Impact of hemodialysis on P-wave amplitude, duration, and dispersion

Atrial fibrillation (AF) is a frequent arrhythmia in patients undergoing hemodialysis (HD). P wave duration (PWdu) and P wave dispersion (PWdi) have been shown to be predictors of emerging AF in different clinical conditions. We sought to study the impact of HD on PWdu, PWdi, and P wave amplitude in a cohort of patients undergoing HD. Seventeen patients (8 men, 31+/-10 years) were studied. Echocardiography parameters, the sum of the amplitude of P waves in all 12 ECG leads (SP), mean PWdu, and PWdi, along with a host of other parameters (body weight, heart rate, electrolytes and hemoglobin/hematochrit) were measured 1/2h, before and after, HD. SP increased (11.8+/-3.9 vs 15.3+/-4.0 mm, p = 0.004), mean PWdu remained stable (82.7+/-11.1 vs 81.6+/-10.5 ms, p = 0.606), PWdi decreased (51.7+/-19.1 vs 41.7+/-19.1 ms, p = 0.03), and left atrial dimension decreased (37.96+/-3.90 vs 30.62+/-3.38 mm, p = 0.0001), after HD. The change in PWdi correlated with fluid removed by HD (r = -0.55, p = 0.022). Re-measurements of P-wave parameters in a random group of 11 of the 17 patients revealed augmented SP (p = 0.01), and stable mean PWdu (p = 0.36), and PWdi (p = 0.31), after HD. Fluid removed by HD leads to an increase in SP, a stable mean PWdu, and decrease (or stability on re-measurement in a subgroup of patients) in PWdi. Stability of PWdu may be due to the effects of augmentation of the P-wave amplitude and the reduction of the left atrial volume, cancelling each other. Variability of PWdi may stem from the occasional impossibility to measure PWdu (or measure it correctly) in minute P-waves in certain ECG leads, which in turn profoundly affects the PWdi.     

The need for studies to evaluate the reproducibility of the T-wave alternans (TWA), and the rationale for a correction index of the TWA

Sudden cardiac death (SCD) due to various cardiomyopathies is currently prevented by the implantation of an automated cardioverter/defibrillator (ICD). ICD impalntation in patients who are not survivors of SCD, or have not suffered potentially lethal ventricular arrhythmias, are based on the presence of cardiomyopathy with a reduced left ventricular ejection fraction. The bulk of patients who are considered suitable for an ICD implantation and receive such devices, do not experience device therapy shocks at follow-up ("false positives"), thus creating a climate of uncertainty among patients and physicians about the soundness of our current eligibility criteria for ICDs. In addition the cost of inappropriate ICDs is staggering, and the undue exposure of "false positive" patients to complications, and hardships is disconcerting. T-wave alternans (TWA) has emerged as a possible "risk detection of SCD" technology, but its reproducibility has not been tested. Peripheral edema (extracardiac) or other cardiac mechanisms, unrelated to the degree of SCD risk, alter the amplitude, and other attributes, of the T-waves. Since TWA may be T-wave amplitude-, or other T-wave attributes-dependent (this is still a speculation), a need may be emerging for its correction by the T-wave amplitude (TWA index); such an index may enhance the reproducibility, and evaluate the true sensitivity, specificity and predictive accuracy of the TWA in detecting future victims of SCD.     

H+/Ca2+ exchange in rabbit renal cortical endosomes

Summary We have examined the effect of second messengers on ATP-driven H⁺ transport in an H⁺ ATPase-bearing endosomal fraction isolated from rabbit renal cortex. cAMP (0.1mm) had no effect on H⁺ transport. Acridine orange fluorescence in the presence of 0.5mm Ca²⁺ (+1mm EGTA) was 19±6% of control. Inhibition of ATP-driven H⁺ transport by Ca²⁺ was concentration dependent; 0.25 and 0.5mm Ca²⁺ (+1mm EGTA) inhibited acridine orange fluorescence by 50 and 80%, respectively. Ca²⁺ also produced a concentration-dependent increase in the rate of pH-gradient dissipation. Ca²⁺ did not affect ATP hydrolysis. ATP-dependent Br^– uptake was virtually unchanged in the presence of 0.5mm Ca²⁺ (+1mm EGTA). These vesicles were also shown to transport Ca²⁺ in an ATP-dependent mode. Inositol 1, 4, 5-trisphosphate had no effect on ATP-dependent Ca²⁺ uptake. These results are consistent with the co-existence of an H⁺ ATPase and an H⁺/Ca²⁺ exchanger on these endosomes, the latter transport system using the H⁺ gradient to energize Ca²⁺ uptake. Attempts to demonstrate an H⁺/Ca²⁺ antiporter in the absence of ATP have been unsuccessful. Yet, when a pH gradient was established by preincubation with ATP and residual ATP was subsequently removed by hexokinase + glucose, stimulation of Ca²⁺ uptake could be demonstrated. A Ca²⁺-dependent increase in H⁺ permeability and an ATP-dependent Ca²⁺ uptake might have important implications for the regulation of vacuolar H⁺ ATPase activity as well as the homeostasis of cytosolic Ca²⁺ concentration.     

QRS Voltage Changes in Heart Failure: A 3-Compartment Mechanistic Model and its Implications

A 3-compartment mechanistic model is proposed to explain the attenuation of the electrocardiographic QRS complexes (↓QRSV) observed in patients with heart failure (HF). This includes the effects of increased intracardiac blood volume and decreased hematocrit due to blood dilution (1st compartment), the heart's alteration in electrogenesis due to possible ischemia or inflammation, leading to myocardial edema, (2nd compartment), and the passive volume conductor of the tissue and organ constituents of the thorax and the entire body, with their resistivity changes due to increased fluid content (pulmonary and peripheral edema) (3rd compartment). The clinical implications of the model are outlined.