Bloqueo AV de primer grado con un intervalo PR de 280 ms, hemibloqueo anterior izquierdo y morfología de bloqueo de rama derecha, compatible con un paciente de 75 años con antecedentes de mareos y cuadros sincopales.
El proceso de atención en diabetes. Isabel Fernández Fernández. Jornadas de la Estrategia de Salud en Diabetes del SNS (Madrid, Ministerio de Sanidad y Consumo, 2007)
2024 State of Marketing Report – by HubspotMarius Sescu
https://www.hubspot.com/state-of-marketing
· Scaling relationships and proving ROI
· Social media is the place for search, sales, and service
· Authentic influencer partnerships fuel brand growth
· The strongest connections happen via call, click, chat, and camera.
· Time saved with AI leads to more creative work
· Seeking: A single source of truth
· TLDR; Get on social, try AI, and align your systems.
· More human marketing, powered by robots
ChatGPT is a revolutionary addition to the world since its introduction in 2022. A big shift in the sector of information gathering and processing happened because of this chatbot. What is the story of ChatGPT? How is the bot responding to prompts and generating contents? Swipe through these slides prepared by Expeed Software, a web development company regarding the development and technical intricacies of ChatGPT!
Product Design Trends in 2024 | Teenage EngineeringsPixeldarts
The realm of product design is a constantly changing environment where technology and style intersect. Every year introduces fresh challenges and exciting trends that mold the future of this captivating art form. In this piece, we delve into the significant trends set to influence the look and functionality of product design in the year 2024.
How Race, Age and Gender Shape Attitudes Towards Mental HealthThinkNow
Mental health has been in the news quite a bit lately. Dozens of U.S. states are currently suing Meta for contributing to the youth mental health crisis by inserting addictive features into their products, while the U.S. Surgeon General is touring the nation to bring awareness to the growing epidemic of loneliness and isolation. The country has endured periods of low national morale, such as in the 1970s when high inflation and the energy crisis worsened public sentiment following the Vietnam War. The current mood, however, feels different. Gallup recently reported that national mental health is at an all-time low, with few bright spots to lift spirits.
To better understand how Americans are feeling and their attitudes towards mental health in general, ThinkNow conducted a nationally representative quantitative survey of 1,500 respondents and found some interesting differences among ethnic, age and gender groups.
Technology
For example, 52% agree that technology and social media have a negative impact on mental health, but when broken out by race, 61% of Whites felt technology had a negative effect, and only 48% of Hispanics thought it did.
While technology has helped us keep in touch with friends and family in faraway places, it appears to have degraded our ability to connect in person. Staying connected online is a double-edged sword since the same news feed that brings us pictures of the grandkids and fluffy kittens also feeds us news about the wars in Israel and Ukraine, the dysfunction in Washington, the latest mass shooting and the climate crisis.
Hispanics may have a built-in defense against the isolation technology breeds, owing to their large, multigenerational households, strong social support systems, and tendency to use social media to stay connected with relatives abroad.
Age and Gender
When asked how individuals rate their mental health, men rate it higher than women by 11 percentage points, and Baby Boomers rank it highest at 83%, saying it’s good or excellent vs. 57% of Gen Z saying the same.
Gen Z spends the most amount of time on social media, so the notion that social media negatively affects mental health appears to be correlated. Unfortunately, Gen Z is also the generation that’s least comfortable discussing mental health concerns with healthcare professionals. Only 40% of them state they’re comfortable discussing their issues with a professional compared to 60% of Millennials and 65% of Boomers.
Race Affects Attitudes
As seen in previous research conducted by ThinkNow, Asian Americans lag other groups when it comes to awareness of mental health issues. Twenty-four percent of Asian Americans believe that having a mental health issue is a sign of weakness compared to the 16% average for all groups. Asians are also considerably less likely to be aware of mental health services in their communities (42% vs. 55%) and most likely to seek out information on social media (51% vs. 35%).
El proceso de atención en diabetes. Isabel Fernández Fernández. Jornadas de la Estrategia de Salud en Diabetes del SNS (Madrid, Ministerio de Sanidad y Consumo, 2007)
2024 State of Marketing Report – by HubspotMarius Sescu
https://www.hubspot.com/state-of-marketing
· Scaling relationships and proving ROI
· Social media is the place for search, sales, and service
· Authentic influencer partnerships fuel brand growth
· The strongest connections happen via call, click, chat, and camera.
· Time saved with AI leads to more creative work
· Seeking: A single source of truth
· TLDR; Get on social, try AI, and align your systems.
· More human marketing, powered by robots
ChatGPT is a revolutionary addition to the world since its introduction in 2022. A big shift in the sector of information gathering and processing happened because of this chatbot. What is the story of ChatGPT? How is the bot responding to prompts and generating contents? Swipe through these slides prepared by Expeed Software, a web development company regarding the development and technical intricacies of ChatGPT!
