The American journal of cardiology
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This viewpoint expresses reservations about using the inverse (or negative) aVR lead in the so-called Cabrera limb lead sequence and the implementation of inverse representations of any of the other 12 standard electrocardiographic leads. Instead, the author proposes that in patients with suspected acute coronary syndromes and a nondiagnostic electrocardiographic results, electrocardiography be repeated ("double electrocardiography"), with the V1 to V6 electrodes used to record leads V3R, V4R, V7 to V9 to the left of the spine, and V9R to the right of the spine to aid in triaging patients to the appropriate management.
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A significant proportion of patients with myocardial infarction are missed upon initial presentation to the emergency department. The 12-lead electrocardiogram (ECG) has a low sensitivity for the detection of acute myocardial infarction, especially if the culprit lesion is in the left circumflex artery (LCA). This study was designed to evaluate the benefit of adding 3 posterior chest leads on top of the 12-lead ECG to detect ischemia resulting from LC disease, using a model of temporary balloon occlusion to produce ischemia. ⋯ The 15-lead ECG was able to detect>or=0.5 mm (74% vs 38%, p<0.0001) and >or=1 mm (62% vs 34%, p<0.0001) ST elevation in any 2 contiguous leads more frequently than the 12-lead ECG. In conclusion, the 15-lead ECG identified more patients with posterior myocardial wall ischemia because of temporary balloon occlusion of the LC than the 12-lead ECG. This information may enhance the detection of posterior MI in the emergency department and potentially facilitate early institution of reperfusion therapy.
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Multicenter Study Comparative Study
Prognostic value of a multimarker approach for patients presenting to hospital with acute chest pain.
To evaluate the prognostic role of novel biomarkers for the risk stratification of patients admitted with ischemic-type chest pain, a prospective study of 664 patients presenting to 2 coronary care units with ischemic-type chest pain was conducted over 3 years beginning in 2003. Patients were assessed on admission for clinical characteristics, electrocardiographic findings, renal function, cardiac troponin T (cTnT), markers of myocyte injury (heart fatty acid-binding protein [H-FABP] and glycogen phosphorylase BB), neurohormonal activation (N-terminal-pro-brain natriuretic peptide [NT-pro-BNP]), hemostatic activity (fibrinogen and D-dimer), and vascular inflammation (high-sensitivity C-reactive protein, myeloperoxidase, matrix metalloproteinase-9, pregnancy-associated plasma protein-A, and soluble CD40 ligand). A >or=12-hour cTnT sample was also obtained. ⋯ Patients without elevations of H-FABP, NT-pro-BNP, or peak cTnT formed a very low risk group in terms of death or MI within 1 year. A very high risk group had elevations of all 3 biomarkers. In conclusion, the measurement of H-FABP and NT-pro-BNP at the time of hospital admission for patients with ischemic-type chest pain adds useful prognostic information to that provided by the measurement of baseline and 12-hour cTnT.
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Randomized Controlled Trial Comparative Study
Medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure.
Studies have shown that patients with compensated heart failure (HF) receiving high diuretic doses associated with normal sodium diet and fluid intake restrictions demonstrated significant reductions in readmissions and mortality compared with those who received low-sodium diets, and over a 6-month observation period, a reduction in neurohormonal activation was also observed. The aim of this study was to evaluate the effects of different sodium diets associated with different diuretic doses and different levels of fluid intake on hospital readmissions and neurohormonal changes after 6-month follow-up in patients with compensated HF. Four hundred ten consecutive patients with compensated HF (New York Heart Association class II to IV) aged 53 to 86 years, with ejection fractions <35% and serum creatinine <2 mg/dl, were randomized into 8 groups: group A (n = 52): 1,000 ml/day of fluid intake, 120 mmol/day, and 250 mg furosemide twice daily; group B (n = 51): 1,000 ml/day of fluid intake, 120 mmol/day, and 125 mg furosemide twice daily; group C (n = 51): 1,000 ml/day fluid intake, 80 mmol/day, and 250 mg furosemide twice daily; group D (n = 51): 1,000 ml/day fluid intake, 80 mmol/day, and 125 mg furosemide twice daily; group E (n = 52): 2,000 ml/day fluid intake, 120 mmol/day, and 250 mg furosemide twice daily; group F (n = 50): 2,000 ml/day fluid intake, 120 mmol/day, and 125 mg furosemide twice daily; group G (n = 52): 2,000 ml/day fluid intake, 80 mmol/day, and 250 mg furosemide twice daily; and group H (n = 51): 2,000 ml/day fluid intake, 80 mmol/day, and 125 mg furosemide twice daily. ⋯ Signs of HF, body weight, blood pressure, heart rate, laboratory parameters, electrocardiograms, echocardiograms, brain natriuretic peptide, aldosterone, and plasma renin activity were examined at baseline and 180 days later. Group A showed the best results, with a significant reduction (p <0.001) in readmissions, brain natriuretic peptide, aldosterone, and plasma renin activity compared with the other groups during follow-up (p <0.001). In conclusion, these data suggest that the combination of a normal-sodium diet with high diuretic doses and fluid intake restriction, compared with different combinations of sodium diets with more modest fluid intake restrictions and conventional diuretic doses, leads to reductions in readmissions, neurohormonal activation, and renal dysfunction.
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The Duke Activity Status Index (DASI) provides an accurate estimate of functional capacity in patients with chronic heart failure (HF). The aim of this study was to evaluate the prognostic value of the DASI against well-established prognostic factors in 130 consecutive patients hospitalized for worsening HF symptoms (mean age 64 +/- 12 years, mean left ventricular ejection fraction 26 +/- 7%), followed for 9 months for major cardiovascular events, defined as death or hospitalization for HF decompensation. During follow-up, 77 of 130 patients (59%) experienced major cardiovascular events after a median time of 60 days (range 5 to 220). ⋯ The combination of the 2 cutoffs predicted events with 33% sensitivity and 95% specificity. Event-free survival was significantly lower in patients with the 2 markers positive (BNP >697 pg/ml and DASI score <8) compared with those with with 2 markers negative (63 +/- 27 vs 183 +/- 15 days, log-rank p <0.0001). In conclusion, functional status assessment by the DASI bears prognostic value, and its combination with plasma BNP may provide quite specific risk stratification in patients with chronic HF.