Diagnostic value of standard electrocardiogram in acute right ventricular myocardial infarction

Myocardial infarction (MI) (i.e., heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia) which accounts for a large number of deaths in the hospital. Diagnosis of myocardial infarction is confirmed based on clinical manifestations and electrocardiographic changes along with increased cardiac enzymes. Electrocardiogram (ECG) is one of the safest and easiest methods in the first place. Therefore, this study aimed to investigate the diagnostic value of standard electrocardiogram in the diagnosis of acute right ventricular infarction following lower cardiac infarction. This research was carried out at a time interval of one and a half years to diagnose acute primary infarction. In this method, the diagnostic value of ST↓ in lead I, ST↓ in lead aVL and I ST↓ + aVL, compared with ST↑ in lead V4R was investigated for diagnosis of right ventricular infarction. ST↑ in the lead V4R is a gold standard for the detection of right ventricular MI. All the patients who had the inclusion criteria were allowed to participate in the study. A total of 66 patients participated in the study. Accordingly, 58 (87%) were male and 8 (13%) were female. The mean age of the population was 54.9 ± 11.41. According to the ST↑ standard in lead V4R, 26 patients (39%) had right ventricular myocardial infarction. There was no significant relationship between angina pectoris and premature infarction (P-Value = 0.869). In this study, the right ventricular was most commonly involved in right coronary artery (RCA) (78%). There was no significant relationship between the occlusion of right coronary artery and right ventricular infarction in 60 patients (P-Value = 0.94). The results showed that electrocardiogram manifestations help determine the occlusion site and the area at risk (ST↓ in lead aVL and aVL + I, sensitivity = 96%). In myocardial infarction, symptoms such as the ST-Segment elevation in lead aVR and ST-Segment depression in the lower leads are possible. Accordingly, in the lower infarction, ST changes in the leads V1-V6 are helpful in detecting patients at risk. Thus, the use of electrocardiogram in acute myocardial infarction (AMI) helps detect more invasive patients and prevents extensive myocardial damage and other complications

Designing and Validating the Tool for Assessing the Professional Behavior of Clinical Faculty Members; A Tool in Stakeholder’s View

Introduction: Despite the consensus on the role of teachers in identity formation of learners, the assessment of the professional behavior of faculty members has not been paid enough attention. Professionalism is best taught in clinical settings through role modeling of teachers. Students can observe the behavior of the physicians, this way, professionalism evaluation in practicing physicians is important. This study endeavored to develop a 360-degree tool for assessing the professional behavior of clinical attending. Methods: This study was conducted in four phases. In the first phase we designed item pool based on a review of literature and experts’ views, in the second phase, content validity and face validity of items were authnticated. In the next phase a pilot study was conducted on 40 people (20 faculty members & 20 assistants). In the versy last phase the reliability of the instrument was calculated on 18 faculty members, 10 head of departments, 16 residents and 17 nurses. Results: Based on validity and reliability assessment, item pool reduced to 18. Seven items were assigned to department heads, 6 items to colleagues, 8 items to assistants, and 5 items to nurses. It was also found that patients were able to evaluate the professional behavior of clinical members in four aspects. Conclusion: A 360 degree instrument containing five sections and 18 items was developed that can examine the professional behavior of faculty of members of school of medicine, taking into account the views of stakeholders including service providers and patients

Doppler Tissue Imaging: A Non-Invasive Technique for Estimation of Left Ventricular End Diastolic Pressure in Severe Mitral Regurgitation

Background: Conventional Doppler measurements, including mitral inflow and pulmonary venous flow, are used to estimate left ventricular end diastolic pressure (LVEDP). However, these parameters have limitations in predicting LVEDP among patients with mitral regurgitation. This study sought to establish whether the correlation between measurements derived from tissue Doppler echocardiography and LVEDP remains valid in the setting of severe mitral regurgitation.Methods: Thirty patients (mean age: 57.37 ± 13.29 years) with severe mitral regurgitation and a mean left ventricular ejection fraction (EF) of 46.0 ± 14.95 were enrolled; 16 (53.4%) patients were defined to have EF < 50% and 14 (46.6%) patients had EF ≥ 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and Doppler tissue imaging indices were obtained, and LVEDP was measured invasively through cardiac catheterization.Results: The majority of the standard Doppler and Doppler tissue imaging indices were not significantly correlated with LVEDP in the univariate analysis. In the multiple linear regression, however, early (E) transmitral velocity to annular E' (E/E') ratio (ß = 1.09, p value < 0.01), E wave velocity to propagation velocity (E/Vp) ratio (ß = 7.87, p value < 0.01), and isovolumic relaxation time (ß = 0.21, p value = 0.01) were shown as independent predictors of LVEDP (R2 = 91.7%).Conclusion: The ratio of E/Vp and E/E' ratio and also the isovolumic relaxation time could be applied properly to estimate LVEDP in mitral regurgitation patients even in the setting of severe mitral regurgitation

