoms. Patients were 5-49 years old (mean 16 years) and 16 of the 21 had no functional limitation. ⋯ Hence, some patients with hypertrophic cardiomyopathy may have substantial hypertrophy present in unusual locations of the left ventricular wall. Although electrocardiographic abnormalities suggested the presence of myocardial disease, conventional M-mode echocardiography (performed from standard parasternal positions) did not reliably identify such sites of hypertrophy, which were limited to regions of the left ventricle not accessible to the M-mode beam. Only wide-angle two-dimensional echocardiography permits definitive identification of these unusually located regions of cardiac hypertrophy and confirmation of the diagnosis of hypertrophic cardiomyopathy.
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Medical control for paramedics by means of radio and ECG telemetry is costly, time consuming, and of unproved value. We assessed the interaction between emergency room physicians and paramedics during ambulance transport of "seriously ill" cardiac patients (cardiac arrest, acute myocardial infarction, or new onset of crescendo angina pectoris) with paramedics in service. Thirty-five percent of all arrhythmias and 35% of potentially life-threatening arrhythmias were misclassified. ⋯ Mortality reflected correct diagnosis and treatment. In-hospital and overall mortalities were 12% and 33%, respectively, for patients who were correctly diagnosed and treated (p < 0.06), compared with 20% and 43%, respectively, for patients who were incorrectly diagnosed or incorrectly treated (p < 0.04). More rigorous medical control is needed to improve the quality of patient care and outcome and to further integrate the advanced life support program into the health care system.