Dr. Kiron Varghese

Following decongestive therapy in patients with acute heart failure, it has been observed that there is an increase in the QRS amplitude in the bipolar limb leads on the surface electrocardiogram (ECG). We wanted to study this phenomenon to identify any markers of improvements in heart failure. Patients with atrial flutter, atrial fibrillation, implanted permanent pacemaker, acute coronary syndrome and those treated with sodium nitroprusside were excluded. Net fluid loss over the course of diuresis was calculated as fluid lost-fluid administered. All patients had two standard 12-lead ECGs recorded at admission prior to starting diuresis and after conclusion of therapy which was at discharge. There were 59 patients. All were treated with decongestive therapy and observed over a period of 8 ± 3.2 days. The urine output following therapy was similar in both groups of patients. The left ventricular internal diameter in diastole (LVIDd) and left ventricular internal diameter in systole (LVIDs) were less in the group with increase in QRS amplitude (Group 2) compared to the group who did not show change in QRS amplitude (Group 1), 4.4 0.8 cm vs 4.9 0.8 cm, p = 0.036, and 3.1 0.5 cm vs 3.7 1.0 cm, p = 0.002. The ratio between the peak velocity blood flow in early (E wave) and late diastole (A wave) in group 2 was 1.2 0.7 compared to 1.7 1.0 in group 1, p = 0.087. The deceleration time (DT) was higher by 45.2 21.5 ms in group 2 compared to group 1 with no change in QRS amplitude, p = 0.04. Following decongestive therapy in a group of patients with heart failure, the QRS amplitude reflected in the limb leads improved significantly from pre-treatment values in the patients with less LV remodelling in terms of LV dilatation and LV diastolic dysfunction.

The gold standard for diagnosis of pulmonary hypertension is right heart catheterization. This procedure requires considerable expertise and has its own procedure related complications. If not done properly, it can lead to misinterpretations of its findings. We have highlighted the procedural technique and major pitfalls in the diagnosis of pulmonary hypertension.

A 16 year old girl diagnosed with systemic lupus erythematosus (SLE) presented to our hospital with acute myocardial infarction. She was hemodynamically stable. Atherosclerosis tends to be more aggressive in these patients. We are reporting this case to highlight the fact that these patients require more intense surveillance and aggressive treatment.