Product Design Trends in 2024 | Teenage EngineeringsPixeldarts
The realm of product design is a constantly changing environment where technology and style intersect. Every year introduces fresh challenges and exciting trends that mold the future of this captivating art form. In this piece, we delve into the significant trends set to influence the look and functionality of product design in the year 2024.
How Race, Age and Gender Shape Attitudes Towards Mental HealthThinkNow
Mental health has been in the news quite a bit lately. Dozens of U.S. states are currently suing Meta for contributing to the youth mental health crisis by inserting addictive features into their products, while the U.S. Surgeon General is touring the nation to bring awareness to the growing epidemic of loneliness and isolation. The country has endured periods of low national morale, such as in the 1970s when high inflation and the energy crisis worsened public sentiment following the Vietnam War. The current mood, however, feels different. Gallup recently reported that national mental health is at an all-time low, with few bright spots to lift spirits.
To better understand how Americans are feeling and their attitudes towards mental health in general, ThinkNow conducted a nationally representative quantitative survey of 1,500 respondents and found some interesting differences among ethnic, age and gender groups.
Technology
For example, 52% agree that technology and social media have a negative impact on mental health, but when broken out by race, 61% of Whites felt technology had a negative effect, and only 48% of Hispanics thought it did.
While technology has helped us keep in touch with friends and family in faraway places, it appears to have degraded our ability to connect in person. Staying connected online is a double-edged sword since the same news feed that brings us pictures of the grandkids and fluffy kittens also feeds us news about the wars in Israel and Ukraine, the dysfunction in Washington, the latest mass shooting and the climate crisis.
Hispanics may have a built-in defense against the isolation technology breeds, owing to their large, multigenerational households, strong social support systems, and tendency to use social media to stay connected with relatives abroad.
Age and Gender
When asked how individuals rate their mental health, men rate it higher than women by 11 percentage points, and Baby Boomers rank it highest at 83%, saying it’s good or excellent vs. 57% of Gen Z saying the same.
Gen Z spends the most amount of time on social media, so the notion that social media negatively affects mental health appears to be correlated. Unfortunately, Gen Z is also the generation that’s least comfortable discussing mental health concerns with healthcare professionals. Only 40% of them state they’re comfortable discussing their issues with a professional compared to 60% of Millennials and 65% of Boomers.
Race Affects Attitudes
As seen in previous research conducted by ThinkNow, Asian Americans lag other groups when it comes to awareness of mental health issues. Twenty-four percent of Asian Americans believe that having a mental health issue is a sign of weakness compared to the 16% average for all groups. Asians are also considerably less likely to be aware of mental health services in their communities (42% vs. 55%) and most likely to seek out information on social media (51% vs. 35%).
AI Trends in Creative Operations 2024 by Artwork Flow.pdfmarketingartwork
This article is all about what AI trends will emerge in the field of creative operations in 2024. All the marketers and brand builders should be aware of these trends for their further use and save themselves some time!
A report by thenetworkone and Kurio.
The contributing experts and agencies are (in an alphabetical order): Sylwia Rytel, Social Media Supervisor, 180heartbeats + JUNG v MATT (PL), Sharlene Jenner, Vice President - Director of Engagement Strategy, Abelson Taylor (USA), Alex Casanovas, Digital Director, Atrevia (ES), Dora Beilin, Senior Social Strategist, Barrett Hoffher (USA), Min Seo, Campaign Director, Brand New Agency (KR), Deshé M. Gully, Associate Strategist, Day One Agency (USA), Francesca Trevisan, Strategist, Different (IT), Trevor Crossman, CX and Digital Transformation Director; Olivia Hussey, Strategic Planner; Simi Srinarula, Social Media Manager, The Hallway (AUS), James Hebbert, Managing Director, Hylink (CN / UK), Mundy Álvarez, Planning Director; Pedro Rojas, Social Media Manager; Pancho González, CCO, Inbrax (CH), Oana Oprea, Head of Digital Planning, Jam Session Agency (RO), Amy Bottrill, Social Account Director, Launch (UK), Gaby Arriaga, Founder, Leonardo1452 (MX), Shantesh S Row, Creative Director, Liwa (UAE), Rajesh Mehta, Chief Strategy Officer; Dhruv Gaur, Digital Planning Lead; Leonie Mergulhao, Account Supervisor - Social Media & PR, Medulla (IN), Aurelija Plioplytė, Head of Digital & Social, Not Perfect (LI), Daiana Khaidargaliyeva, Account Manager, Osaka Labs (UK / USA), Stefanie Söhnchen, Vice President Digital, PIABO Communications (DE), Elisabeth Winiartati, Managing Consultant, Head of Global Integrated Communications; Lydia Aprina, Account Manager, Integrated Marketing and Communications; Nita Prabowo, Account Manager, Integrated Marketing and Communications; Okhi, Web Developer, PNTR Group (ID), Kei Obusan, Insights Director; Daffi Ranandi, Insights Manager, Radarr (SG), Gautam Reghunath, Co-founder & CEO, Talented (IN), Donagh Humphreys, Head of Social and Digital Innovation, THINKHOUSE (IRE), Sarah Yim, Strategy Director, Zulu Alpha Kilo (CA).
