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Leivo J, Anttonen E, Jolly SS, Džavík V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola M. The prognostic significance of Q waves and T wave inversions in the ECG of patients with STEMI: A substudy of the TOTAL trial. J Electrocardiol 2023; 80:99-105. [PMID: 37295167 DOI: 10.1016/j.jelectrocard.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/20/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The prognostic significance of Q waves and T-wave inversions (TWI) combined and separately in STEMI patients undergoing primary PCI has not been well established in previous studies. METHODS We included 7,831 patients from the TOTAL trial and divided the patients into categories based on Q waves and TWIs in the presenting ECG. The primary outcome was a composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock or new or worsening NYHA class IV heart failure within one year. The study evaluated the effect of Q waves and TWI on the risk of primary outcome and all-cause death, and whether patient benefit of aspiration thrombectomy differed between the ECG categories. RESULTS Patients with Q+TWI+ (Q wave and TWI) pattern had higher risk of primary outcome compared to patients with Q-TWI- pattern [33 (10.5%) vs. 221 (4.2%); adjusted hazard ratio (aHR) 2.10; 95% CI, 1.45-3.04; p<0.001] within 40-days' period. When analyzed separately, patients with Q waves had a higher risk for the primary outcome compared to patients with no Q waves in the first 40 days [aHR 1.80; 95% CI, 1.48-2.19; p<0.001] but there was no additive risk after 40 days. Patients with TWI had a higher risk for primary outcome only after 40 days when compared to patients with no TWI [aHR 1.63; 95% CI, 1.04-2.55; p=0.033]. There was a trend towards a benefit of thrombectomy in patients with the Q+TWI+ pattern. CONCLUSIONS Q waves and TWI combined (Q+TWI+ pattern) in the presenting ECG is associated with unfavourable outcome within 40-days. Q waves tend to affect short-term outcome, while TWI has more effect on long-term outcome.
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Affiliation(s)
- Joonas Leivo
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Arvo Ylpön katu 34, 33520 Tampere, Finland.
| | - Eero Anttonen
- Päijät-sote, Primary Health Care, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Sanjit S Jolly
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada; Hamilton Health Sciences, P.O. Box 2000, Hamilton, ON L8N 3Z5, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, 6-246A EN, Toronto General Hospital, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Jyri Koivumäki
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland
| | - Minna Tahvanainen
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland
| | - Kimmo Koivula
- Internal Medicine, South Karelia Central Hospital, Valto Käkelän katu 1, 53130 Lappeenranta, Finland
| | - Kjell Nikus
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Faculty of Health Sciences, 1280 Main St. W., Hamilton, Ontario L8S4K1, Canada
| | - John A Cairns
- The University of British Columbia, 2329 West Mall, Vancouver, British Columbia V6T1Z4, Canada
| | - Kari Niemelä
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland
| | - Markku Eskola
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Arvo Ylpön katu 34, 33520 Tampere, Finland
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2
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Istolahti T, Lyytikäinen LP, Huhtala H, Nieminen T, Kähönen M, Lehtimäki T, Eskola M, Anttila I, Jula A, Rissanen H, Nikus K, Hernesniemi J. The prognostic significance of T-wave inversion according to ECG lead group during long-term follow-up in the general population. Ann Noninvasive Electrocardiol 2020; 26:e12799. [PMID: 32975832 PMCID: PMC7816818 DOI: 10.1111/anec.12799] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/14/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022] Open
Abstract
Background Inverted T waves in the electrocardiogram (ECG) have been associated with coronary heart disease (CHD) and mortality. The pathophysiology and prognostic significance of T‐wave inversion may differ between different anatomical lead groups, but scientific data related to this issue is scarce. Methods A representative sample of Finnish subjects (n = 6,354) aged over 30 years underwent a health examination including a 12‐lead ECG in the Health 2000 survey. ECGs with T‐wave inversions were divided into three anatomical lead groups (anterior, lateral, and inferior) and were compared to ECGs with no pathological T‐wave inversions in multivariable‐adjusted Fine–Gray and Cox regression hazard models using CHD and mortality as endpoints. Results The follow‐up for both CHD and mortality lasted approximately fifteen years (median value with interquartile ranges between 14.9 and 15.3). In multivariate‐adjusted models, anterior and lateral (but not inferior) T‐wave inversions associated with increased risk of CHD (HR: 2.37 [95% confidence interval 1.20–4.68] and 1.65 [1.27–2.15], respectively). In multivariable analyses, only lateral T‐wave inversions associated with increased risk of mortality in the entire study population (HR 1.51 [1.26–1.81]) as well as among individuals with no CHD at baseline (HR 1.59 [1.29–1.96]). Conclusions The prognostic information of inverted T waves differs between anatomical lead groups. T‐wave inversion in the anterior and lateral lead groups is independently associated with the risk of CHD, and lateral T‐wave inversion is also associated with increased risk of mortality. Inverted T wave in the inferior lead group proved to be a benign phenomenon.
