A complex case of PCI ( Rota-stenting strategy for heavily calcified coronary lesions ) ,

 A journal published article , written by Dr.Nabil Paktin

What is Electrical alternans vs. Pseudo-electrical alternans and pseudo literature reports ?

Electrical alternans is a broad term that describes alternate-beat variation in the direction, amplitude, and duration of any component of the ECG waveform (ie, P, PR, QRS, R-R, ST, T, U)
It was first recognized by Hearing in 1909 and further characterized by Sir Thomas Lewis in 1910 as occurring “either when the heart muscle is normal but the heart rate is very fast or when there is serious heart disease and the rate is normal.”
Kalter and Schwartz first identified electrical alternans on surface ECG in 1948
Electrical alternans must be distinguished from mechanical alternans (eg, pulsus alternans), although both may coexist 

The pathophysiologic mechanisms that cause electrical alternans can be divided into 3 categories:

-Repolarization alternans (ST, T, U alternans)

-Conduction and refractoriness alternans (P, PR, QRS alternans)

-Alternans due to cardiac motion

Electrical Alternans Associated with cardiac motion is due to alternation in the position of the heart with relation to recording electrodes.

The most common underlying disorder is an enlarged pericardial sac; however, not all pericardial effusions cause electrical alternans.

The presence of pericardial disease and total electrical alternans (P, QRS, and T wave) frequently suggests cardiac tamponade, but total electrical alternans is seen in only 5-10% of patients with cardiac tamponade.

Heart movement in patients with hypertrophic cardiomyopathy also may result in electrical alternans of this type .

Whenever what appears to be electrical alternans is not due to a large pericardial effusion, then pseudoelectrical alternans should be considered. Pseudoelectrical alternans is due to alternation in axis or amplitude because of events that alter conduction and do not alter the physical orientation of the heart.

In 1978, Klein, Segni and Kaplinsky coined the term ‘pseudoelec- trical alternans’ in a case report of intermittent left anterior hemiblock, in which the axis shifted every other beat due to the development of alternating normal and then leftward axis shift, presumably related to procaina- mide therapy.

Unfortunately, some literature defining interchangeably as true electrical alternans is a repolarization or conduction abnormality of the Purkinje fibers or myocardium.
Electrical alternans due to cardiac motion is effectively artifact, as the heart swings in relation to the chest wall and electrodes, with a period twice that of the heart rate. However, tamponade related electrical alternans is the true one .

Exclusively in Dr.Nabil Paktin Cardiology Notes

Time course and hemodynamics of Mitral stenosis ( MS) causing Pulmonary arterial Hypertension ( PAH)

Mitral stenosis occurs
Left atrial pressure rise
Left atrium enlarges
Cephalization
PIE
PAH develops
PVR increases
RV enlarges
Pulmonic regurgitation develops
Tricuspid annulus dilates
Tricuspid insufficiency
RV failure

Please Click over image for a better resolution 

What is Cardiac cachexia?

What is Goose neck appearance in Atrioventricular septal defect (AVSD)?

Echogenic Foci ( bright spot in the baby's heart) , Is it normal or abnormal ?

References

1. Petrikovsky BM, Challenger M, Wyse LJ. Natural history of echogenic foci within ventricles of the fetal heart. Ultrasound Obstet Gynecol. 1995;5:92-94.

2. Brown DL, Roberts DJ, Miller WA. Left ventricular echogenic focus in the fetal heart: pathologic correlation. J Ultrasound Med. 1994;13:613-616.

3. Tennstedt C, Chaoui R, Vogel M, Goldner B, Dietel M. Pathologic correlation of sonographic echogenic foci in the fetal heart. Prenat Diagn. 2000;20:287-292.

4. Dildy GA, Judd VE, Clark SL. Prospective evaluation of the antenatal incidence and postnatal significance of the fetal echogenic cardiac focus: a case-control study. Am J Obstet Gynecol. 1996;175:1008-1012.

5. Barsoom MJ, Feldman DM, Borgida AF, Esters D, Diana D, Egan JF. Is an isolated fetal cardiac echogenic focus an indication for fetal echocardiography? J Ultrasound Med. 2001;20:1043-1046.

6. Lamont RF, Havutcu E, Salgia S, Adinkra P, Nicholl R. The association between isolated fetal echogenic cardiac foci on second-trimester ultrasound scan and trisomy 21 in low-risk unselected women. Ultrasound Obstet Gynecol. 2004;23:346-351.

7. Simpson JM, Cook A, Sharland G. The significance of echogenic foci in the fetal heart: a prospective study of 228 cases. Ultrasound Obstet Gynecol. 1996;8:225-228.

8. Bradley KE, Santulli TS, Gregory KD, Herbert W, Carlson DE, Platt LD. An isolated intracardiac echogenic focus as a marker for aneuploidy. Am J Obstet Gynecol. 2005;192:2021-2026; discussion 2026-2028.

Diabetes is not CAD equivalent anymore

Diabetes and Prior Coronary Heart Disease are Not Necessarily Risk Equivalent for Future Coronary Heart Disease Events

The prevalence and burden of diabetes mellitus remains high.After Haffner et al.reported that adults with diabetes had the same risk for future myocardial infarction (MI) as adults with previous MI and without diabetes, the Adult Treatment Panel (ATP) III guidelines in 2001 recommended that all individuals with diabetes be considered as “Coronary heart disease (CHD) risk equivalent”.However, the latest 2013 ACC/AHA assessment of risk guidelines considers diabetes as only one of the many variables in its risk assessment equation.
The assertion that all patients with diabetes are CHD equivalent has been controversial.Existing evidence is based on relatively small studies with various limitations.
Some studies were limited to a single gender, while others were based on self-reported diagnosis of diabetes.

Some lacked the ability to adjust for important confounding risk factors.Most of the studies have comprised cohorts from the 1990s, and only a few studies have been able to evaluate the impact of the duration of diabetes. There is also a paucity of data among relatively young (30–40 years) patients with diabetes. For all these reasons, updated evidence from a contemporary population is needed to inform our understanding of CHD risk in diabetes patients

Based on a recent examination of the 2013 ACC/AHA Pooled Cohort Equation, the inclusion of diabetes in the scoring criteria rather than considering diabetes as an automatic CHD equivalent led to important differences in predicted risk that might influence decision-making in younger patients with diabetes.

The recent study expressed as follow:

-Individuals with diabetes alone had significantly lower risk of CHD across all age and sex strata compared to those with CHD alone (12.2 versus 22.5 per 1000 person-years).
-The risk of future CHD for patients with a history of either DM or CHD was similar only among those with diabetes of long duration (≥10 years) to can call diabetes equivalent.
-Not all individuals with diabetes should be unconditionally assumed to be a risk equivalent of those with prior CHD.