Evaluation of Cardiac Systolic Function in Cirrhotic Patients Undergoing Liver Transplantation

We assessed different systolic cardiac indices to detect left and right ventricular systolic dysfunction in cirrhotic patients before liver transplantation. Between 2010-2011, 81 consecutive individuals with confirmed hepatic cirrhosis who were a candidate for liver transplantation were enrolled in this study. A total of 32 age and sex matched healthy volunteers were also selected as the control group. A detailed two-dimensional, Color Flow Doppler, and Tissue Doppler echocardiography were performed in all patients and control participants. Left atrial diameter and area, right atrial area, left ventricular enddiastolic volume, and basal right ventricular diameter were significantly higher in the cirrhotic group (P<0.05). Left ventricular ejection fraction, stroke volume, left ventricular outflow tract velocity time integral and tricuspid annular plane systolic excursion were also higher in the cirrhotic group (P<0.05). Peak systolic velocities of tricuspid annulus, basal segment of RV free wall and basal seg ent of septal wall, peak strains of basal and mid portions of septal wall, mid portion of lateral wall and peak strain rates of basal and mid portions of septal and lateral walls were higher significantly in cirrhotic group, as well (P<0.05). Isovolumic contraction time, LV systolic time interval and Tei indexes of left and right ventricles which all are representatives of systolic dysfunction were higher in cirrhosis. Peak systolic velocity of a mid-segment of the lateral wall was lower in the cirrhotic group (P<0.05) as well. Most of the cirrhotic patients display signs of cardiovascular disturbances that become more manifest following exposure to stresses such as transplantation. Cardiac failure is an important cause of death following liver transplantation. Because of the load dependency we cannot use most of the cardiac systolic indices for evaluatio of systolic function in cirrhotic patients. Thus, we suggest th t LV systolic time interval and Tei indices of left and right ventricles might be useful in ices in the evaluation of systolic function in cirrhotic patients

Left ventricular strain echocardiography in advanced uremic cardiomyopathy compared to dilated cardiomyopathy

Abstract Background Cardiac involvement is common in end-stage renal disease patients. The presenting study aimed to evaluate the global and segmental longitudinal strain in patients with advanced uremic cardiomyopathy (AUCM) and compare it to dilated cardiomyopathy (DCM). Results The mean global longitudinal strain (GLS) was significantly lower in AUCM (P value = 0.045). Comparing segmental strain showed a lower strain in mid inferoseptal (P value = 0.048), base and mid anterolateral (P value = 0.026, 0.001 respectively), base and mid anteroseptal (P value = 0.005, 0.009 respectively), base and mid inferior (P value = 0.015, 0.034 respectively) and mid anterior (P value = 0.015) in patients with AUCM compared with DCM. In both groups, the segmental strain increased from base to apex. Conclusions Segmental and GLSs in advanced uremic cardiomyopathy were significantly lower than those of dilated cardiomyopathy. In both groups, the segmental strain increased from base to apex

Cardiac systolic function in cirrhotic patients’ candidate of liver trans-plantation compared with control group