Trends In Paid Search: Navigating The Digital Landscape In 2024Search Engine Journal
The search marketing landscape is evolving rapidly with new technologies, and professionals, like you, rely on innovative paid search strategies to meet changing demands.
It’s important that you’re ready to implement new strategies in 2024.
Check this out and learn the top trends in paid search advertising that are expected to gain traction, so you can drive higher ROI more efficiently in 2024.
You’ll learn:
- The latest trends in AI and automation, and what this means for an evolving paid search ecosystem.
- New developments in privacy and data regulation.
- Emerging ad formats that are expected to make an impact next year.
Watch Sreekant Lanka from iQuanti and Irina Klein from OneMain Financial as they dive into the future of paid search and explore the trends, strategies, and technologies that will shape the search marketing landscape.
If you’re looking to assess your paid search strategy and design an industry-aligned plan for 2024, then this webinar is for you.
5 Public speaking tips from TED - Visualized summarySpeakerHub
From their humble beginnings in 1984, TED has grown into the world’s most powerful amplifier for speakers and thought-leaders to share their ideas. They have over 2,400 filmed talks (not including the 30,000+ TEDx videos) freely available online, and have hosted over 17,500 events around the world.
With over one billion views in a year, it’s no wonder that so many speakers are looking to TED for ideas on how to share their message more effectively.
The article “5 Public-Speaking Tips TED Gives Its Speakers”, by Carmine Gallo for Forbes, gives speakers five practical ways to connect with their audience, and effectively share their ideas on stage.
Whether you are gearing up to get on a TED stage yourself, or just want to master the skills that so many of their speakers possess, these tips and quotes from Chris Anderson, the TED Talks Curator, will encourage you to make the most impactful impression on your audience.
See the full article and more summaries like this on SpeakerHub here: https://speakerhub.com/blog/5-presentation-tips-ted-gives-its-speakers
See the original article on Forbes here:
http://www.forbes.com/forbes/welcome/?toURL=http://www.forbes.com/sites/carminegallo/2016/05/06/5-public-speaking-tips-ted-gives-its-speakers/&refURL=&referrer=#5c07a8221d9b
ChatGPT and the Future of Work - Clark Boyd Clark Boyd
Everyone is in agreement that ChatGPT (and other generative AI tools) will shape the future of work. Yet there is little consensus on exactly how, when, and to what extent this technology will change our world.
Businesses that extract maximum value from ChatGPT will use it as a collaborative tool for everything from brainstorming to technical maintenance.
For individuals, now is the time to pinpoint the skills the future professional will need to thrive in the AI age.
Check out this presentation to understand what ChatGPT is, how it will shape the future of work, and how you can prepare to take advantage.
A brief introduction to DataScience with explaining of the concepts, algorithms, machine learning, supervised and unsupervised learning, clustering, statistics, data preprocessing, real-world applications etc.
It's part of a Data Science Corner Campaign where I will be discussing the fundamentals of DataScience, AIML, Statistics etc.
Time Management & Productivity - Best PracticesVit Horky
Here's my presentation on by proven best practices how to manage your work time effectively and how to improve your productivity. It includes practical tips and how to use tools such as Slack, Google Apps, Hubspot, Google Calendar, Gmail and others.
The six step guide to practical project managementMindGenius
The six step guide to practical project management
If you think managing projects is too difficult, think again.
We’ve stripped back project management processes to the
basics – to make it quicker and easier, without sacrificing
the vital ingredients for success.
“If you’re looking for some real-world guidance, then The Six Step Guide to Practical Project Management will help.”
Dr Andrew Makar, Tactical Project Management
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...Applitools
During this webinar, Anand Bagmar demonstrates how AI tools such as ChatGPT can be applied to various stages of the software development life cycle (SDLC) using an eCommerce application case study. Find the on-demand recording and more info at https://applitools.info/b59
Key takeaways:
• Learn how to use ChatGPT to add AI power to your testing and test automation
• Understand the limitations of the technology and where human expertise is crucial
• Gain insight into different AI-based tools
• Adopt AI-based tools to stay relevant and optimize work for developers and testers
* ChatGPT and OpenAI belong to OpenAI, L.L.C.
