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13 A year of acute myocarditis in northern alberta
IntroductionAcute myocarditis (AM) is a major cause of troponin positive chest pain in patients without obstructive coronary disease. Many cases relate to viral infection. Drug toxicity, alcohol and auto-immune diseases have also been implicated. Diagnosis is difficult and cardiac MR (CMR) can confirm/exclude the diagnosis. We reviewed all cases of suspected AM referred for CMR in 2017.MethodsPatients were identified from referral information recorded in the CMR daybook. All cases underwent pre- & post-contrast imaging to assess bi-ventricular function, myocardial oedema and late gadolinium enhancement (LGE).ResultsOf 1753 adult patients undergoing CMR, 95 (5%) were for suspected myocarditis. 37 had no troponin rise or peak troponin I < 0.5µg/L (normal range ≤ 0.15µg/L). None of these had AM by MRI criteria (15 dilated cardiomyopathy, 1 pericarditis, 1 LV hypertrophy and 20 normal). Of the remaining 58, 31 showed edema and LGE typical of AM and 9 had non-ischemic LGE suggesting possible myocarditis. 9 patients had acute infarcts and 9 were normal. Seven of the normal patients had troponin I rise of <2 µg/L.ConclusionSuspected acute myocarditis is a common indication for CMR. None of our cohort had a positive CMR for AM if troponin I was < 0.5µg/L. The demographics of positive cases mirrors previous series in terms of age and gender. Interestingly, the majority of positive AM cases had normal bi-ventricular function (26/40 or 65%). Longterm outcome of these patients has yet to be established and routine follow-up CMR may not be needed.
Journal Article
Case report on Arrhythmogenic Right Ventricular Dysplasia
Arrhythmogenic cardiomyopathy (AC) is a genetic disease characterized by fibro-fatty replacement of either ventricles in isolation or in combination. It may cause tachyarrhythmias to sudden cardiac death, especially in young adult. When ventricular tachycardia (VT) is the principal manifestation then the condition is termed as arrhythmogenic right ventricular dysplasia (ARVD). Here we present a case of ARVD in a 36 years old hypertensive male who presented with sudden onset of chest tightness, palpitations, breathing difficulty, dizziness for 20 minutes. In emergency department his electrocardiogram (ECG) showed sustained VT. After 200 joule DC cardioversion he was reverted to sinus rhythm, then resting ECG showed T-wave inversion (TWI) in V1-V3 along with epsilon wave. His echocardiogram also revealed dilated right ventricle (RV) along with hypertrabeculation, RV wall motion abnormality and low RV ejection fraction (EF), his coronaries were normal on coronary angiogram (CAG). He was discharged from the hospital after Implantable Cardioverter Defibrilator (ICD) implantation with beta-blocker and advised to restrict excessive physical activity. J Bangladesh Coll Phys Surg 2024; 42: 86-91
Journal Article
Trigeminy electrocardiogram spectral characteristics study
This paper presents the results of a study in which the method of ECG decomposition in the time domain (DMTD) was applied, followed by a spectral analysis. A digital signal with trigeminy of the first lead of a standard electrocardiograph was processed. Using digital filtering in time domain, the electrocardiogram (ECG) was cleared of noise, what results the reduction of spurious components by 10-20%. To represent and classify the frequency characteristics throughout the entire processed cardiac signal, the QRS complexes were removed, P and T waves were left unchanged. Due to considerable influence on the spectral analysis sharp peaks of the ECG signal with small characteristic times of the leading and trailing edges, the obtained result differs considerably from the sum of the harmonic components of the smooth part of the signal. The spectral processing reveals peaks at multiple frequencies, 1.6 Hz, 3.2 Hz, 4.7 Hz, corresponding to a smooth function of P and T waves before the appearance of extra systoles. Based on the obtained data, the frequencies corresponding to the peaks of the cardiogram with a stable sinus rhythm were identified. The acquired data represent regular harmonics, which allow adequate quantitative ECG analysis.
Journal Article
Comparison of diagnostic value using a small, single channel, P-wave centric sternal ECG monitoring patch with a standard 3-lead Holter system over 24 hours
To compare simultaneous recordings from an external patch system specifically designed to ensure better P-wave recordings and standard Holter monitor to determine diagnostic efficacy.
Holter monitors are a mainstay of clinical practice, but are cumbersome to access and wear and P-wave signal quality is frequently inadequate.
