PR interval prolongation and 1-year mortality among emergency department patients: a multicentre transnational cohort study

ObjectivesEmerging evidence supports that PR interval prolongation is associated with increased mortality. However, most previous studies have limited confounder control, and clinical impact in a population of acute ill patients is unknown. The aim of this study was to investigate whether 1-year all-cause mortality was increased in patients presenting with PR interval prolongation in the emergency department (ED).Design and settingWe conducted a register-based cohort study in two Swedish and two Danish EDs. We included all adult patients with an ECG performed at arrival to the Danish EDs during March 2013 to May 2014 and Swedish EDs during January 2010 to January 2011. Using propensity score matching, we analysed HR for 1-year all-cause mortality comparing patients with PR interval prolongation (>200 ms) and normal PR interval (120–200 ms).Participants and resultsWe included 106 124 patients. PR interval prolongation occurred in 8.9% (95% CI 8.7% to 9.0%); these patients were older and had more comorbidity than those with a normal PR interval. The absolute 1-year risk of death was 13% (95% CI 12.3% to 13.7%) for patients with PR interval prolongation and 7.9% (95% CI 7.7% to 8.0%) for those without. After confounder adjustments by propensity score matching, PR interval prolongation showed no association with 1-year mortality with a HR of 1.00 (95% CI 0.93% to 1.08%).ConclusionPR interval prolongation does not constitute an independent risk factor for 1-year mortality in ED patients.

Utilizing smartphone-based electrocardiography and thoracic radiography to evaluate cardiac function and morphology in geriatric Sika deer (Cervus nippon)

OBJECTIVE To describe qualitative and quantitative cardiothoracic values in geriatric Sika deer (Cervus nippon) using digital radiography, 6-lead ECG (sECG), and smartphone-based ECG (aECG). ANIMALS 10 healthy geriatric Sika deer (9 females and 1 male). PROCEDURES Deer were chemically immobilized, thoracic radiographs were obtained, and inhalant anesthesia was initiated. An sECG and aECG were simultaneously recorded for each animal using the same ECG specifications. Results were compared between devices. RESULTS Radiographically, no deer had any cardiopulmonary abnormalities. Median (range) values for the most important cardiac measurements were 170 (153–193) mm for cardiac height, 135 (122–146) mm for cardiac width, 9 (8–9) for vertebral heart score, and 99 (69–124) mm for cardiosternal contact. All deer had a normal sinus rhythm with no pathological arrhythmias noted. A significant difference between sECG and aECG was identified for minimum heart rate (49 vs 51 beats/min, respectively), P wave duration (0.05 vs 0.03 seconds), P wave amplitude (0.28 vs 0.10 mV), PR interval (0.15 vs 0.12 seconds), and QT interval (0.39 vs 0.30 seconds). CLINICAL RELEVANCE Thoracic radiographs were suitable to evaluate basic cardiothoracic morphology in Sika deer. The aECG was useful for assessing heart rate and rhythm but, compared with sECG, proved no substitute for evaluating duration and amplitude of ECG waveforms.

Abstract 16643: Pacemaker For First Degree AV Block Without Bradycardia: Pseudo-pacemaker Syndrome

Case Presentation: An 86 year old man underwent PCI of distal LAD for severe single vessel coronary artery disease identified after a high risk pharmacologic nuclear stress test (evaluation of exertional fatigue prior to abdominal aortic aneurysm surgical repair). ECHO was consistent with preserved LVEF (60-65%), moderate concentric LVH and mild left atrial enlargement. Less than a week after PCI, he presented to the emergency department for NYHA III dyspnea and fatigue. The patient was not taking any negative chronotropic medications. CT angiography of the chest excluded pulmonary edema, pneumonia and pulmonary embolism; repeat limited ECHO was unchanged. EKG showed first degree AV block (PR 400ms, figure 1). Severely prolonged PR interval with otherwise-unexplained exertional symptoms raised suspicion for pseudo-pacemaker syndrome. In the absence of an alternative cause of declining exertional tolerance, a dual chamber pacemaker with short programmed AV delay (<200ms) was implanted. The patient reported resolution of exertional fatigue and dyspnea on one-month followup. Discussion: Pseudo-pacemaker syndrome is a rare, infrequently reported, complication of first degree AV block with severely prolonged PR>300ms. P-wave at the end of the preceding T-wave suggests AV dyssynchrony (arrowhead, figure 1). Left atrial contraction against a closed mitral valve led to loss of atrial contribution to cardiac output, and elevated left atrial pressure. These changes, accentuated by physiologic increase in heart rate on exertion, most likely caused symptoms in this patient. It is interesting that AV dyssynchrony in pacemaker syndrome is caused by the pacemaker (VVI pacing) whereas the AV dyssynchrony in pseudo-pacemaker syndrome from severely prolonged PR interval is treated with a pacemaker. In the appropriate clinical picture, it is an indication for dual-chamber pacemaker implantation for first degree AV block without bradycardia or pauses.

