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Holter ECG assessment of the effects of three different local anesthetic solutions on cardiovascular system in the sedated dental patients with coronary artery disease/Uc farkli lokal anestezik solusyonun koroner arter hastaligi olan sedatize edilmis dental hastalarda kardiyovaskuler sisteme olan etkilerinin EKG Holter cihazi ile degerlendirilmesi.

Introduction

Coronary artery disease and hypertension are the most common chronic systemic disease in adults and its prevalence tends to increase with age. As the number of these patients increases, it is expected to encounter more of these patients in minor oral surgery. Premedication (local anesthesia and sedation) is an important concern in these patients as the anesthetic solution may cause serious complications (1).

Administration of a vasoconstrictor in combination with a local anesthetic has evolved as a method to decrease systemic toxicity, increase the duration of anesthesia and provide hemostasis during surgery (2). Lidocaine with epinephrine is commonly used throughout the world. However, epinephrine-containing anesthetics in patients with cardiovascular disease may lead to dangerous side effects such as arrhythmias, unstable angina, increase in blood pressure, cardiac output and stroke volume and even myocardial infarction. Octapressin, a vasoconstrictor agent, does not cause significant alterations in heart rate, but its vasoconstrictor action is lower than epinephrine (3-6).

Dental anxiety is a phenomenon prevalent in dental surgery, which has a complex etiology involving many factors. Previous traumatic dental experiences, painful dental treatment processes, fainting during injection of local anesthetic and erroneous extraction are some of these factors. Pain and stress during dental procedures are responsible for release of endogenous catecholamines likely to activate hemodynamic disturbances, including increases in blood pressure, heart rate and the frequency of arrhythmias (7). Importance of monitoring such patients for ischemic changes has been recognized (8-10). To avoid any adverse cardiovascular effects, especially in high risk patients, some authors have recommended the use of octapressin-containing local anesthetics or epinephrine-free local anesthetics after premedication of diazepam (11). In the dental patients with cardiovascular disease, both beta-blocking and non-potassium sparing diuretic drugs can exacerbate unwanted effects of epinephrine in dental local anesthetics and dose reduction of epinephrine is wise (12). Nevertheless, local anesthetics without epinephrine have some disadvantages such as hemorrhage and less deep analgesia of shorter duration (13, 14).

Coronary artery disease (CAD) constitutes the majority of cardiac diseases. Heart rate, pause, missed beats, isolated and ectopic beats, extrasystoles and ST segment deviations are some parameters that are measured by an electrocardiographic (ECG) Holter device during oral surgery under local anesthesia. Especially ST segment deviation is a reliable marker of important events in the myocardium which may cause myocardial damage (12, 13, 15, 17).

On the other hand, vasoconstrictor dose used in dentistry are very low (16). According to Malamed et al. (2), intramuscular or intravenous dose of epinephrine (1:100.000 or 1:10.000 concentrations) used in the treatment of anaphylaxis or cardiac arrest is 0.5 to 1 mg whereas an anesthetic cartridge with epinephrine contains only 0.018 mg. Therefore, at this dose, epinephrine offers many advantages and few disadvantages and is only contraindicated, in oral surgery, in very specific cases (2-16).

Some authors hypothesize that increased heart rate and alterations in blood pressure in dental procedures owing to endogenous catecholamine release from the adrenal medulla result from emotional stress, anxiety and pain but not from a pharmacologic process (15-19). However, other authors consider that cardiovascular response to dental treatment under local anesthesia may be further influenced by the anesthetic used (20-23).

The unique study compares electrocardiographic changes in a sedated cardiac patient exposed to oral operation under local anesthesia with lidocaine alone, epinephrine-combined lidocaine and prilocaine with octapressin in the same patient. The study also compares the cardiovascular effects of local anesthetics with and without vasoconstrictors in sedated cardiac dental patients in one-hour periods of time.

Methods

Study design

A prospective cohort study.