More than Just Lines on a Map: Best Practices for U.S Bike Routes
This session highlights best practices and lessons learned for U.S. Bike Route System designation, as well as how and why these routes should be integrated into bicycle planning at the local and regional level.
Presenters:
Presenter: Kevin Luecke Toole Design Group
Co-Presenter: Virginia Sullivan Adventure Cycling Association
AI Trends in Creative Operations 2024 by Artwork Flow.pdfmarketingartwork
This article is all about what AI trends will emerge in the field of creative operations in 2024. All the marketers and brand builders should be aware of these trends for their further use and save themselves some time!
A report by thenetworkone and Kurio.
The contributing experts and agencies are (in an alphabetical order): Sylwia Rytel, Social Media Supervisor, 180heartbeats + JUNG v MATT (PL), Sharlene Jenner, Vice President - Director of Engagement Strategy, Abelson Taylor (USA), Alex Casanovas, Digital Director, Atrevia (ES), Dora Beilin, Senior Social Strategist, Barrett Hoffher (USA), Min Seo, Campaign Director, Brand New Agency (KR), Deshé M. Gully, Associate Strategist, Day One Agency (USA), Francesca Trevisan, Strategist, Different (IT), Trevor Crossman, CX and Digital Transformation Director; Olivia Hussey, Strategic Planner; Simi Srinarula, Social Media Manager, The Hallway (AUS), James Hebbert, Managing Director, Hylink (CN / UK), Mundy Álvarez, Planning Director; Pedro Rojas, Social Media Manager; Pancho González, CCO, Inbrax (CH), Oana Oprea, Head of Digital Planning, Jam Session Agency (RO), Amy Bottrill, Social Account Director, Launch (UK), Gaby Arriaga, Founder, Leonardo1452 (MX), Shantesh S Row, Creative Director, Liwa (UAE), Rajesh Mehta, Chief Strategy Officer; Dhruv Gaur, Digital Planning Lead; Leonie Mergulhao, Account Supervisor - Social Media & PR, Medulla (IN), Aurelija Plioplytė, Head of Digital & Social, Not Perfect (LI), Daiana Khaidargaliyeva, Account Manager, Osaka Labs (UK / USA), Stefanie Söhnchen, Vice President Digital, PIABO Communications (DE), Elisabeth Winiartati, Managing Consultant, Head of Global Integrated Communications; Lydia Aprina, Account Manager, Integrated Marketing and Communications; Nita Prabowo, Account Manager, Integrated Marketing and Communications; Okhi, Web Developer, PNTR Group (ID), Kei Obusan, Insights Director; Daffi Ranandi, Insights Manager, Radarr (SG), Gautam Reghunath, Co-founder & CEO, Talented (IN), Donagh Humphreys, Head of Social and Digital Innovation, THINKHOUSE (IRE), Sarah Yim, Strategy Director, Zulu Alpha Kilo (CA).
Trends In Paid Search: Navigating The Digital Landscape In 2024Search Engine Journal
The search marketing landscape is evolving rapidly with new technologies, and professionals, like you, rely on innovative paid search strategies to meet changing demands.
It’s important that you’re ready to implement new strategies in 2024.
Check this out and learn the top trends in paid search advertising that are expected to gain traction, so you can drive higher ROI more efficiently in 2024.
You’ll learn:
- The latest trends in AI and automation, and what this means for an evolving paid search ecosystem.
- New developments in privacy and data regulation.
- Emerging ad formats that are expected to make an impact next year.
Watch Sreekant Lanka from iQuanti and Irina Klein from OneMain Financial as they dive into the future of paid search and explore the trends, strategies, and technologies that will shape the search marketing landscape.
If you’re looking to assess your paid search strategy and design an industry-aligned plan for 2024, then this webinar is for you.
5 Public speaking tips from TED - Visualized summarySpeakerHub
From their humble beginnings in 1984, TED has grown into the world’s most powerful amplifier for speakers and thought-leaders to share their ideas. They have over 2,400 filmed talks (not including the 30,000+ TEDx videos) freely available online, and have hosted over 17,500 events around the world.
With over one billion views in a year, it’s no wonder that so many speakers are looking to TED for ideas on how to share their message more effectively.
The article “5 Public-Speaking Tips TED Gives Its Speakers”, by Carmine Gallo for Forbes, gives speakers five practical ways to connect with their audience, and effectively share their ideas on stage.
Whether you are gearing up to get on a TED stage yourself, or just want to master the skills that so many of their speakers possess, these tips and quotes from Chris Anderson, the TED Talks Curator, will encourage you to make the most impactful impression on your audience.
