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      Right Precordial and Posterior Electrocardiographic Leads Do Not Increase Detection of Ischemia in Low-Risk Patients Presenting with Chest Pain

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          Abstract

          Background: A number of innovative approaches have been investigated for their value in the early detection of acute ischemia or infarction in patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac origin. Prior investigations have demonstrated the utility of adding right precordial and posterior chest leads to the standard 12-lead electrocardiogram (ECG) for identifying right ventricular and posterior wall infarctions in the ED. Hypothesis: To assess the utility of additional ECG leads in low-risk patients presenting to the ED with symptoms suggestive of acute coronary syndromes who are managed in a chest pain evaluation unit (CPEU). Methods: We studied low-risk patients who presented to the ED with chest pain compatible with myocardial ischemia. Low-risk patients were identified by a normal 12-lead ECG, no arrhythmias or hemodynamic instability, and one negative serum cardiac troponin I. Patients were admitted to the CPEU where a 16-lead ECG was recorded by the addition of 2 right-sided precordial leads (V4R, V5R) and 2 posterior leads (V8, V9) to the standard 12-lead ECG. Results: The 16-lead ECG system was applied to 316 consecutive patients. The study group was a middle-aged population with equal numbers of men and women and an average of 2 cardiac risk factors per patient. The 16-lead ECG demonstrated evidence of myocardial injury in only 1 patient and no evidence of ischemia in any of the 316 patients. Conclusion: In patients presenting to the ED with chest pain and evidence of low clinical risk by our criteria, the addition of both right-sided precordial and posterior chest leads to the standard 12-lead ECG did not provide additional information for risk stratification.

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          Most cited references 6

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          Right ventricular infarction.

          Right ventricular infarction complicates up to half of inferior left ventricular infarctions. The term represents a spectrum of disease from mild, asymptomatic right ventricular dysfunction to cardiogenic shock, and it includes transient ischemic myocardial dysfunction as well as myocardial necrosis. Right ventricular infarction is associated with considerable morbidity and mortality, and its presence defines a high-risk subgroup of patients with inferior left ventricular infarction. Diagnosis of this condition requires a high degree of suspicion based on clinical findings and the early recording of the electrocardiogram through right precordial leads, as well as elevated right-sided filling pressures out of proportion to left-sided filling pressures. The proper management of right ventricular infarction requires sustaining adequate right ventricular preload with volume loading and maintenance of atrioventricular synchrony, reduction of right ventricular afterload (particularly when left ventricular dysfunction is present), and inotropic support of the right ventricle. Early reperfusion with fibrinolytic therapy or direct angioplasty is also warranted. Survivors of right ventricular infarction generally have a restoration of normal right ventricular function with resolution of hemodynamic abnormalities.
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            Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain.

            Our purpose was to determine the safety and accuracy of immediate exercise testing in low-risk patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac etiology. Safe, efficient management of low-risk patients presenting to the ED with chest pain is a continuing challenge. We have employed immediate exercise testing to evaluate a large, heterogeneous group of low-risk patients presenting with chest pain. Patients presenting to the ED with chest pain compatible with a cardiac origin and clinical evidence of low risk on initial assessment underwent immediate exercise treadmill testing in our chest pain evaluation unit. Indicators of low clinical risk included no evidence of hemodynamic instability, arrhythmias or electrocardiographic signs of ischemia. Serial measurements of cardiac injury markers were not obtained. Exercise testing was performed to a sign- or symptom-limited end point in 1,000 patients (520 men, 480 women; age range 31 to 82 years) and was positive for ischemia in 13%, negative in 64% and nondiagnostic in 23% of patients. There were no adverse effects of exercise testing, and all patients with a negative exercise test were discharged directly from the ED. At 30-day follow-up there was no mortality in any of the three groups. Cardiac events in the three groups included: negative group, 1 non-Q-wave myocardial infarction (MI); positive group, 4 non-Q-wave MIs and 12 myocardial revascularizations; nondiagnostic group, 7 myocardial revascularizations. Immediate exercise testing of patients presenting to the ED with chest pain and evidence of low clinical risk is safe and accurate for determining those who require admission and those who can be discharged to further outpatient evaluation.
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              Acute myocardial infarction with isolated ST-segment elevation in posterior chest leads V7–9

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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2004
                July 2004
                09 July 2004
                : 102
                : 2
                : 100-103
                Affiliations
                Divisions of Cardiovascular Medicine and Emergency Medicine, Department of Internal Medicine, University of California School of Medicine (Davis) and Medical Center (Sacramento), Sacramento, Calif., USA
                Article
                77912 Cardiology 2004;102:100–103
                10.1159/000077912
                15103180
                © 2004 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 1, References: 20, Pages: 4
                Categories
                Noninvasive and Diagnostic Cardiology

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