Study population

A total of twenty patients (37-71 years of age) in both sexes with the indication of at least 3 similar oral operations were included in this prospective cohort study. All the cases were at high risk (CAD or CAD risk equivalents) according to the National Cholesterol Education Programme, Adult Treatment Panel III (NCEP ATP 3) guidelines (which means that their 10-year risk of major cardiovascular event is > 20%) (24). According to European Society of Cardiology (ESC) guidelines for perioperative cardiac management in non-cardiac surgery, dental procedures are included in low-risk (<1 %) category. CAD covered history of myocardial infarction, unstable angina, stable angina, coronary artery procedures (angioplasty or bypass surgery), or evidence of clinically significant myocardial ischemia. CAD risk equivalents included clinical manifestations of non-coronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease 'transient ischemic attacks or stroke of carotid origin or >50% obstruction of a carotid artery'), diabetes, and 2+ risk factors with 10-year risk for hard CAD >20%.

Patient selection criteria: Patients with acute myocardial infarction (occurring<6 months), imminent indication of cardiac surgery or angioplasty, severe hypertension (SP>180 mmHg and/ or DP>110 mmHg) and uncontrolled diabetes mellitus were excluded. In addition, patients with acute symptoms for whom oral minor operation was found to be unfeasible at the time of the scheduled procedure were excluded.

The patients were fully informed of the purposes of the study and the procedures involved and written consent was obtained. The Ethics Committee of the university approved the study protocol.

Study protocol

We planned and conducted three dental intervention of equivalent difficulty on the cases each.

Dental operations

Oral operations of comparable difficulty included dental extractions, soft tissue interventions and surgical extraction of impacted third molars or surnumerary teeth using 3.6 mL local anesthetic in every case. Each operation was performed on three different days with at least one-week intervals. Aspiration was performed before the administration of the local anesthetic solution and the application of various nerve blocks with different solutions were successful in all the patients who underwent local anesthesia with 3.6 mL of two percent lidocaine with 1:80.000 epinephrine ([Jetokain.sup.R], Adeka), 3.6 mL of two percent lidocaine without a vasoconstrictor (Jetokain [Simplex.sup.R], Adeka) and 3.6 mL of three percent prilocaine with 0.03 IU (international units)/mL octa-pressin (Citanest [Octapressin.sup.R], Astra Zeneca). We planned that it was sufficient for us to use 2 cartridges local anesthetics with each being 1.8 mL.

Prior to the dental intervention, an ECG was recorded and the patients showed no abnormal findings, having their blood drawn for routine biochemical tests (Plasma glucose, total cholesterol, high-density lipoprotein, low-density lipoprotein and triglyceride levels).

Holter monitoring

Holter ECG device which uses Syne View Holter ECG Analysis Software (MinHR/24h, Syne Flash, France) was employed to record and compare the ECG changes during the operations.

The pre-operative period took an hour after a Holter ECG device was installed to obtain electrocardiographic records (Fig. 1). After 30 minutes it was connected to the case, 5 mg diazepam was given to the patients intramuscularly and the blood pressure values measured in 30 minute-intervals. Intramuscular sedation was administered in the preoperative period of an hour since ECG changes were to be assessed as the resting process and what could be changed and how following the injection should be observed. The operative period which is supposed to take 2 hours does not imply the surgical period but the process in which significant ECG variations could be expected including dental intervention. It was started with the injection of the local anesthetic solution. At the end of the third hour, another two-hour period was used to assess the postoperative period (Fig. 2). Entire Holter ECG monitoring time took 1 preoperative, 2 operative and 2 postoperative hours with a total of 5 hours.

Holter ECG device Syneflash Card MinHR/24h revealed findings composed of an hour intervals of the heart-rate, pause, missed beats, supraventricular extrasystoles (isolated and couplet), ventricular extrasystoles (isolated and couplet), total extrasystoles and ST segment deviations each.

Statistical analysis

SPSS for Windows (SPSS Inc, Chicago, IL, USA) was used to perform statistical calculations and 0.05 level set for significance. ANOVA for repeated measurements was used for comparing heart rate the three local anesthetics for. Friedman test and non-parametric multiple comparison test were conducted to compare number of arrhythmic events between groups of local anesthetics and different periods for the ECG changes.

