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May 27, 2015

Feed your Brain with ECG Today

Many people think electrocardiograph (thusly called ECG or EKG) a tough talk to understand and interpret. This is not such a huge task or need to do specialization in cardiology. This is just cardiology, simple biological pipes and wires. ECGs are simpler still, being a moving real time map of the “wires” part and how they conduct electricity.  Reading EKGs only seems hard because most cardiologists use long (expensive) words.
Most healthy hearts pump blood through the body when stimulated by an electrical signal that travels along predetermined pathways.This causes the cardiac cells to contract in just the right order, resulting in a magical four chambered pumping action. 
An EKG is a graph tracing the strength and direction of this electrical signal. Leads equipped with conductive goo are placed on different parts of the body allowing a view of the heart from different angles. If the electrical activity of the heart at any given moment is traveling toward the lead being viewed, the line on the graph goes up (positive deflection).  If the electrical activity is traveling away from the lead, the line goes down (negative deflection). This graph is being traced by a stylus on a moving piece of graph paper. In a normal healthy heart, an ECG representing one complete heartbeat looks about like this :
That first petite little hump, affectionately called the P wave, represents the electrical signal that starts in a group of cells called the Sinoatrial Node. This signal then travels through the atria (the smaller and upper two chambers of the heart) causing them to contract and push blood in to the larger and more powerful ventricles below.
The “PR Interval” segment represents a delay in the signal at another grouping of cells called the AtrioVentricular Node.This delay allows time for the atria to completely deliver their bounty into the Ventricles. With perfect timing this signal continues through the Bundle of His.The signal splits and speeds along down the left and right bundle branches, making its way to the Purkinje fibers and turning north again.This stimulates those Ventricular beefcakes to contract and deliver their payload to the lungs and body (if hearts had biceps, the left ventricle would be the proverbial “gun show”….it’s such a glory hog!).
The journey causing this second contraction through the ventricles is represented by the QRS portion of the ECG. The larger T wave which then finishes off our heartbeat is the repolarization of the ventricles.I know what you’re thinking, either “what in the what now goes where?” or hopefully, “what wave represents the repolarization of the atria”? Well, the repolarization of the atria is buried in the larger signal of the QRS and therefore not visible on the graph.
This pattern is called normal sinus rhythm.  It is the basic ECG of any normal healthy heart. Naturally, there are variations of normal within the healthy population. For example, my boyfriend is very fit and has a *huge* R wave (hands off his big left ventricle ladies, it’s all mine! And don’t get me started on his early repolarization…and no…being early in this case is definitely not a bad thing). However, anything outside of the normal range is analyzed along with the patient’s symptoms to create a working diagnosis.There are several types of common abnormalities. A PR interval that is too long is called a first degree block. A QRS that takes longer than .12 seconds is likely to be caused by a delay in one or both bundle branches, called a bundle branch block. A complete lack of P waves, and in their place a squiggly line, combined with an irregular heartbeat is likely to be atrial fibrillation. What really gets a Paramedic or ER doctor excited is when they see an elevation of the ST segment in a few consecutive leads.This is referred to as an ST elevation myocardial infarction (heart attack) and generally results in a speedy trip to the catheterization. 
Feeding points:
1) Each small box on the modern ECG strip represents 0.04 seconds on the horizontal axis.
2) ECG paper is calibrated to move at 25mm per second past the stylus.
3) The ECG was invented by the Dutch Dr. Willhelm Einthoven in 1903, for which he received the Nobel Prize in 1924. More impressively, he also had a triangle named after him.
4) It is very rare, but possible for an ECG to show a flat line, called asystole, when in fact the heart is still beating and producing a pulse.  It is because of this that it’s common practice to confirm death in a patient by looking for asystole in more than one lead.
5) Conversely it is also possible, and more common, to have an ECG show heart activity, and even normal sinus rhythm, after a person has died and their heart is no longer pumping blood. This is called a PEA, pulseless electrical activity, and shows what is left of the heart’s intact electrical system after the muscle itself has failed.
I hope you understand well. 

Thanking you
Dr.Akshaya Srikanth B, PharmD


May 26, 2015

Cardiac Biomarkers

A blood screening technology has uncovered many biomarkers that improve the prediction of the risk for heart attack or stroke with in the next 15 years. The blood profiling technique may eventually help doctors to identify those people who would benefit the most from early treatment and high-throughput profiling of circulating metabolites may improve cardiovascular risk prediction over established rik prediction over established risk factors. 
Biomarkers can potentially be used to detect and monitor a wide range of cardiac conditions in the critical care setting. Currently the only biomarker acceptable for changing management in acute coronary syndrome is the troponin test. In the future, a tailored multi-marker approach may have use in guiding diagnosis and therapy – this is a long way off!

POTENTIAL USES OF CARDIAC BIOMARKERS
Myocardial Ischemia
·         Troponin
·         H-FABP
·         ischaemic modified albumin
Thrombosis
·         CRP
·         ESR
·         different binding proteins
·         Myocardial injury
·         Troponin (level peaks at 12h, proportional to infarct size, but altered by washout phenomenom after reperfusion therapy)
·         CK
·         CK-MB
·         myoglobin
·         AST
·         LDH
Novel: copeptin (C-terminal provasopressin), BNP/ NTproBNP, GP-BB, myleoperoxidase, pregnancy associated plasma protein A
Inflammation, endothelial activation and neutrophilic activation
·         CRP
·         ESR
·         PaPPA
·         endothelin/ CTproET-1
·         adrenomedullin/ MRproADM
·         myeloperoxidase
·         matrix metalloproteinases (MMP9, MMP2, TIMP1)
Heart failure
·         BNP/ NTproBNP
·         ANP/ N-ANP/ MRproANP
·         Troponin
·         IL18
·         CA125
·         Urocortin
Sepsis-induced myocardial dysfunction
·         Troponin
·         BNP/ NTproBNP
·         Right ventricular strain in pulmonary embolism
·         Troponin
·         BNP/ NTproBNP

ADVANTAGES AND DISADVANTAGES 


In addition these biomarkers mentioned above four new biomarkers were identified in 2015. The scientists identified over 200 biomarkers for body metabolism from a single blood sample using Nuclear Magnetic Resonance (NMR) spectroscopy. The perspectives of new biomarkers for future cardiovascular disease were Phenylalanine, a common amino acid, and the amount of monounsaturated fat in the blood; higher concentrations were linked with higher disease risk. These two biomarkers were as strong predictors of future heart disease as the measures bad cholesterol or blood pressure. In addition, higher blood levels of both omega-3 and omega-6 fatty acids were linked with lower risk for cardiovascular disease. All these molecules are normally present in everyone's blood, but it is the amount of these molecules that was shown to be reflecting the cardiovascular health. 
These new biomarkers can help to better assess the complex molecular processes behind the development of cardiovascular disease. The improved prediction of cardiovascular risk also suggests cost saving in healthcare by advanced biomarker profiling. The low-cost blood screening technology opens a treasure trove to understand the molecular mechanism of heart disease and other metabolic disease.

by 
Dr.Akshaya Srikanth Bhagavathula, Pharm.D 
for Pharm.D India