Fetal echocardiography was performed using a high-frequency vaginal ultrasound probe in 114 singleton pregnancies between 11 and 16 weeks of gestation. The four-chamber view with both atria, atrioventricular valves and ventricles as well as the origin and double-crossing of aorta and pulmonary trunk could always be demonstrated from the 13th week onwards. In 12 of 13 cases, cardiac malformations were diagnosed in the first trimester. Only in one case was transabdominal echocardiography necessary at 20 weeks to make the diagnosis. In several cases, however, additional malformations were overlooked, in particular anomalies of the great arteries, such as coarctation of the aorta. Therefore, the accuracy of second-trimester transabdominal echocardiography is markedly higher. Because of the lower diagnostic accuracy, the high costs of equipment and the high training demanded of the examiner, first-trimester transvaginal echocardiography should be restricted to the high-risk fetus, i.e.: (1) Cases with other fetal anomalies very often associated with cardiac defects, such as nuchal edema and hygroma, non-immune hydrops, omphalocele, situs, inversus, or persisting arrythmia; (2) High-risk families with one or more first-degree relatives with cardiac defects are either inherited by Mendelian rules alone, or as part of a rare syndrome; and (3) In pregestational diabetes of the mother.Thus, many severe cardiac defects can be detected or excluded in the first trimester, reducing maternal anxiety. In these high-risk cases, second-trimester echocardiography using the transabdominal route should always be performed because of its distinctly higher diagnostic accuracy.

Emerg Med (Fremantle). 2003 Apr;15(2):143-54.
Beyond the 12 lead: review of the use of additional leads for the early electrocardiographic diagnosis of acute myocardial infarction.
Carley SD.
Wythenshawe Hospital, Manchester, England.

Despite known limitations, the standard 12 lead ECG is the principal risk stratification device for patients presenting with chest pain to the ED. However, it has a sensitivity of less than 60% for MI. One reason for this is that the standard placement of chest leads fails to interrogate many areas of the myocardium. Various workers have addressed this problem through the use of additional leads or body surface mapping. Additional leads on the posterior and right thoracic surface have been shown to give additional information, which may be important to the emergency physician. This review demonstrates the need for additional leads in the acute setting and makes recommendations about the utility of using additional leads in the ED.

Tidsskr Nor Laegeforen. 2001 Feb 10;121(4):415-20.
New cardiac markers--clinical benefits in early diagnosis of acute heart disease.
Rolstad OJ, Stromme JH, Mangschau A.
Hjerte-lunge-senteret, Ulleval sykehus 0407 Oslo

BACKGROUND: New cardiac markers that may be analysed around the clock in emergency can now be performed in our hospitals with commercially available reagents and equipment. Upon the introduction of a new clinical biochemical regime based on these new markers for the diagnosis of acute coronary syndromes, we evaluated the clinical benefit achieved by the new set-up, especially with respect to early diagnosis. MATERIAL AND METHODS: cTroponinT, CK-MBmass, myoglobin and total-CKactivity were analysed in blood sample taken on admission, after 2-3 hours, and further once or twice over the next 24 hours in 300 patients admitted on suspicion of acute coronary syndromes (ACS). The study was based on results of the cardiac markers and information given on questionnaires by the physicians in charge. RESULTS: With the decision limits applied, CK-MB and myoglobin showed slightly higher sensitivity than cTroponinT for detecting acute myocardial infarction within the first 2-3 hours. cTroponinT showed the highest sensitivity for detecting heart muscle damage in patients with unstable angina. cTroponinT was the most cardiospecific marker. If the patient was considered not having ACS after the first few hours, only 3% ended with a diagnose of unstable angina and none with acute myocardial infarction. Of those considered certain ACS cases after the first few hours, 92% ended up with the diagnosis acute myocardial infarction or unstable angina. Treatment and/or supervision were changed in 68 of 220 patients based on the results of the two first blood samples, 85% of them to a lower level of supervision. INTERPRETATION: cTroponinT and CK-MB are useful markers for early detection of acute myocardial injuries. A prerequisite is that they are determined in two samples with an interval of at least two hours. In this case, myoglobin did not give additional information. Based on the results from two early blood samples, about one quarter of the patients could immediately be transferred to a less expensive level of care.

Ter Arkh. 1999;71(9):52-6.
Early diagnosis of ischemic heart disease in patients with chronic obstructive pulmonary diseases
Pavlov NR, Chereiskaia NK, Afonas'eva IA, Fedorova SI.