Results

Overall, 20 adult cases, 17 men and 3 women (from 37 to 71 with mean age of 59.6) with high risk according to the NCEP ATP 3 guidelines and low risk according to ESC guidelines were included in the study (Table 1). All minor oral operations (Total 60 operations) were well tolerated by all sedated cardiac dental patients. Among patients, 10 had history of percutaneous transluminal angioplasty/stent placement interventions, 6 had coronary artery bypass surgery, 2 were treated with antiarrhythmic drugs and 2 suffered from hypertension with coronary artery disease previously. Blood pressure values measured in 30 minutes intervals showed no significant changes.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

In view of heart rate variables, there was a significant difference (p<0.05) between 3.6 mL of lidocaine with 1:80.000 epinephrine and 3.6 mL of 2% lidocaine without a vasoconstrictor at the first hour following the injection (lidocaine with epinephrine 75.9, pure lidocaine 71.8) which did not create any cardiac risks with all the other differences being insignificant (Table 2, Fig. 3).

There was a significant difference for the mean numbers of total extrasystoles and isolated ectopic beats between local anesthetics over monitoring times. The differences between pure lidocaine with lidocaine+epinephrine and prilocaine with octapressin were significant (Table 3, 4).

There were no significant differences between 3.6 mL of 3% prilocaine with octapressin, 3.6 mL of 2% lidocaine with 1:80.000 epinephrine and 3.6 mL of 2% lidocaine without a vasoconstrictor for ST segment deviation variable (Table 5).

Discussion

The present study compared the electrocardiographic effects of lidocaine, lidocaine with epinephrine and prilocaine with octapressin in the same high risk sedated cardiac patient according to the National Cholesterol Education Programme, Adult Treatment Panel III (NCEP ATP 3) guidelines and low risk according to European Society of Cardiology ESC) guidelines during oral surgery under local anesthesia.

The findings showed that there were significant differences in heart-rate after the administration of 3.6 mL of 2% lidocaine with 1:80.000 epinephrine and 3.6 mL of 2% lidocaine without a vasoconstrictor in sedated cardiac patients in the first hour following the injection during the oral surgery. Normal heart-rate ranges between 60-100 bpm. Increased heart rate of 75.9 bpm was caused by combination of epinephrine with lidocaine, which is therefore not significant in terms of cardiac risk. Greenwood and Meechan (8), and Middlehurst, Coulthard et al. (25) and Bispo et al. (26) emphasized that the use of sedation in patients with cardiac disease might be valuable for reducing the effects of stress and eliminating the need for general anesthesia. Heart rate was significantly higher with the injection of epinephrine-containing lidocaine than pure lidocaine although the use of 5 mL i.m diazepam for premedication agent in the preoperative period. Niwa et al. (27, 28), showed that infiltration anesthesia for dental use with 3.6 mL of lidocaine with 1:80.000 epinephrine could be carried out safely on the patients who have exercise capacity of more than 4 metabolic equivalents. Brkovic et al. (29) found no significant differences in the patients' hemodynamic response with lidocaine with epinephrine concerning the use of local anesthetic injection for single tooth extraction. Our results showed similarity to those by Perusse et al. (17, 20), who reported that the use of epinephrine-containing local anesthetics in dental patients with coronary atherosclerosis could show significant hemodynamic changes and lead to life threatening complications. Malamed (1) recommended the use of epinephrine and other vasoconstrictors in such patients if the vasoconstrictor was administered slowly in small amounts after negative aspiration has been ensured.

As shown in table 3 and 4, we found a significant difference in terms of the mean numbers of total extra systoles and isolated ectopic beats between pure lidocaine with lidocaine + epinephrine and prilocaine with octapressin were significant in the second hour following the injection. 3.6 mL of 3% prilocaine with octapressin effected total extrasystoles and isolated ectopic beats more than 3.6 mL of 2% lidocaine without a vasoconstrictor. Also 3.6 mL of 2% lidocaine with 1:80.000 epinephrine effected total extrasystoles and isolated ectopic beats more than 3.6 mL of 2% lidocaine without a vasoconstrictor. Our clinical results about extra systoles and ectopic beats on sedated cardiac dental patients are similar to those by Blinder's (21) who found significant electrocardiographic changes two hours after the administration of the local anesthetic. Furthermore, Meechan et al. (14) showed a significant tachycardia 10 minutes after injection of 4.4 mL lidocaine with 1:80.000 epinephrine in cardiac transplant patients.