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Affiliation(s)
- Tiia Istolahti
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland
| | - Leo-Pekka Lyytikäinen
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland.,Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Tuomo Nieminen
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Mika Kähönen
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | - Terho Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
| | - Markku Eskola
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | | | - Antti Jula
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Harri Rissanen
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Kjell Nikus
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Jussi Hernesniemi
- Faculty of Medicine and Health Technology, Tampere University, and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
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3
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Leivo J, Anttonen E, Jolly SS, Dzavik V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola MJ. The high-risk ECG pattern of ST-elevation myocardial infarction: A substudy of the randomized trial of primary PCI with or without routine manual thrombectomy (TOTAL trial). Int J Cardiol 2020; 319:40-45. [PMID: 32470531 DOI: 10.1016/j.ijcard.2020.05.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Useful tools for risk assessment in patients with STEMI are needed. We evaluated the prognostic impact of the evolving myocardial infarction (EMI) and the preinfarction syndrome (PIS) ECG patterns and determined their correlation with angiographic findings and treatment strategy. METHODS This substudy of the randomized Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI (TOTAL) included 7860 patients with STEMI and either the EMI or the PIS ECG pattern. The primary outcome was a composite of death from cardiovascular causes, recurrent MI, cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within one year. RESULTS The primary outcome occurred in 271 of 2618 patients (10.4%) in the EMI group vs. 322 of 5242 patients (6.1%) in the PIS group [AdjustedHR, 1.54; 95% CI, 1.30 to 1.82; p < .001]. The primary outcome occurred in the thrombectomy and PCI alone groups in 131 of 1306 (10.0%) and 140 of 1312 (10.7%) patients with EMI [HR 0.94; 95% CI, 0.74-1.19] and 162 of 2633 (6.2%) and 160 of 2609 (6.1%) patients with PIS [HR 1.00; 95% CI, 0.81-1.25], respectively (pinteraction = 0.679). CONCLUSIONS Patients with the EMI ECG pattern proved to have an increased rate of the primary outcome within one year compared to the PIS pattern. Routine manual thrombectomy did not reduce the risk of primary outcome within the different dynamic ECG patterns. The PIS/EMI dynamic ECG classification could help to triage patients in case of simultaneous STEMI patients with immediate need for pPCI.
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Affiliation(s)
- Joonas Leivo
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland.