See the full article and more summaries like this on SpeakerHub here: https://speakerhub.com/blog/5-presentation-tips-ted-gives-its-speakers
See the original article on Forbes here:
http://www.forbes.com/forbes/welcome/?toURL=http://www.forbes.com/sites/carminegallo/2016/05/06/5-public-speaking-tips-ted-gives-its-speakers/&refURL=&referrer=#5c07a8221d9b
ChatGPT and the Future of Work - Clark Boyd Clark Boyd
Everyone is in agreement that ChatGPT (and other generative AI tools) will shape the future of work. Yet there is little consensus on exactly how, when, and to what extent this technology will change our world.
Businesses that extract maximum value from ChatGPT will use it as a collaborative tool for everything from brainstorming to technical maintenance.
For individuals, now is the time to pinpoint the skills the future professional will need to thrive in the AI age.
Check out this presentation to understand what ChatGPT is, how it will shape the future of work, and how you can prepare to take advantage.
A brief introduction to DataScience with explaining of the concepts, algorithms, machine learning, supervised and unsupervised learning, clustering, statistics, data preprocessing, real-world applications etc.
It's part of a Data Science Corner Campaign where I will be discussing the fundamentals of DataScience, AIML, Statistics etc.
Time Management & Productivity - Best PracticesVit Horky
Here's my presentation on by proven best practices how to manage your work time effectively and how to improve your productivity. It includes practical tips and how to use tools such as Slack, Google Apps, Hubspot, Google Calendar, Gmail and others.
The six step guide to practical project managementMindGenius
The six step guide to practical project management
If you think managing projects is too difficult, think again.
We’ve stripped back project management processes to the
basics – to make it quicker and easier, without sacrificing
the vital ingredients for success.
“If you’re looking for some real-world guidance, then The Six Step Guide to Practical Project Management will help.”
Dr Andrew Makar, Tactical Project Management
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...Applitools
During this webinar, Anand Bagmar demonstrates how AI tools such as ChatGPT can be applied to various stages of the software development life cycle (SDLC) using an eCommerce application case study. Find the on-demand recording and more info at https://applitools.info/b59
Key takeaways:
• Learn how to use ChatGPT to add AI power to your testing and test automation
• Understand the limitations of the technology and where human expertise is crucial
• Gain insight into different AI-based tools
• Adopt AI-based tools to stay relevant and optimize work for developers and testers
* ChatGPT and OpenAI belong to OpenAI, L.L.C.
More than Just Lines on a Map: Best Practices for U.S Bike Routes
This session highlights best practices and lessons learned for U.S. Bike Route System designation, as well as how and why these routes should be integrated into bicycle planning at the local and regional level.
Presenters:
Presenter: Kevin Luecke Toole Design Group
Co-Presenter: Virginia Sullivan Adventure Cycling Association
6. Autor Año Criterio S(%)* E(%)*
Casale 1987 28 mm (H)
(criterio de Cornell) RaVL+SV3 > 42 96
20 mm (M)
Sokolow-Lyon 1949 SV1+RV5 o V6>35 mm 32 100
Rodríguez Padial 1991 QRS>120 mm 80 54
RV6:RV5>0.65 89 21
Schillaci 1994 24 mm (H) 26 96
20 mm (M) 19 95
RaVL+SV3 >
16 mm (H) 28,9 92,7
Dalfó 1997 14 mm (M) 42,6 93,5
Molloy (RaVL+SV3) x dur. QRS >2.440 mm/ms (H) 51 95
(producto de 1992 (RaVL+SV3+6)x dur. QRS>2.440 mm/ms (M)
Cornell)
*Sensibilidad y especificidad en los estudios originales, H: hombre, M: mujer
Adaptada de: De la Figuera M, Dalfó A. HTA. Atención Primaria, conceptos, organización y
práctica clínica.
7. R-aVL
≥ 12 mm
** Revisión de las Guías sobre HTA 2009. Cada 0,1 mV de incremento en R-aVL se asocia a un aumento del 9% de
eventos cardiovasculares
12. • Índice de Cornell: 31 mm
• Sobrecarga VI
17
14
13. • Índice de Sokolow: 67 mm
• Sobrecarga VI
20
47
14. • Índice de Cornell: 30 mm
• Sobrecarga VI
22
8
15. • Índice de Sokolow: 37 mm
• Sobrecarga VI
15
22
16. Varón de 69 años
DM y HTA. Ex fumador.
Cornell:30
Consuegra L. et al. 2006
Edhouse J et al, 2002
www.svcardio.org/formacion
www.bmj.com
17. Causas de exclusión para la lectura y diagnóstico de HVI la
presencia detectada en el ECG de:
• Necrosis miocárdica
• Bloqueo completo de la rama izquierda del haz de Hiss
• Derrame pericárdico.
18. Prevalencia de hipertrofia
ventricular izquierda (%)
59-73
24,6
17,5 20,3
11,5 13,7
7,2
Llisterri JL et al. Med Clin Barc 2004;122:165-71; Leal M. et al Hipertensión;2008;(3)99-107. Martín-Rioboó et al. Med Clin (en prensa).