The present study found no significant differences between 3.6 mL of 3% prilocaine with octapressin, 3.6 mL of 2% lidocaine with 1:80.000 epinephrine and 3.6 mL of 2% lidocaine without a vasoconstrictor for ST segment deviation while Meechan et al. (14) experienced a significant tachycardia 10 minutes after the injection of 4.4 mL of lidocaine with 1:80.000 epinephrine in cardiac transplant patients. Blinder et al. (21, 22) reported that when the local anesthetic contained a vasopressor, there was a greater incidence of tachycardia only with less arrhythmia or ST depression.

Conclusion

In conclusion, our evidence appears consistent with the opinion of the authors that administration of 3.6 mL of 2% lidocaine with 1:80.000 epinephrine or a less amount could be recommended safely during oral surgery in high risk cardiac patients sedated with diazepam.

doi: 10.5152/akd.2013.146

Conflict of interest: None declared.

Peer-review: External peer-review.

Authorship contributions: Concept--M.Z., U.T., M.C.A., I.S.; Design--M.Z., I.S.; Supervision--M.Z., U.T.; Resource--M.Z., U.T., I.S.; Material--M.Z.; Data collection&/or Processing--M.Z., U.T.; Analysis &/or interpretation--M.Z., M.C.A.; Literature search M.Z.; Writing--M.Z., I.S.; Critical review--M.Z., U.T., I.S.

References

(1.) Ezmek B, Arslan A, Delilbasi C, Sencift K. Comparison of hemodynamic effects of lidocaine, prilocaine and mepivacaine solutions without vasoconstrictor in hypertensive patients. J Appl Oral Sci 2010; 18: 354-9. [CrossRef]

(2.) Malamed SF. Handbook of local anesthesia 2nd ed. St Louis: Mosby-Year Book; 1986.p.39-41.

(3.) Laragnoit AB, Neves RS, Neves IL, Vieira JE. Locoregional anesthesia for dental treatment in cardiac patients: a comparative study of 2% plain lidocaine and 2% lidocaine with epinephrine (1:100.000) Clinics 2009; 64: 177-82. [CrossRef]

(4.) Campbell RL, Langston WG, Ross GA. A comparison of cardiac rate-pressure product and pressure-rate quotient with Holter monitoring in patients with hypertension and cardiovascular disease: a follow-up report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84: 125-8. [CrossRef]

(5.) Cardiovascular Effects of Epinephrine in Hypertensive Dental Patients. Summary, Evidence Report/Technology Assessment Number 48. AHRQ Publication Number 02-E005, 2002.

(6.) Bortoluzzi MC, Manfro R, Nardi A. Glucose levels and hemodynamic changes in patients submitted to routine dental treatment with and without local anesthesia. Clinics 2010; 65: 975-8. [CrossRef]

(7.) Garip H, Abali O, Goker K, Gokturk U, Garip Y. Anxiety and extraction of third molars in Turkish patients. Br J Oral Maxillofac Surg 2004; 42: 551-4. [CrossRef]

(8.) Campbell RL, Langston WG. A comparison of cardiac rate-pressure product and pressure-rate quotient in healthy and medically compromised patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80: 145-52. [CrossRef]

(9.) Greenwood M, Meechan JG. General medicine and surgery for dental practitoners. Part 1: Cardiovascular system. Br Dent J 2003; 1: 537-42. [CrossRef]

(10.) Neves RS, Neves IL, Giorgi DM, Grupi CJ, Cesar LA, Hueb W, et al. Effects of epinephrine in local dental anesthesia in patient with coronary artery disease. Arq Bras Cardiol 2007; 88: 545-51. [CrossRef]

(11.) Matharu LL, Roberts GJ. Effectiveness and acceptability of intravenous sedation in child and adolescent dental patients: report of a case series at King's College Hospital, London. British Dental Journal 2011; 210: 567-72. [CrossRef]

(12.) Liau FL, Kok SH, Lee JJ, Kuo RC, Hwang CR, Yang PJ, et al. Cardiovascular influence of dental anxiety during local anesthesia for tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 16-26. [CrossRef]

(13.) Wahl MJ, Overton D, Howell J, Siegel E, Schmitt MM, Muldoon M. Pain on injection of prilocaine vs. lidocaine with epinephrine. A prospective double-blind study. J Am Dent Assoc 2001; 132: 1396-401.