This study compared the diagnostic efficacy of the P-wave centric electrocardiogram (ECG) patch (Carnation Ambulatory Monitor) to standard 3-channel (leads V1, II, and V5) Holter monitor (Northeast Monitoring, Maynard, MA). Patients were referred to a hospital Holter clinic for standard clinical indications. Each patient wore both devices simultaneously and served as their own control. Holter and Patch reports were read in a blinded fashion by experienced electrophysiologists unaware of the findings in the other corresponding ECG recording. All patients, technicians, and physicians completed a questionnaire on comfort and ease of use, and potential complications.
In all 50 patients, the P-wave centric patch recording system identified rhythms in 23 patients (46%) that altered management, compared to 6 Holter patients (12%), P<.001. The patch ECG intervals PR, QRS and QT correlated well with the Holter ECG intervals having correlation coefficients of 0.93, 0.86, and 0.94, respectively. Finally, 48 patients (96%) preferred wearing the patch monitor.
A single-channel ambulatory patch ECG monitor, designed specifically to ensure that the P-wave component of the ECG be visible, resulted in a significantly improved rhythm diagnosis and avoided inaccurate diagnoses made by the standard 3-channel Holter monitor.
Journal Article
Investigation of the relationship of frontal QRS-T angle and digoxin use and blood digoxin level
Objectives: Digoxin is an antiarrhythmic drug with a narrow therapeutic range and used in clinical conditions such as heart failure and atrial fibrillation. The planar frontal QRS-T angle reflects the deviations between the depolarization and repolarization of the ventricles, and it has been reported that an increase in this angle is associated with an increase in mortality. In our study, the relationship between frontal QRS-T angle and digoxin use and blood digoxin level was investigated. Methods: The study included 105 digoxin users who used digoxin, whose levels were measured, who had an electrocardiogram (ECG) on the system, and 15 patients with similar characteristics, who had an ECG and did not use digoxin. Patients using digoxin and whose levels were measured were also divided into three groups as < 0.8 ng/mL, 0.8-1.2 ng/mL, and > 1.2 ng/mL. The absolute value of the value obtained by subtracting the axis of the T wave from the axis of the QRS angle indicated on the paper, calculated automatically on the 12-lead ECG, was accepted as the frontal QRS-T angle value. Results: Planar frontal QRS-T angle measured by 12-lead ECG in digoxin users was 120º (55.5º-155.5º), while it was 106º (32º-163º) in non-users, and there was no statistical difference between the two groups (p = 0.833). In the evaluation made according to different blood drug levels as < 0.8 ng/mL, 0.8-1.2 ng/mL, > 1.2 ng/mL in digoxin users, no significant difference was observed between the frontal QRS-T angle between the groups (109.5° [60.25°-154.25°] for < 0.8 ng/mL, 136.5° [48.5°-158.5°] for 0.8-1.2 ng/mL, 117° [34°-154°] for 1.2 ng/mL) (p = 0.773).Conclusions: There was no significant difference in frontal QRS-T angle between digoxin users and non-users. There was no significant relationship between different blood digoxin levels and frontal QRS-T angle.
Journal Article
Is 7-day event triggered ECG recording equivalent to 7-day Holter ECG recording for atrial fibrillation screening?
ObjectiveProlonged ECG monitoring is standard for atrial fibrillation (AF) screening. This study investigated whether 7-day event triggered (tECG) ECG recording is equivalent to 7-day continuous Holter (cECG) ECG recording for AF screening.DesignBoth a cECG (Lifecard CF) and a tECG (R.Test Evolution 3) were simultaneously worn for 7 days by patients with known or suspected paroxysmal AF.ResultsIn 100 corresponding recordings, median effective duration of monitoring was 165 h (range 10–170 h) for cECG and 137 h (0–169 h) for tECG (p<0.001). Median number and total duration of arrhythmias (AF, atrial flutter or atrial tachycardia) of ≥30 s duration recorded by cECG were 10 (1–428) and 1030 min (≤1–10 020), respectively. An arrhythmia was recorded in 42 cECGs (42%) versus 37 tECGs (37%, p=0.56). Triggered ECG failed to record an arrhythmia in cECG positive cases because of interrupted monitoring in four cases and because of recording failure in one case. Sensitivity, specificity, and positive and negative predictive values of tECG therefore were 88%, 100%, 100%, and 92%, respectively. Quantitative cECG analysis required a median of 20 min (3–205 min) and qualitative tECG analysis 4 min (1–20 min; p<0.001). Skin irritation was a frequent side effect (42%) resulting in premature removal of devices in 16% of patients.ConclusionSensitivity of tECG for AF screening as compared to cECG is lower, mainly because of shorter effective monitoring duration. Qualitative tECG analysis is less time consuming than quantitative cECG analysis. Skin irritation is a frequent side effect and reason for premature device removal.
Journal Article