Barrios V et al. Hipertension 2002;19:114-20; Lozano JV et al. Med Clin Barc 2005; 125:247-51; González-Juanatey JR et al; Rev Esp Cardiol
2007;60:148-56; Coca A et al: J Hypertens 1999;17:1471-80
19. HVI HVI (voltajes
Cornell Sokolow- Ambos
(sólo y Producto de
(voltaje) Lyon (voltaje) voltajes
voltajes) Cornel)
Varones 3,3 1,6 0,8 5,8 7,3
Mujeres 20,2 0,7 0,3 21,1 21,1
Ambos sexos 12,6 1,6 0,5 13,7 14,2
• Prevalencia global utilizando sólo voltajes de Cornell y Sokolow-Lyon:
13,7% (varones 5,8%; mujeres 21,1%)
• Prevalencia global utilizando voltajes de Cornell y Sokolow-Lyon y producto
de Cornell: 14,2 (varones 7,3%; mujeres, sin cambio)
Martín Rioboó et al. Med Clin 2008 2009 Feb 28;132(7):243-50
20. • Incidencia / 5 años: 18,6%
• Intervalo de detección: 41+19 meses
• Clasificación de las alteraciones ECG
– Pooling Project
• Mayores: 13%
• Menores: 3,2%
• Ambas: 1,9%
De la Figuera M, et al. Hipertensión 2001;18:213
21. Alteraciones mayores Alteraciones menores
• HVI • Hipertrofia Auricular
• Bloqueo A-V 2º y 3er grado • Bloqueo A-V 1er grado
• BCRD y BCRI
• Desnivelación ST < 1 mm
• Bloqueo Intraventricular
• • Onda T “plana”
Desnivelación ST ≥ 1 mm
• Inversión T ≥ 1 mm • Inversión T < 1 mm u Onda T isodifásica
• Onda Q ≥ 0,04 seg. Q/R ≥ 1/3 • Onda Q < 0,04 seg.
• Síndrome de pre-excitación
• Extrasistolia ventricular
22. • Alteraciones específicas
– Desnivelación ST: 48%
– Inversión mayor onda T: 10%
– Onda T menor: 26%
– Ondas Q mayor: 6%
– HVI: 10%
De la Figuera M, et al. Hipertensión 2001;18:213
23. Mal control de la PA durante el seguimiento
Odds ratio: 3,2 (IC 95%: 1,2-8,6)
De la Figuera M, et al. Hipertensión 2001;18:213
24.
25.
26.
27. HR hombres: 1,85
HR mujeres: 2,39
Schillaci G, et al J Hypertens 2004;22:407
32. • El ECG es la prueba fundamental en la evaluación inicial del
hipertenso.
• El ECG debe realizarse periódicamente y evaluar posibles cambios
de voltajes y repolarización.
• Los fármacos inhiben el SRA (ARAII,IECA) y los BCC son de
elección en hipertensos con HVI.
35. Pregunta 1:
¿Cuál es el eje del plano frontal?
•Aproximadamente +90°
•Aproximadamente +180°
•Aproximadamente 0°
•Entre +90° y +180°
36. Pregunta 2:
¿Qué alteraciones observa en las derivaciones precordiales?
1.Desviación del eje hacia la derecha
2.Cambios especulares
3.Aumento del ST en derivaciones izquierdas
4.QRS estrecho
37. Pregunta 3:
¿Qué diagnóstico electrocardiográfico le sugieren las alteraciones
identificadas?
1.Crecimiento ventricular izquierdo
2.Fibrilación auricular
3.Bloqueo de rama izquierda
4.Compatible con la normalidad
38. Crecimiento ventricular izquierdo. Paciente con HTA de larga evolución. Obsérvese el
aumento de voltaje, la horizontalización del eje en el plano frontal, la presencia de
alteraciones de la repolarización en derivaciones izquierdas (descenso de ST con T
negativa asimétrica) y los cambios especulares en las derivaciones precordiales
derechas
39. ALGORITMO
Complejo QRS
Complejo QRS
Normal Duración
Duración Aumentada
Eje del QRS
Eje del QRS Intervalo PR
Normal Izquierdo Corto Normal
HEMIBLOQUEO
HEMIBLOQUEO WPW BLOQUEO
BLOQUEO
WPW
ANTERIOR DE
ANTERIOR DE DE RAMA
DE RAMA
RAMA IZQUIERDA
RAMA IZQUIERDA
Morfología
Voltaje V11
Voltaje V Morfología
RSR’ QS
BLOQUEO DE
BLOQUEO DE BLOQUEO DE
BLOQUEO DE
CRECIMIENTO
CRECIMIENTO RAMA RAMA
VENTRICULAR NORMAL
NORMAL NECROSIS
NECROSIS RAMA RAMA
VENTRICULAR DERECHA
DERECHA IZQUIERDA
IZQUIERDA
40. ECG de un paciente de 75 años de
edad. Historia previa de mareos y dos
cuadros sincopales.