(14.) Caceres MT, Ludovice AC, Brito FS, Darrieux FC, Neves RS, Scanavacca MI, et al. Effect of local anesthetics with and without vasoconstrictor agent in patients with ventricular arrhythmias. Arq Bras Cardiol 2008; 91: 128-33.

(15.) Meechan JG, Parry G, Rattray DT, Thomason JM. Effects of dental local anesthetics in cardiac transplant recipients. Br Dent J 2002; 192: 161-3. [CrossRef]

(16.) Conrado VC, de Andrade J, de Angelis GA, de Andrade AC, Timerman L, Andrade MM, et al. Cardiovascular effects of local anesthesia with vasoconstrictor during dental extraction in coronary patients. Arq Bras Cardol 2007; 88: 507-13. [CrossRef]

(17.) Atalay C, Dagli C, Bayram E, Alici HA, Erdem AF, Keles MS, et al. Effects of three different methods of anesthesia on the release of brain natriuretic peptide in patients with cardiac risk undergoing lower extremity surgery. Turk J Med Sci 2010; 40: 405-14.

(18.) Perusse R, Goulet JP, Turcotte JY, Contraindications to vasoconstrictors in dentistry: Part I. Cardiovascular diseases. Oral Surg Oral Med Oral Pathol 1992; 74: 679-86. [CrossRef]

(19.) Hill CM, Mostafa P, Stuart AG, Thomas DW, Walker RV. ECG variations in patients pre- and post-local anaesthesia and analgesia. Br Dent J 2009; 207: E23. [CrossRef]

(20.) Perusse R, Goulet JPTurcotte JY, Contraindications to vasoconstrictors in dentistry: Part II. Hyperthyroidism, diabetes, sulfite sensitivity, cortico-dependent asthma, and pheochromocytoma. Oral Surg Oral Med Oral Pathol 1992; 74: 687-91. [CrossRef]

(21.) Blinder D, Shemesh J, Taicher S. Electrocardiographic changes in cardiac patients undergoing dental extractions under local anesthesia. J Oral Maxillofac Surg 1996; 54: 162-5. [CrossRef]

(22.) Blinder D, Manor Y, Shemesh J, Taicher S. Electrocardiographic changes in cardiac patients having dental extractions under local anesthetic containing a vasopressor. J Oral Maxillofac Surg 1998; 56: 1399-402. [CrossRef]

(23.) Brown RS, Lewis VH. More on the contraindications to vasoconstrictors in dentistry. Oral Surg Oral Med Oral Pathol 1993; 76: 2-5. [CrossRef]

(24.) Grundy SM, Cleeman JI, Merz CNB, Brewer Jr HB, Clark LT, Hunninghake DB, et al. Implications of Recent Clinical Trials fort he National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004; 110: 227-39. [CrossRef]

(25.) Middlehurst R, Coulthard P. The effect of midazolam sedation on indicators for myocardial ischemia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88: 400-5. [CrossRef]

(26.) Bispo CG, Tortamano IP, Rocha RG, Francischone CE, Borsatti MA, da Silva JC Jr, et al. Cardiovascular responses to different stages of restorative dental treatment unaffected by local anesthetic type. Aust Dent J 2011; 56: 312-6. [CrossRef]

(27.) Niwa H, Sato Y, Matsuura H. Safety of dental treatment in patients with previously diagnosed acute myocardial infarction or unstable angina pectoris. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89: 35-41. [CrossRef]

(28.) Niwa H, Satoh Y, Matsuura H. Cardiovascular responses to epinephrine--containing local anesthetics for dental use: a comparison of hemodynamic responses to infiltration anesthesia and ergometer-stres testing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90: 171-81. [CrossRef]

(29.) Brkovic BM, Savic M, Andric M, Jurisic M, Todorovic L. Intraseptal vs. periodontal ligament anesthesia for maxillary tooth extraction: quality of local anesthesia and hemodynamic response. Clin Oral Investiq 2010; 14: 675-81. [CrossRef]

Mert Zeytinoglu, Umit Tuncay, M. CemalAkay, Inan Soydan *

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, * Department of Cardiology, Faculty of Medicine, Ege University, Izmir-Turkey
Table 1. The patients data and number
of dental operations

Gender   Number of   Number of dental
         patients       operations

Male        17              51
Female       3              9
Total       20              60

Table 2. Differences for heart rate between the local
anesthetics at ECG Holter monitoring times