| | - Eero Anttonen
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Hamilton Health Sciences, Hamilton, Canada
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Jyri Koivumäki
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Minna Tahvanainen
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Kimmo Koivula
- Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland; Internal medicine, Helsinki University Hospital, Finland
| | - Kjell Nikus
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Canada
| | | | - Kari Niemelä
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Markku J Eskola
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
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4
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Reindl M, Reinstadler SJ, Feistritzer HJ, Niess L, Koch C, Mayr A, Klug G, Metzler B. Persistent T-wave inversion predicts myocardial damage after ST-elevation myocardial infarction. Int J Cardiol 2017; 241:76-82. [PMID: 28499665 DOI: 10.1016/j.ijcard.2017.03.164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/19/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Persistent T-wave inversion (PTI) after ST-elevation myocardial infarction (STEMI) is associated with worse clinical outcome; however, the underlying mechanism between PTI and poor prognosis is incompletely understood. We sought to investigate the relationship between PTI and myocardial damage assessed by cardiac magnetic resonance (CMR) following STEMI. METHODS In this prospective observational study, we included 142 consecutive revascularized STEMI patients. Electrocardiography to determine the presence and amplitude of PTI and pathological Q-waves was conducted 4months after infarction. CMR was performed within 1week after infarction and at 4months follow-up to evaluate infarct characteristics and myocardial function. RESULTS Patients with PTI (n=103, 73%) showed a larger acute (21[11-29] vs. 6[1-13]%; p<0.001) and chronic infarct size (IS) (14[8-19] vs. 3[1-8]%; p<0.001) and more frequently microvascular obstruction (59 vs. 33%; p=0.02). The association between PTI and chronic IS remained significant (odds ratio: 9.02, 95%CI 3.49-23.35; p<0.001) after adjustment for pathological Q-wave and other IS estimators (high-sensitivity cardiac troponin T and C-reactive protein, N-terminal pro B-type natriuretic peptide, culprit vessel, pre-interventional TIMI flow). The value of PTI amplitude for the prediction of large chronic IS>11% (AUC: 0.84, 95%CI 0.77-0.90) was significantly higher compared to Q-wave amplitude (AUC: 0.72, 95%CI 0.63-0.80; p=0.009); the combination of PTI with pathological Q-wave (Q-wave/T-wave score) led to a net reclassification improvement of 0.43 (95% CI 0.29-0.57; p<0.001) as compared to PTI alone. CONCLUSIONS PTI following STEMI is independently and incrementally associated with more extensive myocardial damage as visualized by CMR. An electrocardiographic score combining PTI with pathological Q-wave allows for a highly accurate IS estimation post-STEMI.
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Affiliation(s)
- Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Hans-Josef Feistritzer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Lea Niess
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Constantin Koch
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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5
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Ola O, Dumancas C, Mene-Afejuku TO, Akinlonu A, Al-Juboori M, Visco F, Mushiyev S, Pekler G. Left Ventricular Aneurysm May Not Manifest as Persistent ST Elevation on Electrocardiogram. Am J Case Rep 2017; 18:410-413. [PMID: 28412760 PMCID: PMC5402854 DOI: 10.12659/ajcr.902884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Patient: Male, 67 Final Diagnosis: Left Ventricular aneurysm post myocardial infarction Symptoms: Chest pain Medication: Dual antiplatelet therapy • anticoagulation Clinical Procedure: Cardiac catheterization Specialty: Cardiology
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Affiliation(s)
- Olatunde Ola
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Carissa Dumancas
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | | | - Adedoyin Akinlonu
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Mohammed Al-Juboori
- Department of Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Ferdinand Visco
- Division of Cardiology, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Savi Mushiyev
- Division of Cardiology, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Gerald Pekler
- Division of Cardiology, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
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6
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Rovai D, Gimelli A, Coceani M, Sbrana F, Masini G, Rossi G. T wave abnormalities identify patients with previous lateral wall myocardial infarction and circumflex artery disease. J Electrocardiol 2016; 49:216-22. [DOI: 10.1016/j.jelectrocard.2015.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Indexed: 10/22/2022]
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7
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Rovai D, Rossi G, Pederzoli L, Aquaro GD, Di Bella G, Pingitore A. Prominent T wave in V2 with respect to V6 as a sign of lateral myocardial infarction. Int J Cardiol 2015; 189:148-52. [PMID: 25897894 DOI: 10.1016/j.ijcard.2015.04.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 03/13/2015] [Accepted: 04/07/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the absence of confounding electrocardiographic features, a prominent R wave in leads V1-V2 reflects a lateral myocardial infarction (MI). We hypothesized that repolarization abnormalities in V1-V2 could also reflect a lateral MI. METHODS We retrospectively selected a group of 57 patients with a recent or previous first Q-wave MI involving left ventricular (LV) inferior and/or lateral wall at contrast-enhanced cardiac magnetic resonance (CMR). The location and extent of the MI at CMR were compared with electrocardiographic features. RESULTS The infarction was located in the inferior wall in 12 patients (21%), in the lateral wall in 8 (14%), and in both walls in 37 patients (65%). Infarct size corresponded to 16.8 (SD 9.0%) of LV myocardium. Infarct extent in the inferior and lateral wall (8.3%, SD 7.2% vs. 8.4%, SD 7.5% of LV myocardium) did not differ significantly. Using multiple linear regression analysis, inferior Q-waves and inferior negative T waves were directly associated with infarct extent in the inferior wall (p = 0.014 and p = 0.010, respectively). A prominent R wave in V1 and a prominent anterior T wave (expressed by the T wave amplitude in V2 minus its amplitude in V6) were directly associated with MI extent in the lateral wall (p = 0.008 and p = 0.018), while inferior negative T waves were negatively associated (p = 0.006). CONCLUSIONS In patients with MI of the inferior and/or lateral wall, a prominent T wave in V2 with respect to V6 reflects greater infarct extent in the lateral wall.