AIM: To study incidence rate, course features, principles of diagnosis and therapy of ischemic heart disease (IHD) in patients with chronic obstructive pulmonary diseases (COPD). MATERIALS AND METHODS: Standard clinical examinations, ECG, chest x-ray, echo-CG, 24-h Holter monitoring, coronarography were performed in 60 patients over 40 years of age with bronchial asthma or chronic obstructive bronchitis. Autopsy data were analyzed for 20 patients who died of COPD. RESULTS: IHD was diagnosed in 53.3% of the examinees. 70% of the patients treated with preductal (trimetasidine) benefited from the treatment: they had less frequent episodes of painless myocardial ischemia. Autopsy material has shown that COPD patients frequently suffer of aortic and coronary atherosclerosis. CONCLUSION: IHD diagnosis in COPD patients is rather difficult as there are no well-defined correlations between clinical picture of IHD and data of device investigations, IHD is painless more frequently than in general population (in 84.4% of patients in this study). Preductal is a drug of choice for treatment of IHD in COPD patients.

Exp Clin Endocrinol Diabetes. 1998;106(1):16-24.
Heart disease in diabetes mellitus: a challenge for early diagnosis and intervention.
Tschoepe D, Roesen P.
Diabetes Research Institute at the Heinrich Heine University, Dusseldorf, Germany.

Most people with diabetes die from thrombotic complications superimposed to degenerative arterial vascular lesions, mostly myocardial infarction. Diabetes is a risk factor per se for such complications, but often clusters with dyslipoproteinemia, hypertension and obesity. In NIDDM (Type-II) patients this is referred to as "metabolic syndrome" and often operates on a genetically programmed susceptibility which accelerates the pathogenesis of coronary artery disease in front of a much wider diabetes specific cardiopathy. From a pathophysiological point of view none of these associated risk factors explains the pathogenetic series of events leading to the precipitation of an occlusive thrombus at sites of complicated coronary plaques. In patients with diabetes the coagulation system is switched towards a prethrombotic state, involving increased plasmatic coagulation, diminished fibrinolysis, decreased endothelial thromboresistance and predominantly platelet hyperreactivity ("diabetic thrombocytopathy"). Some of these factors are associated with an increased coronary risk (e.g. fibrinogen, PAI-1, platelets), but are also directly linked to the pathogenesis of "atherothrombosis". Altered cardiac remodelling together with adhesion and coagulation mechanisms appears suitable to explain decreased functional performance of infarcted organs, decreased success of acute (reduced fibrinolytic response, reperfusion injury) and longterm intervention strategies (PTCA, CABG) in diabetes. Glucose adjustment alone will not adequately neutralize these complex mechanisms. Particularly in diabetes a multidimensional interventional repertoire is required including antihypertensive, antidyslipoproteinemic and antithrombotic drugs, customized according to the individual patients needs as assessed by early diagnostic measures ("early secondary prevention").

Dtsch Med Wochenschr. 1978 Apr 21;103(16):688-94.
Exercise ECG as a screening test in the early diagnosis of coronary heart disease. Result of a trial study.
Wollenweber J, Christl HL, Hausen W, Rau G.

1500 men (aged 30-55 years) volunteered in a trial of early recognition of cardiovascular disease. History and clinical as well as biochemical data were obtained and compared with results of exercise ECGs. In the group as a whole abnormal ECGs were obtained in 6.2%, in a subgroup of those without exercise-dependent pain in the thorax, without hypertension and noraml resting ECG it was 3.8%, while in the presence of one or several of these risk factors it was as high as 17.8%. It is concluded that in any screening programme it is not reasonable to perform exercise ECGs in asymptomatic persons without risk factors, because in this group there is likely to be only a small percentage of abnormal findings and the number of false-positive ones is higher than that or correct positive ones. In connection with the known risk factors and risk indicators it would be best to define the risk group and, using selective indications, to go step-by-step from exercise ECG to additional invasive diagnostic measures such as coronary angiography.

Nurse Pract. 1996 May;21(5):57-8, 61-4, 67-9; quiz 70-1.
Women and heart attacks: prevention, diagnosis, and care.
Arnstein PM, Buselli EF, Rankin SH.
Boston College School of Nursing, Massachusetts, USA.

Despite being viewed as a male health problem, more women die from heart disease than men. The literature and preliminary research data reviewed clearly support that gender differences exist. The higher prevalence of myocardial infarction in older women and those with other known risk factors suggests the etiology, pathophysiology, and treatment is the same as for men. Differences in socioeconomic status, psychosocial profiles, presenting symptoms, disease progression, and a poorer response to treatment suggests that myocardial infarction in women is not fully understood. Women need to know they are at risk and not delay seeking treatment for subtle but important symptoms. Assessment strategies that take into account the woman's body, personal profile, and the female pattern of variant angina, non-Q wave, nonocclusive infarction are reviewed. Considering the literature that links social support with survival, mobilizing support to help the women direct energies to her own recovery becomes a necessary intervention. Implications to health teaching, diagnostic testing, diagnosis, referral, and the effective management of women with myocardial infarction are delineated.