Buckground: Because the most characteristic and sensitive electrocardiographic (ECG) correlate of pulmonary emphysema in adults is verticalization of the frontal plane P-wave vector (P axis), we investigated its strength as a lone criterion to screen for obstructive pulmonary disease (OPD) in an adult hospital population.Methods: In all, 954 consecutive unselected ECGs were required to yield 100 with P axis 2 +70" (unequivocally negative P in aVL during sinus rhythm) and pulmonary function tests, and I 0 0 with P axis I +50" (unequivocally positive P-aVL).Results: Obstructive pulmonary disease by both pulmonary function test and clinical criteria was present in 89 of 100 patients with vertical P axes and 4 of 100 patients without OPD.Conclusion: The high sensitivity (89% for this series) and high specificity (96%) makes vertical P axis a useful screening criterion. Its at-a-glance simplicity makes it "user-friendly."

The diagnostic accuracy and clinical benefits of instantaneous wave-free ratio (iFR) compared to fractional flow reserve (FFR) have been well-established in the literature. Despite the advantages of non-hyperemic pressure indices, approximately 20% of iFR and FFR measurements are discordant. Efforts have been made to establish the mechanisms as well as identify causative factors that lead to such a discordance. Recent studies have identified many factors of discordance including sex differences, age differences, bradycardia, coronary artery stenosis location, elevated left ventricular end-diastolic pressure, and diastolic dysfunction. Additionally, discordance secondary to coronary artery microcirculation dysfunction, as seen in diabetics and patients on hemodialysis, has sparked interest amongst experts. As more interventional cardiologists are utilizing iFR independent of FFR to guide percutaneous coronary intervention an emphasis has been placed on identifying factors leading to discordance. The aim of this review is to outline recent studies that have identified factors of FFR and iFR discordance.

Objective. We aimed to study the differences in perception of pain during cardiac catheterization with midazolam monotherapy compared to the current standard of midazolam plus fentanyl. Background. Procedural sedation is important to ensure comfort and safety in patients undergoing left heart catheterization. Despite the widespread use of midazolam and fentanyl for procedural sedation, the effectiveness of this dual agent approach to sedation has never been studied in comparison to midazolam monotherapy. Methods. A total of 129 patients undergoing sedation for outpatient elective cardiac catheterization were randomly assigned to either midazolam monotherapy (n = 69) or combination of midazolam and fentanyl (n = 60). The primary outcome was assessment of pain perception prior to discharge by patient completion of a pain questionnaire. Participants were asked if they experienced any pain during their procedure (yes/no) and, if yes, asked to rate their overall pain level using a 10-point Likert scale that ranged from 1 (minimal pain) to 10 (worst pain imaginable). Results. Most patients (n = 94, 73%) reported no pain during their procedure. Patients sedated with midazolam monotherapy reported similar average pain scores compared to patients sedated with the combination of midazolam and fentanyl (1.1 vs. 1.1, p = 0.95 ). Conclusions. Among patients undergoing elective cardiac catheterization, no significant differences in pain scores were noted between sedation with midazolam alone compared to midazolam and fentanyl. Due to fentanyl’s unfavorable interaction with P2Y12 agents, increased costs, and addiction potential, it is imperative that cardiologists revisit the role of effective procedural sedation with a single agent and avoid the use of fentanyl.

Background Instantaneous wave-free ratio (iFR)-guided physiological assessment has been shown to be non-inferior to fractional flow reserve (FFR)-guided assessment for deciding best treatment strategy for angiographically intermediate stenosis. The diagnostic accuracy of iFR compared to FFR reported in various studies is around 80%. Many factors can lead to iFR/FFR discordance, though underlying physiological mechanism of discordance and its associated factors have not been fully evaluated. The effect of left ventricle end diastolic pressure (LVEDP) on iFR/FFR discordance is unknown and needs further evaluation. Methods We performed a single center, non-randomized, both retrospective and prospective study. A total of 65 patients with intermediate coronary stenosis undergoing physiological assessment were included in the study. Patients were assigned to two groups (normal LVEDP and high LVEDP group) based on LVEDP cutoff of 15 mm Hg. iFR and FFR were measured for each patient and iFR/FFR results were compared between the two groups. Results A significantly large number of patients in elevated LVEDP group had iFR/FFR discordance compared to normal LVEDP group (42.8% vs. 6.7%, P = 0.001). More patients with acute coronary syndrome (ACS) had discordance compared to stale coronary artery disease (CAD) patients (53% vs. 15%, P = 0.003). Conclusions Elevated LVEDP can affect iFR and FFR measurements and can lead to discordance. Further studies are required to determine effect of elevated LVEDP on iFR/FFR discordance and whether such discordance is clinically relevant. “Normal range” iFR results should be cautiously interpreted in patients with elevated LVEDP, especially those with ACS.