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Madias J.E.,Mount Sinai School of Medicine | Madias J.E.,Elmhurst Hospital Center
PACE - Pacing and Clinical Electrophysiology | Year: 2011

The electrocardiogram (ECG) has not as yet realized its potential in the diagnosis and management of patients with heart failure (HF). The current model of using the ECG qualitatively with reference to the presence of arrhythmias, heart rate changes, hypertrophy, previous myocardial infarctions, ischemia, and conduction abnormalities is nonspecific and of modest value. The author argues, using examples, that the employment of the ECG metrics of amplitude(s) of leads aVR, sum of leads I & II, sum of all six limb leads, and dimensions and the area of the negative component of the P-wave from lead V1, in repeat ECGs from different clinical encounters, could provide the clinician with a powerful specific diagnostic and follow-up instrument in the management of the edematous state of patients with HF. Although "eye-balling" of changes in ECG hardcopies could suffice for this purpose, the increased availability at the "point of care" of automated measurements of ECG management systems renders application of these ideas all too easy. © 2010 Wiley Periodicals, Inc. Source


Madias J.E.,Mount Sinai School of Medicine | Madias J.E.,Elmhurst Hospital Center
International Journal of Cardiology | Year: 2014

This viewpoint pertains to the still elusive pathophysiology of the Takotsubo syndrome (TTS), maintaining the position that this affliction is not the result of coronary vasospasm (CV) involving one or more coronary arteries. Although CV has been rarely encountered in the acute stage of TTS, or elicited via provocative testing in the subacute stage of the disease, it does not appear to be the cause of TTS as shown by the bulk of the published relevant literature. The author provides some speculations to explain the spontaneous appearance of CV, or its artificial elicitation, in some patients with TTS. However while we are striving to unravel the pathophysiology of TTS, we should keep an open mind about a possible role for CV in the causation of TTS. © 2014 Elsevier Ireland Ltd. All rights reserved. Source


Madias J.E.,Mount Sinai School of Medicine | Madias J.E.,Elmhurst Hospital Center
PACE - Pacing and Clinical Electrophysiology | Year: 2013

A case is presented revealing the common phenomenon of heart rate-dependent diagnosis of electrocardiographic (ECG) diagnosis of left ventricular hypertrophy (LVH), which consists of satisfaction of LVH criteria only at faster rates whereas ECGs with a slow heart rate do not satisfy such criteria. The mechanism of the phenomenon has been attributed to the tachycardia-mediated underfilling of the left ventricle bringing the electrical "centroid" of the heart closer to the recording electrodes, which results in augmentation of the amplitude of QRS complexes, particularly in leads V2-V4. ©2012, The Author. Journal compilation ©2012 Wiley Periodicals, Inc. Source


Madias J.E.,Mount Sinai School of Medicine | Madias J.E.,Elmhurst Hospital Center
International Journal of Cardiology | Year: 2014

Diagnosis of Takotsubo syndrome (TTS), the reversible, acute heart failure pathological entity, precipitated by stress, is based on the fulfillment of sets of criteria, developed by careful characterization of the precipitants, symptoms, results of imaging testing, clinical course, and follow-up of many patients presented with this affliction. As understanding of TTS, increase in its awareness, and the diversion in its presentation have evolved, the various proposed diagnostic criteria, naturally have started to appear outmoded. The author argues that the initially proposed Mayo Clinic criteria, the subsequently revised Mayo Clinic criteria, the Japanese Circulation Society guidelines, the Johns Hopkins criteria, and the Gothenburg criteria for the diagnosis of TTS have been outpaced by the rapidly accumulating clinical experience, and thus need to be replaced by more realistic sets of diagnostic rules. To this effect the author proposes a set of diagnostic criteria for TTS, which include 2 plausible, albeit speculative, notions, that of the milder forms or formes frustes of TTS, and the existence of "TTS comorbidity" in patients with various other illnesses, which either precipitate TTS, or are being brought about by TTS. © 2014 Elsevier Ireland Ltd. Source


Madias J.E.,Mount Sinai School of Medicine | Madias J.E.,Elmhurst Hospital Center
Journal of Electrocardiology | Year: 2012

The interpretation of the electrocardiogram (ECG) T-wave alternans (TWA) as positive or negative depends on its magnitude, regardless whether the frequency domain or the time domain analysis is employed. The author argues that a number of cardiac and extracardiac influences can confound the magnitude of TWA. The amplitude of the ECG T waves, considered in the measurement/calculation of TWA, and possibly myocardial edema are examples of cardiac influences. Peripheral edema with its effect in attenuating the amplitude of all components of the ECG, including the T waves, is an example of extracardiac influence. Another concern is the variation in the evolution of the T-wave amplitudes during the 3- to 6-month period after an acute myocardial infarction, and whether such variation confounds the results of the TWA testing, which often is undertaken at that time bracket. The T-wave amplitude changes may impact the sensitivity and specificity of TWA testing after an acute myocardial infarction. Perhaps the measured TWA magnitude should be adjusted to the amplitude of the T waves or voltage-time integral of the J-T interval, depending on the method used for the calculation of TWA. These issues need to be considered and investigated in an effort to render TWA testing more reliable in predicting sudden cardiac death. © 2012 Elsevier Inc. All rights reserved. Source

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