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Affiliation(s)
- Daniele Rovai
- CNR, Clinical Physiology Institute, Via Moruzzi 1, 56124 Pisa, Italy.
| | - Giuseppe Rossi
- CNR, Clinical Physiology Institute, Via Moruzzi 1, 56124 Pisa, Italy.
| | - Laura Pederzoli
- Pederzoli Hospital, Via Monte Baldo 24, 37019 Peschiera del Garda, Italy.
| | | | - Gianluca Di Bella
- Department Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Via C. Valeria, 98125 Messina, Italy.
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8
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Kylmälä MM, Konttila T, Vesterinen P, Kivistö SM, Lauerma K, Lindholm M, Väänänen H, Stenroos M, Nieminen MS, Hänninen H, Toivonen L. Assessment of myocardial infarct size with body surface potential mapping: validation against contrast-enhanced cardiac magnetic resonance imaging. Ann Noninvasive Electrocardiol 2014; 20:240-52. [PMID: 25234825 DOI: 10.1111/anec.12198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Assessment of myocardial infarct (MI) size is important for therapeutic and prognostic reasons. We used body surface potential mapping (BSPM) to evaluate whether single-lead electrocardiographic variables can assess MI size. METHODS We performed BSPM with 120 leads covering the front and back chest (plus limb leads) on 57 patients at different phases of MI: acutely, during healing, and in the chronic phase. Final MI size was determined by contrast-enhanced cardiac magnetic resonance imaging (DE-CMR) and correlated with various computed depolarization- and repolarization-phase BSPM variables. We also calculated correlations between BSPM variables and enzymatic MI size (peak CK-MBm). RESULTS BSPM variables reflecting the Q- and R wave showed strong correlations with MI size at all stages of MI. R width performed the best, showing its strongest correlation with MI size on the upper right back, there representing the width of the "reciprocal Q wave" (r = 0.64-0.71 for DE-CMR, r = 0.57-0.64 for CK-MBm, P < 0.0001). Repolarization-phase variables showed only weak correlations with MI size in the acute phase, but these correlations improved during MI healing. T-wave variables and the QRSSTT integral showed their best correlations with DE-CMR defined MI size on the precordial area, at best r = -0.57, P < 0.0001 in the chronic phase. The best performing BSPM variables could differentiate between large and small infarcts at all stages of MI. CONCLUSIONS Computed, single-lead electrocardiographic variables can estimate the final infarct size at all stages of MI, and differentiate large infarcts from small.