Local Anesthetics     Prilocaine with octa.      Lidocaine

                    Mean    Standard Error   Mean    Standard Error

Preop. Period       77.7       12.8682       76.15      10.5195
Operative 1.hr      72.9       10.0205       71.8       10.8511
Operative 2.hr      72.9        11.021       72.15      13.8916
Postop 1.hr         69.15      10.4744       71.35      14.0348
Postop 2. hr        72.2        9.9979       75.3       14.3384
* F                 F[2;57] = 0.158               p = 0.855
* p

Local Anesthetics        Lidocaine with epi. * F
                                             * p

                    Mean    Standard Error

Preop. Period       78.2       11.7545       F = 12.096
Operative 1.hr      75.9        9.9255       p < 0.0001
Operative 2.hr      72.95       12.072
Postop 1.hr         72.65      10.7374
Postop 2. hr        74.1        9.6567
* F
* p

ANOVA test

ECG--electrocardiogram, epi.--epinephrine, octa.--octapressin

Table 3. Differences for the mean numbers of total extrasystoles

                        Mean Rank

Total ventricular         1.58        The differences between
  events opr. 2. hr.                pure lidocaine with lidocaine
  pure lidocaine
Total ventricular         2.10
  events opr. 2. hr.                     + epinephrine were
  lidocaine with epi.                  significant. (p < 0.05)
Total ventricular         2.33      The differences between pure
  events opr. 2. hr.                  lidocaine with prilocaine
  prilocaine with octa.                   + octapressin were
N                          20           significant. (p<0.05)
Chi-Square                6.077
Df                          2
p                         .048
Friedman test

Df--degrees of freedom, epi.--epinephrine, octa.--octapressin,
opr. 2. hr--operative 2nd hour

Table 4. Differences for the mean numbers of isolated ectopic beats

                                  Mean Rank

Isolated ectopic beats              1.55
  Opr. 2. hr. Pure ldocaine
Isolated ectopic beats Opr.         2.13      The differences between
  2 hr. Lidocaine with epi.                     pure lidocaine with
                                              lidocaine + epinephrine
                                                 were significant.
                                                      (p<0.05)
Isolated ectopic beats Opr.         2.33      The differences between
  2. hr. Prilocaine with octa.                  pure lidocaine with
                                              prilocaine + octapressin
                                                 were significant.
                                                      (p<0.05)
N                                    20
Chi-Square                          6.816
Df                                    2
p                                   .033
Friedman test

epi.--epinephrine, octa.- octapressin, opr.2.hr--operative 2nd hour

Table 5. Differences for ST segment deviation
variable

Local anesthetics             N    ST Segment   %
                                   deviations

Lidocaine with epinefrin      20       13       65
Pure lidocaine                20       8        40
Prilocaine with octapressin   20       10       50

Chi square= 2.91 p>0.05

Figure 1. An example of Holter electrocardiogram device reports
(Syneflash Card MinHR/24h)

Time    Analysed      Total      Heart Rate (bpm)     Pause   Missed
hh:mm   Time (mn)   no.of QRS                                  Beat

                                Average   Min   Max

09:48      59         4056        68      57    91      0       0
10:48      59         3825        63      54    81      0       0
11:48      59         3848        64      55    85      0       0
12:48      59         3714        61      52    72      0       0
13:48      51         3497        67      57    93      0       0
14:48       0           0          0       0     0      0       0
15:48       0           0          0       0     0      0       0
16:48       0           0          0       0     0      0       0
17:48       0           0          0       0     0      0       0

Time      Supraventricular ES        Ventricular ES
hh:mm

        Isolated   Couplet   Run   Isolated   Couplet   Run

09:48      1          0       0       7          3       0
10:48      1          0       0       5          0       0
11:48      4          0       0       9          1       1
12:48      1          0       0       2          0       0
13:48      1          0       0       21         6       3
14:48      0          0       0       0          0       0
15:48      0          0       0       0          0       0
16:48      0          0       0       0          0       0
17:48      0          0       0       0          0       0
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Title Annotation:Original Investigation/Ozgun Arastirma
Author:Zeytinoglu, Mert; Tuncay, Umit; Akay, M. Cemal; Soydan, Inan
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Report
Date:Aug 1, 2013
Words:3871
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