Background: We assessed different systolic cardiac indices to describe left and right ventricular dysfunction in cirrhotic patients before liver transplantation. Methods: In this case-control study, eighty-one consecutive individuals with the confirmed hepatic cirrhosis and candidate for liver transplantation in the Imam Khomeini Hospital between March 2008 and March 2010 were selected. Thirty-two age and gender cross-matched healthy volunteers were also selected as the control group. A detailed two-dimensional and Doppler echocardiography was obtained in all patients and controls performed by the same operator on the day of admission. Results: Dimensions of both left and right atriums as well as left ventricular end-diastolic volume and basal right ventricular dimension in the cirrhotic group were significantly higher than control group. Left ventricular end-systolic dimensions as well as aortic annulus diameter were not different between the two study groups. Left ventricular outflow tract velocity time integral, isovolumic pre-ejection time, isovolumic relaxation time, stroke volume, left ventricular ejection fraction, IVCT+IVRT+ET, systolic velocity of tricuspid annulus, systolic velocity of basal segment of RV free wall, systolic velocity of basal segment of septal wall, peak strain of septal margin (base), peak strain of septal margin (midpoint), peak strain of lateral margin (midpoint), strain rate of septal margin (base), strain rate of septal margin (midpoint), strain rate of lateral margin (base), strain rate of lateral margin (midpoint), Tei index (left and right ventricles), systolic time interval and tricuspid annular plane systolic excursion were higher in cirrhotic group, significantly, (P< 0.05). Left ventricular ejection time and systolic velocity of mid segment of lateral wall were lower in cirrhotic group, significantly, (P< 0.05). Conclusion: In this study, the effects of liver on heart were volume overload, hyperdynamic state and systolic dysfunction in cirrhotic patients. These effects were due to chamber enlargement and we cannot use the most of cardiac indices for evaluation systolic function in cirrhotic patients. So, we suggest that systolic time interval and Tei index are useful indices in evaluation of systolic function in cirrhotic patients

Echocardiographic estimation of left ventricular filling pressures in heart transplant recipients

Abstract Background Echocardiographic estimation of left ventricular filling pressure in heart transplant (HTx) recipients is challenging. The ability of echocardiography to detect elevated left ventricular end-diastolic pressure (LVEDP) in HTx patients was assessed in this study. Results This descriptive cross-sectional study included 39 HTx recipients who were candidates for endomyocardial biopsy as a part of their routine post-transplantation surveillance. Doppler transthoracic echocardiography was done before the procedure, and left heart catheterization was done during the endomyocardial biopsy. Thirty-nine patients (15 female, 24 male), with a mean age of 39.6 years (range 13–70), were enrolled. A strong relation was observed between lateral E/e′ and LVEDP (R = 0.64, P value < 0.001) and average E/e′ and LVEDP (R = 0.6, P value < 0.001). The best cutoff value for LVEDP prediction was the average E/e′ ≥ 6.8 with a sensitivity of 96.15% and specificity of 68.5% for the prediction of LVEDP more than or equal to 20 mmHg. Two predictive models comprising age, gender, and lateral E/e′ or average E/e′ were also proposed. A significant relationship was also found between LVEDP and left ventricular global longitudinal strain (R = − 0.31, P value < 0.01). Conclusions Lateral E/e′ was the best predictor of LVEDP. The cutoff of average E/e′ had the best validity for the estimation of LVEDP. Despite the strong observed association, echocardiographic parameters cannot be considered a surrogate for invasive LVEDP measurements when seeking information about left ventricle filling pressure on heart transplant recipients

Caspofungin-Induced Cardiotoxicity in Patients Treating for Candidemia

Echinocandins selectively inhibit fungal cell wall synthesis and, therefore, have few side effects. However, there are reports of hemodynamic and cardiac complications. We conducted this study to investigate the effects of caspofungin both on the noninvasive echocardiographic indices of myocardial function and myocardial injury based on serum high-sensitivity cardiac troponin I (hs-cTnI) levels. This study was conducted on patients treated for candidemia. The hs-cTnI level and echocardiographic parameters were measured before and 1 h after the infusion of the induction dose of caspofungin. Data were compared between central and peripheral venous drug administration routes. Fifteen patients were enrolled in the study. There were no significant differences in the echocardiographic parameters between the baseline and post-treatment period. The mean hs-cTnI level exhibited a significant rise following drug administration (0.24 &plusmn; 0.2 ng/mL vs 0.32 &plusmn; 0.3 ng/mL; p = 0.006). There was also a significant difference concerning the hs-cTnI level between central and peripheral venous drug administration routes (p = 0.034). Due to differences in the hs-cTnI level, it appears that the administration of caspofungin may be associated with myocardial injury. Our findings also showed a higher possibility of cardiotoxicity via the central venous administration route