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Affiliation(s)
- Minna M Kylmälä
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland.,BioMag Laboratory, Hospital District of Helsinki and Uusimaa HUSLAB, Helsinki University Central Hospital, Helsinki, Finland
| | - Teijo Konttila
- Department of Biomedical Engineering and Computational Science, Aalto University, Espoo, Finland
| | - Paula Vesterinen
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland.,BioMag Laboratory, Hospital District of Helsinki and Uusimaa HUSLAB, Helsinki University Central Hospital, Helsinki, Finland
| | - Sari M Kivistö
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Kirsi Lauerma
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Mats Lindholm
- Department of Biomedical Engineering and Computational Science, Aalto University, Espoo, Finland
| | - Heikki Väänänen
- Department of Biomedical Engineering and Computational Science, Aalto University, Espoo, Finland
| | - Matti Stenroos
- Department of Biomedical Engineering and Computational Science, Aalto University, Espoo, Finland
| | - Markku S Nieminen
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Helena Hänninen
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Lauri Toivonen
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
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9
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The relationship between serial postinfarction T wave changes and infarct size and ventricular function as determined by cardiac magnetic resonance imaging. J Electrocardiol 2011; 44:555-60. [PMID: 21872002 DOI: 10.1016/j.jelectrocard.2011.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND The value of sequential T wave changes on the electrocardiogram (ECG) has less well been described than ST-segment changes in the follow-up of patients with myocardial infarction (MI). We investigated whether the amplitude of T wave positivity correlates with infarct size (IS) and left ventricular ejection fraction (LVEF) measured using cardiac magnetic resonance imaging 3 months after reperfusion therapy. MATERIALS AND METHODS Fifty-five patients with a first acute MI referred for primary percutaneous coronary intervention were included. Electrocardiograms were analyzed within 4 hours after reperfusion and at 3 months, measuring T wave ampitudes in 2 contiguous infarct-related leads, summed up as one value called T wave amplitude. Cardiac magnetic resonance imaging was performed at 3 months of follow-up. Correlations between T wave amplitude, IS, and LVEF were tested with Pearson r correlation coefficient test. Subanalyses were performed using a 2-sample t test. RESULTS A good correlation was found between LVEF and IS (r = -0.7, P < .0001). Most of the patients had inferior MI location (69%). In this group, there were significant positive correlations between the amount of T wave positivity and both IS (r = -0.40, P = .012) and LVEF (r = 0.33, P = .043). Results were similar in patients with and without an increase in T wave amplitude during follow-up. CONCLUSIONS In this study of patients with reperfused MI, patients with inferior locations demonstrated a statistically significant relationship between the amount of positivity of T wave amplitude and both IS and LVEF measured at 3 months. Furthermore, these results were independent of whether the T wave positivity was persistent or evolutionary between the immediate postreperfusion and 3-month ECG recordings.
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10
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Truong QA, Banerji D, Ptaszek LM, Taylor C, Fontes JD, Kriegel M, Irlbeck T, Nagurney JT, Hoffmann U. Utility of nonspecific resting electrocardiographic features for detection of coronary artery stenosis by computed tomography in acute chest pain patients: from the ROMICAT trial. Int J Cardiovasc Imaging 2011; 28:365-74. [PMID: 21287278 DOI: 10.1007/s10554-011-9823-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
Abstract
Twelve-lead surface electrocardiography (ECG) and computed tomography (CT) are used to evaluate for myocardial ischemia and coronary artery disease (CAD), respectively. We aimed to determine features on resting ECG that predict coronary artery stenosis by cardiac CT. In 309 acute chest pain patients, we compared the initial triage resting ECG to contrast-enhanced 64-slice cardiac CT angiography. We assessed for 6 quantitative (QT interval, QTc interval, QTc > 440 ms, gender-specific QTc, QT dispersion and QRS duration) and 4 qualitative ECG parameters (ST depression >0.05 to ≤0.1 mV, T wave inversion ≥0.1 mV, T wave flattening, and any T wave abnormalities) and for the presence of coronary stenosis by CT (>50% luminal narrowing). Specificities of these ECG parameters were excellent (83.6-97.0%) while sensitivities were poor (12.2-29.3%). For coronary stenosis detection, the ECG features with the greatest performance were the presence of ST depression (positive likelihood ratio [LR+] 4.09) and T wave inversion (LR+ 4.58). In multivariable analyses, the risk for coronary stenosis increased by 33-41% for every 20 ms prolongation of the QTc interval after adjusting for age, gender, and cardiac risk factors or adjustment for Framingham risk score. Similarly, there was an increase of fourfold with the presence of ST depression >0.05 to ≤0.1 mV or T wave inversion ≥0.1 mV. In acute chest pain patients, resting ECG features of QTc interval prolongation, mild ST depression, and T wave inversion are independently associated with the presence of CT coronary stenosis and their presence suggests an increase risk of CAD.
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Affiliation(s)
- Quynh A Truong
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA.