HRONIČNA RENALNA INSUFICIJENCIJA KOD PACIJENTA NA SUPSTITUCIONOJ TERAPIJI METADONOM

Uvod. Zavisnost od opijata je hronično stanje povezano s različitim morbiditetima. Metadonska supstituciona terapija opijatskog zavisnika u kombinaciji sa socijalnim, zdravstvenim i psihološkim uslugama, zlatni je standard u lečenju. Svi opioidi ispoljavaju brojna neželjena dejstva. Oštećenje bubrega kod opijatskih zavisnika može nastati zbog sepse, rabdomiolize, pada glomerularne filtracije, hipotenzije, edema pluća, renalne lipidoze ili amiloidoze.Prikaz slučaja. Pacijent, 40 godina, na metadonskoj supstitucionoj terapiji, oseća slabost, znojenje, bol u mišićima i visoko je febrilan. U laboratorijskim analizama: kaliemija 9.87 mmol/L, urea 18.3 mmol/L, kreatinin 268 µmol/L, klirens uree 0,20 ml/s klirens kreatinina 0,81 ml/s, eGFR 23 ml/ min/1,73m2, kreatin fosfokinaza 1180 IU/L, Hgb 79 g/L, Er 2.81x1012/L, C-reaktivni protein 13.2 µg/mL, Le 7.41x109/L, PCO2 41 mmHg, 22 HCO3 mmol/L i acidoza pH 7.21. Krvni pritisak 130/80 mmHg i srčana frekvencija 64/min, na EKG produžen PR interval i visoki T-talasi. Lečen je infuzijama kristaloidnih rastvora, 8.4% rastvorom bikarbonata, diureticima, kalcijum glukonatom, kratkodelujućim insulinom, antibioticima i antikoagulansima. Dolazi do normalizacijekalijemije, diureze i regresije promena na elektrokardiogramu. Nakon 24 dana bolničkog lečenja, pacijent je otpušten na kučno lečenje.Zaključak. Pacijenti na metadonskoj supstitucionoj terapiji imaju povećan rizik od multiplog oštećenja funkcije svih organa. Posebno je ugrožena renalna funkcija. Od izuzetne važnosti je da se među lekarima poveća svest o opasnosti nastanka rabdomiolize kod ovih pacijenata. Redovne laboratorijske analize kod pacijenata na supstitucionoj terapiji metadonom, mogu na vreme da otkriju postojanje akutne i hronične bubrežne komplikacije i omoguće blagovremeno sprovođenje terapije.

A Case Report on Osborn Waves of Hypothermia Induced LV Systolic Dysfunction

Hypothermia, described as a core body temperature of < 95%, is associated with ECG alteration abnormalities. Sinus bradycardia occurs when the body temperature drops below 90°F, and is correlated with gradual prolongation of the PR interval, QRS complex, QT interval. It can progress to ventricular and atrial fibrillation at a temperature reaching 89°F, which can lead to left ventricular dysfunction. Hypothermia is connected to the osborn waves, which at the end of the QRS complex consist of additional deflection. The inferior and lateral precordial leads are seen by Osborn waves, also known as J waves, Camel hump waves and hypothermic waves. As the body temperature decreases, it becomes more pronounced and a gradual expansion of the QRS complex raises the likelihood of ventricular fibrillation causing ventricle dysfunction.

Develop and Apply Electrocardiography-Based Risk Score to Identify Community-Based Elderly Individuals at High-Risk of Mortality

With an aging world population, risk stratification of community-based, elderly population is required for primary prevention. This study proposes a combined score developed using electrocardiographic (ECG) parameters and determines its long-term prognostic value for predicting risk of cardiovascular mortality. A cohort-study, conducted from December 2008 to April 2019, enrolled 5,380 subjects in Taiwan, who were examined, using three-serial-12-lead ECGs, and their health/demographic information were recorded. To understand the predictive effects of ECG parameters on overall-survival, Cox hazard regression analysis were performed. The mean age at enrollment was 69.04 ± 8.14 years, and 47.4% were males. ECG abnormalities, LVH [hazard ratio (HR) = 1.39, 95% confidence intervals (CI) = (1.16–1.67), P = 0.0003], QTc [HR = 1.31, CI = (1.07–1.61), P = 0.007] and PR interval [HR = 1.40, CI = (1.01–1.95), P = 0.04], were significantly associated with primary outcome all-cause death. Furthermore, LVH [HR = 2.37, CI = (1.48–3.79), P = 0.0003] was significantly associated with cardiovascular death, while PR interval [HR = 2.63, CI = (1.24– 5.57), P = 0.01] with unexplained death. ECG abnormality (EA) score was defined based on the number of abnormal ECG parameters for each patient, which was used to divide all patients into sub-groups. Competing risk survival analysis using EA score were performed by using the Gray's test, which reported that high-risk EA groups showed significantly higher cumulative incidence for all three outcomes. Prognostic models using the EA score as predictor were developed and a 10-fold cross validation design was adopted to conduct calibration and discrimination analysis, to establish the efficacy of the proposed models. Overall, ECG model could successfully predict people, susceptible to all three death outcomes (P &lt; 0.05), with high efficacy. Statistically significant (P &lt; 0.001) improvement of the c-indices further demonstrated the robustness of the prediction model with ECG parameters, as opposed to a traditional model with no EA predictor. The EA score is highly associated with increased risk of mortality in elderly population and may be successfully used in clinical practice.