41.
42. Pregunta 4:
¿Qué indica la longitud del PR?
1.PR> 0,12 seg, compatible con bloqueo de rama izquierda.
2.PR variable, compatible con taquicardia auricular.
3.Alargamiento progresivo del PR indicativo de bloqueo sinoauricular.
4.PR > 0,28 seg compatible con bloqueo AV de primer grado.
43. Pregunta 5:
¿Qué otras alteraciones elctrocardiográficas le verifican este
diagnóstico?
1.El bloqueo de rama izquierda se confirmaría por la presencia de QS en
III.
2.La ausencia de ondas P sinusales y el QRS ancho confirman el
diagnóstico de taquicardia auricular.
3.La ausencia de algunas ondas P junto con el alargamiento progesivo del
intervalo PR verificarían el diagnóstico de bloqueo sinoauricular.
4.La morfología de bloqueo de rama derecha y la desviación del eje del
QRS hacia la izquierda confirmarían el diagnóstico de bloqueo AV de
primer grado.
44. Bloqueo AV 1er grado: ECG de un paciente de 75 años de edad. Historia
previa de mareos y dos cuadros sincopales. Destaca la presencia de un
intervalo PR de 280 ms (BAV de primer grado), con un complejo QRS con
morfología de BRD y eje a -75º, por la presencia de hemibloqueo anterior
izquierdo
45. ALGORITMO
Complejo QRS
Complejo QRS
Normal Duración
Duración Aumentada
Eje del QRS
Eje del QRS Intervalo PR
Normal Izquierdo Corto Normal
HEMIBLOQUEO
HEMIBLOQUEO WPW BLOQUEO
BLOQUEO
WPW
ANTERIOR DE
ANTERIOR DE DE RAMA
DE RAMA
RAMA IZQUIERDA
RAMA IZQUIERDA
Morfología
Voltaje V1 Morfología
RSR’ QS
BLOQUEO DE
BLOQUEO DE BLOQUEO DE
BLOQUEO DE
CRECIMIENTO
CRECIMIENTO RAMA RAMA
VENTRICULAR NORMAL
NORMAL NECROSIS
NECROSIS RAMA RAMA
VENTRICULAR DERECHA
DERECHA IZQUIERDA
IZQUIERDA
Notas del editor
En el estudio de los pacientes hipertensos, según las recomendaciones de las Sociedades Europeas, debe realizarse siempre un ECG. En algunos casos deben realizarse un ecocardiograma para completar es estudio dirigido a evaluar la presencia de afectación cardiaca.
La presencia de HVI en el ECG o en la ecocardiografía incrementa de forma notable el riesgo de padecer enfermedad cerebrovascular en los pacientes hipertensos. Como puede verse, el riesgo de los pacientes con HVI es más que el doble de los pacientes que no tienen HVI. En este estudio se estudiaron 2363 hipertensos no tratados (51 años; 47% mujeres) durante 14 años. La prevalencia basal de HVI fue de 17,6% por ECG y 23,7% por ECO. La incidencia de Ictus fue de 105 (58 isquémicos, 12 hemorrágicos y 6 indeterminados). Nueve ocurrieron en pacientes con ACxFA (del total 50 pacientes que desarrollaron ACxFA) HVI por ECG. RR 1,79 (IC 95%: 1,17-2,76) HVI por ECO. RR 1,64 (IC 95%: 1,07-2,68) Por SD de la Masa VI (29 g/m 2 ) RR: 1,31 (IC 95% 1,09-1,58)
Dentro de los criterios de voltaje específicamente, conviene insistir en los más utilizados habitualmente. Tal vez el criterio de Sokolow-Lyon sea el más conocido y utilizado. En los casos de HVI moderada y severa, tal vez es más sensible que el criterio de Cornell; sin embargo, en la HTA, la HVI suele ser ligera ó moderada, y en esas circunstancias el criterio de Sokolow pierde algo de sensibilidad si lo comparamos por ejemplo con el criterio de Cornell. Entre sus limitaciones, hay que considerar que la interposición de grasa entre el corazón y las precordiales disminuye la amplitud del voltaje, como pasa en los obesos y con la mama en las mujeres. Además, con la edad, también se reduce la amplitud del voltaje. Otro factor a considerar, sobre todo en el seguimiento de la HVI por ECG, es la posible variabilidad secundaria a la colocación de los electrodos.