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Ström Möller C, Zethelius B, Sundström J, Lind L. Persistent ischaemic ECG abnormalities on repeated ECG examination have important prognostic value for cardiovascular disease beyond established risk factors: a population-based study in middle-aged men with up to 32 years of follow-up. Heart 2007; 93:1104-10. [PMID: 17483125 PMCID: PMC1955011 DOI: 10.1136/hrt.2006.109116] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To determine the effect of new, persistent or reverted ischaemic ECG abnormalities at ages 50 and 70 years on the risk of subsequent cardiovascular disease. DESIGN, SETTING AND PARTICIPANTS A prospective community-based observational cohort of 50-year-old men in Sweden, followed for 32 years. 2322 men of age 50 years participated in 1970-3, and 1221 subjects were re-examined at the age of 70 years. MAIN OUTCOME MEASURES Myocardial infarction (MI), cardiovascular mortality and overall mortality. RESULTS At 50 years of age, after adjusting for established conventional risk factors, T wave abnormalities, ST segment depression, major Q/QS pattern and ECG-left ventricular hypertrophy were all found to be independent risk factors for the main outcome measures during the 32 years of follow-up. When ECG variables were re-measured at 70 years of age, they were still found to be independent risk factors for the mortality outcomes, but lost in significance for prediction of MI. Regarding mortality, it was twice as dangerous to have persistent T wave abnormalities (HR 4.63; 95% CI 2.18 to 9.83) or ST segment depression (HR 5.66; 95% CI 1.77 to 18.1), as with new T wave abnormalities (HR 2.20; 95% CI 1.48 to 3.29) or ST segment depression (HR 2.55; 95% CI 1.74 to 3.75), developing between ages 50 and 70 years. The addition of "ECG indicating ischaemia" significantly increased the predictive power of the Framingham score (p<0.001). CONCLUSIONS It is worthwhile to obtain serial ECGs for proper risk assessment, since persistent ST-T abnormalities carried twice as high a risk for future mortality compared with new or reverted abnormalities.
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Moller CS, Byberg L, Sundstrom J, Lind L. T wave abnormalities, high body mass index, current smoking and high lipoprotein (a) levels predict the development of major abnormal Q/QS patterns 20 years later. A population-based study. BMC Cardiovasc Disord 2006; 6:10. [PMID: 16519804 PMCID: PMC1420329 DOI: 10.1186/1471-2261-6-10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2005] [Accepted: 03/06/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most studies on risk factors for development of coronary heart disease (CHD) have been based on the clinical outcome of CHD. Our aim was to identify factors that could predict the development of ECG markers of CHD, such as abnormal Q/QS patterns, ST segment depression and T wave abnormalities, in 70-year-old men, irrespective of clinical outcome. METHODS Predictors for development of different ECG abnormalities were identified in a population-based study using stepwise logistic regression. Anthropometrical and metabolic factors, ECG abnormalities and vital signs from a health survey of men at age 50 were related to ECG abnormalities identified in the same cohort 20 years later. RESULTS At the age of 70, 9% had developed a major abnormal Q/QS pattern, but 63% of these subjects had not been previously hospitalized due to MI, while 57% with symptomatic MI between age 50 and 70 had no major Q/QS pattern at age 70. T wave abnormalities (Odds ratio 3.11, 95% CI 1.18-8.17), high lipoprotein (a) levels, high body mass index (BMI) and smoking were identified as significant independent predictors for the development of abnormal major Q/QS patterns. T wave abnormalities and high fasting glucose levels were significant independent predictors for the development of ST segment depression without abnormal Q/QS pattern. CONCLUSION T wave abnormalities on resting ECG should be given special attention and correlated with clinical information. Risk factors for major Q/QS patterns need not be the same as traditional risk factors for clinically recognized CHD. High lipoprotein (a) levels may be a stronger risk factor for silent myocardial infarction (MI) compared to clinically recognized MI.
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Affiliation(s)
- Christina Strom Moller
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Sweden
- AstraZeneca, Research and Development, Sweden
| | - Liisa Byberg
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Sweden
| | - Johan Sundstrom
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Sweden
| | - Lars Lind
- Department of Medical Science, Uppsala University, Sweden
- AstraZeneca, Research and Development, Sweden
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Atar S, Birnbaum Y. Ischemia-induced ST-segment elevation: classification, prognosis, and therapy. J Electrocardiol 2005; 38:1-7. [PMID: 16226066 DOI: 10.1016/j.jelectrocard.2005.06.098] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 10/25/2022]
Abstract
The standard 12-lead electrocardiogram (ECG) remains the most useful tool for the diagnosis, early risk stratification, triage, and guidance of therapy in patients with acute coronary syndromes. However, the initial and the terminal part of the QRS complex, the ST segments, and the T waves are influenced by anatomical and metabolic factors such as the "myocardium at risk" and "severity" and "duration" of ischemia. Moreover, there are complex interactions between all these factors. The ECG can identify potential candidates for reperfusion therapy as well as the completeness and success of reperfusion, whereas it can also identify those patients who will have no benefit from reperfusion because of either late arrival or nonischemic etiologies of ECG changes. These patients may have a "pseudo" ST-elevation acute myocardial infarction (STEAMI) or "pseudo-pseudo" STEAMI. The presence of Q waves and additional ST-segment depression and T-wave inversion on the admission ECG in patients with STEAMI may provide us information regarding the potential myocardial reserves, and various ECG scoring systems are in current use for that purpose. The pattern and timing of changes in Q waves, ST segment, and T waves may all be markers of the patency status of the infarct-related artery. We review and discuss each of the dynamic ECG variables during ischemia and reperfusion: the initial QRS (Q and R waves), the terminal QRS (Sclarovsky-Birnbaum score), the ST segment, and the T waves.
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Affiliation(s)
- Shaul Atar
- The Division of Cardiology, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
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Birnbaum Y, Ware DL. Electrocardiogram of acute ST-elevation myocardial infarction: the significance of the various "scores". J Electrocardiol 2005; 38:113-8. [PMID: 15892020 DOI: 10.1016/j.jelectrocard.2005.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Electrocardiogram has extensively been used for evaluation and triage of patients with acute chest pain. The clinician admitting a patient with ST elevation acute myocardial infarction should be able to estimate the size and location of the ischemic area at risk, how much of the ischemic myocardium has already undergone irreversible necrosis by the time of presentation, and the "severity of ischemia" (or what is the rate of progression of necrosis as long as ischemia continues). The electrocardiographic variables that are used to make these estimates are the initial portion of the QRS (Q and R waves), the terminal portion of the QRS (the S waves and the J-point), the ST segment, and the configuration of the T waves. This editorial discuss the ability to predict each of the "physiological" parameters using the above mentioned electrocardiographic variables.
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Affiliation(s)
- Yochai Birnbaum
- Division of Cardiology, Department of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA.
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Pierard LA, Lancellotti P. Determinants of persistent negative T waves and early versus late T wave normalisation after acute myocardial infarction. Heart 2005; 91:1008-12. [PMID: 16020585 PMCID: PMC1769044 DOI: 10.1136/hrt.2004.033936] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To determine whether persistent versus early or delayed T wave normalisation of negative T waves after acute myocardial infarction is determined by the myocardial state, the treatment strategy, or both. DESIGN 127 consecutive patients with a first acute myocardial infarction and > or = 2 negative T waves on the 24-36 hour ECG were studied. They underwent dobutamine stress echocardiography and coronary angiography during the first week. ECG was recorded at hospital discharge and at a mean (SD) of 4 (1) months. SETTING University hospital. RESULTS T wave normalisation was observed in 88 patients (early at discharge in 19 and delayed at four months in 69). Early T wave normalisation was associated with sustained contractile reserve during dobutamine stress (13 of 19 (68%)), whereas delayed T wave normalisation was observed mainly in patients with an ischaemic response (49 of 69 (71%)). The persistence of negative T waves was associated with an ischaemic response (21 of 39 (54%)) or persistent akinesis (17 of 39 (44%)). Among patients with an ischaemic response to dobutamine, in-hospital elective angioplasty was an independent determinant of delayed T wave normalisation (39 of 49 v 4 of 21 patients with persistent negative T waves at four months, p < 0.0001). CONCLUSIONS Early T wave normalisation is associated with dobutamine induced, sustained improvement indicating myocardial stunning. Delayed normalisation is observed mainly in patients with ischaemic myocardium who have undergone revascularisation. Persistent negative T waves correspond to either extensive necrosis or non-revascularised, jeopardised myocardium.