ECG de paciente hipertenso de 53 años de edad, con antecedente de AVC hace 12 meses, sin secuelas neurológicas clínicas Destacar los amplísimos voltajes en precordiales que sugieren…
ECG de paciente hipertenso de 53 años de edad, con antecedente de AVC hace 12 meses, sin secuelas neurológicas clínicas Destacar los amplísimos voltajes en precordiales que sugieren…
ECG de paciente hipertenso de 53 años de edad, con antecedente de AVC hace 12 meses, sin secuelas neurológicas clínicas Destacar los amplísimos voltajes en precordiales que sugieren…
Flechas rojas: Criterio de Cornell Flechas azules: Criterio de Sokolow
Flechas rojas: Criterio de Cornell Flechas azules: Criterio de Sokolow
Flechas rojas: Criterio de Cornell Flechas azules: Criterio de Sokolow
CASO CLÍNICO Varón de 69 años que presentaba los antecedentes de hipertensión arterial, diabetes mellitus tipo 2 y extabaquismo. Ingresado inicialmente en cardiología por dolor torácico de perfil anginoso con ECG (fig.1 ) sin signos de isquemia aguda pero fibrilación auricular, patrón de sobrecarga sistólica, Q significativa de necrosis en toda la cara inferior (no conocida) así como ascenso del ST de 0.5- 1 mm en DIII y avF, y amputación de vector septal en precordiales derechas. Ante tales hallazgos se realiza coronariografía, que muestra ausencia de coronariopatía angiograficamente significativa. Durante este ingresó se constató la presencia de hipertrofia ventricular izquierda concéntrica de predominio septoanterior. El paciente vuelve a consultar por nuevos episodios de dolor torácico de perfil probablemente coronario en distintos centros hospitalarios. En uno de ellos el enfermo llega a ser trombolisado por imagen de lesión subepicárdica inferior (ya conocido en registros previos pero dicha información no era conocida en el último centro). El enfermo no presentó criterios eléctricos ni enzimáticos de reperfusión, cediendo el dolor al pautar analgésicos de modo coadyuvante. El paciente se dio de alta como posible IM “abortado”; volviendo a ingresar por dolor torácico sugestivo de cardiopatía isquémica aguda el mes siguiente (sin elevación enzimática ni cambios ECG). Durante el mismo, se decide realizar estudio de isquemia inducible con dipiridamol y viabilidad miocárdica con angioresonancia magnética, la cual muestra ausencia necrosis y ausencia de defectos de perfusión tras inyección de dipiridamol, así como HVI de predominio medioventricular mas acusada en segmentos aneroseptales (fig.2). DISCUSIÓN La importancia de este caso recae en la necesidad de conocer las alteraciones de repolarización que puede asociar la HVI, simulando incluso situaciones tan dramáticas como un IM, con sus consiguientes repercusiones diagnóstico-terapeúticas. Se cree que las alteraciones electrocardiográficas más frecuentes de los paciente con HVI son las anomalias del segmento ST-onda T (61%), los criterios eléctricos de HVI (47%), ondas Q anormales (25%) y crecimiento auricular izquierdo (24%) (2). Referido a alteraciones del ST-T, merecen ser señalados el patrón de sobrecarga sistólica (descenso de ST con onda T negativa asimétrica en cara lateral), el de sobrecarga diastólica (ondas T altas estrechas simétricas con Q en I y avL), ondas T altas picudas en HVI basal-apical (3), las ondas T gigantes negativas del síndrome de Yamaguchi (MCH apical) (4). La amputación de onda r en precordiales derechas es otro hallazgo no menos frecuente (5). Enorme valor tiene recordar que la HVI puede simular IM anterior, inferior, posterior o lateral. La razón de estas ondas Q patológicas puede encontrarse en cambios en la geometría ventricular, así como en la despolarización.
En esta diapositiva, como exponíamos en la anterior, se destacan las prevalencias de HVI en diferentes estudios de ámbito nacional en hipertensos. El estudio PRESCAP, recientemente publicado su revisión del año 2006, con datos obtenidos con registros retrospectivos y por tanto con el sesgo del registro obtuvo una prevalencia baja, probablemente influida por este factor. El estudio MAVI-HTA, demostró en pacientes de la comunidad de Madrid una prevalencia del 11,5% mediante criterios de Cornell. El estudio PREHVIA de próxima publicación, ha demostrado en pacientes Andaluces, y siendo el único que ha utilizado una aleatorización de la muestra, una prevalencia del 13.7%. El estudio Diorisc, y el ERIC HTA con prevalencias del 17,5%-20,3%, muestran prevalencias superiores. El estudio VIIDA ha sido realizado en consultas de cardiología por lo que el sesgo de la selección de la muestra (sin duda de mayor riesgo cardiovascular) ha influido en el resultado. El estudio VITAE fue realizado con ECO y ya sabemos el aumento de prevalencia lógico que se obtiene por la mayor sensibilidad de esta técnica frente al ECG