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Affiliation(s)
- L A Pierard
- Department of Cardiology, University Hospital, Liège, Belgium.
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Kalinauskiene E, Vaicekavicius E, Kulakiene I. Prediction of decrease in myocardial perfusion defect size and severity during a 3-month follow-up by the degree of acute resolution of electrocardiographic changes. J Electrocardiol 2005; 38:100-5. [PMID: 15892018 DOI: 10.1016/j.jelectrocard.2004.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Myocardial perfusion in infarct-related artery (IRA) distribution improves progressively until a few months after successful reperfusion therapy. We assessed the rate of electrocardiographic (ECG) stage dynamics to predict perfusion improvement after mechanical, thrombolytic, or spontaneous recanalization of IRA. Thirteen patients were divided into group A (n = 8, with > or = 2 ECG stages per 2-day change rate) and group B (n = 5, no rapid change of ECG stages). There were no significant technetium Tc 99m sestamibi scintigraphic differences between the groups 3 days after recanalization; however, after 3 months, perfusion deficit size (2.8 +/- 1.8 vs 4.8 +/- 1.2, P < or = .03) and severity (1.8 +/- 0.9 vs 3.0 +/- 0, P < or = .03) were smaller in group A vs group B. The prediction sensitivity of the method was 87.5% for decrease in size and 100% for decrease in severity of perfusion defect; the specificity was 80% and 100%, respectively. A change rate of 2 or more ECG stages per 2 days predicts follow-up improvement of myocardial perfusion after IRA recanalization.
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Affiliation(s)
- Egle Kalinauskiene
- Institute of Cardiology, Kaunas University of Medicine, Kaunas, Lithuania.
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Altun A, Durmus-Altun G, Birsin A, Gultekin A, Tatli E, Ozbay G. Normalization of negative T waves in the chronic stage of Q wave anterior myocardial infarction as a predictor of myocardial viability. Cardiology 2004; 103:73-8. [PMID: 15539785 DOI: 10.1159/000082051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Accepted: 07/08/2004] [Indexed: 11/19/2022]
Abstract
We investigated whether spontaneous normalization of negative T waves (TWN) on infarct-related ECG leads (IRLs) in the chronic phase of Q wave anterior myocardial infarction (MI) could be a predictor of residual viability in infarct areas. We prospectively studied 35 patients (age 60 +/- 8.6 years) in the chronic phase of Q wave anterior MI. Spontaneous TWN (group A, n = 23) were defined as negative T waves that became upright (> or =0.15 mV) in > or =2 IRLs. The presence of negative T waves (group B, n = 12) was defined as symmetric or biphasic negative T wave of > or =0.15 mV. All patients underwent same-day rest 201Tl-stress (99m)Tc sestamibi dual-isotope myocardial perfusion SPECT and 24-hour 201Tl reinjection imaging for ischemia and viability analysis. On scintigraphic examination, ischemic or viable myocardial segments were found in 18 patients (78%) with TWN and 4 patients (33%) of group B (p = 0.013). The use of TWN as a parameter had a marked influence on the sensitivity (82%), specificity (62%), positive (78%) and negative (67%) predictive values and accuracy (74%) of the diagnosis of viable myocardium. If we add the criterion of positive T waves in aVR with negative T waves to our criteria, we found that sensitivity (90%), positive (80%) and negative (80%) predictive values and accuracy (80%) increased. The results of our study suggest that analysis of TWN on IRLs is an accurate marker of residual viability and/or persistent peri-infarct ischemia in patients in the chronic stage of Q wave anterior MI, and therefore optimizes the diagnostic and therapeutic strategies after MI.
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Affiliation(s)
- Armagan Altun
- Department of Cardiology, Medical School, Trakya University, Edirne, Turkey.
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