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Farina J, Clò S, Vitali F, Azzolini G, Malagù M, Pavasini R, Bertini M. ST-segment elevation in pulsed field ablation for atrial fibrillation. Heart Rhythm 2024; 21:698-701. [PMID: 38331304 DOI: 10.1016/j.hrthm.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Jacopo Farina
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy
| | - Stefano Clò
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy
| | - Francesco Vitali
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy.
| | - Giorgia Azzolini
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy
| | - Michele Malagù
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy
| | - Rita Pavasini
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy
| | - Matteo Bertini
- Cardiology Unit, Sant'Anna University Hospital, Department of Translational Medicine, University of Ferrara, Ferrara-Cona, Italy
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Hirayama I, Kamijo Y, Abe H, Nonaka M, Yano T, Ishii M, Tominaga Y. Guanfacine poisoning resulting in transient ST-segment elevation: a case report. Int J Emerg Med 2024; 17:60. [PMID: 38671356 PMCID: PMC11046827 DOI: 10.1186/s12245-024-00634-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/21/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Guanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of guanfacine poisoning have also risen. CASE PRESENTATION A 15-year-old male (height: 170 cm, weight: 48 kg), who was taking 2 mg/day of guanfacine for ADHD, was brought to our emergency department after ingesting 40 tablets of guanfacine due to poor exam results. He presented with impaired consciousness and sinus bradycardia on an electrocardiogram (ECG), leading to diagnosis of guanfacine poisoning. Gastric lavage (5 L) was performed, and activated charcoal was administered. Although his consciousness gradually recovered, he developed ST-segment elevation on the ECG. Despite the absence of chest pain and elevated myocardial enzymes, coronary artery stenosis was not observed on coronary artery computed tomography. As his blood guanfacine level decreased, his ECG returned to normal. CONCLUSIONS This case highlights the need for careful monitoring of guanfacine poisoning patients due to the potential for various cardiovascular events.
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Affiliation(s)
- Ichiro Hirayama
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan.
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan.
| | - Yoshito Kamijo
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Hiroko Abe
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
- Biodesign Inc, Tokyo, Japan
| | - Minaho Nonaka
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Tetsuhiro Yano
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Mitsuru Ishii
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Yoshiteru Tominaga
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
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3
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Zhang J, Lv H, Jiang X, Tang Y, Hou M. Transient changes in the ST-T waveform mimicking myocardial infarction in a child with near-drowning: a case report. J Int Med Res 2024; 52:3000605241233516. [PMID: 38497129 PMCID: PMC10946083 DOI: 10.1177/03000605241233516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/29/2024] [Indexed: 03/19/2024] Open
Abstract
Drowning is a common cause of childhood morbidity and mortality worldwide. Anoxia, hypothermia, and metabolic acidosis are mainly responsible for this morbidity. Drowning may lead to multiple organ damage, especially cardiac damage, in cases in which severe hypothermia and hypoxemia occur. We report a case of a 4-year-old girl who was admitted to our hospital's Emergency Department because of drowning. She had elevated troponin I concentrations and ST-segment elevation with T wave inversion. However, cardiovascular computed tomography showed no obvious abnormalities in the coronary arteries. We suggest that cardiac damage in this situation is caused by coronary artery spasms. To the best of our knowledge, this is the first case of cardiac damage with electrocardiographic changes after drowning in a preschool child.
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Affiliation(s)
- Jianmin Zhang
- Department of Traditional Chinese Medicine, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Haitao Lv
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xue Jiang
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yunjia Tang
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Miao Hou
- Department of Cardiology, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
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Jiang J, Jin C, Yu S, Cheng Y, Wu Y, Ma H. Persistent convex ST-segment elevation in a patient with a history of prior intracerebral haemorrhage. ESC Heart Fail 2024. [PMID: 38321818 DOI: 10.1002/ehf2.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
Management of patients with acute chest pain poses a significant challenge in identifying those requiring urgent coronary reperfusion. Electrocardiogram (ECG) constitutes the cornerstone in making prompt clinical decisions by identifying ST-segment elevation, commonly associated with ST-segment elevation myocardial infarction. It is important to note that ST-segment elevation can also be a manifestation of various cardiac and non-cardiac conditions, from acute myocarditis, early repolarization syndrome, acute pericarditis, and left bundle branch block to unknown origins. The similarity of ECG changes among these conditions complicates clinical differential diagnosis, necessitating a detailed medical history and thorough examinations. Here, we presented a case of a 52-year-old female with chest pain and unidentified convex ST-segment elevation. Considering the negative emergent coronary angiography results, normal echocardiography, and long-lasting ST-segment elevation for the following 1 year, the final diagnosis was non-myocardial infarction, probably related to a prior cerebral haemorrhage.
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Affiliation(s)
- Jian Jiang
- The Second Affiliated Hospital (Quzhou Campus), School of Medicine, Zhejiang University, Quzhou, China
- Department of Cardiology, The Second People's Hospital of Quzhou, Quzhou, China
| | - Chengjiang Jin
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Shuo Yu
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yunxian Cheng
- The Second Affiliated Hospital (Quzhou Campus), School of Medicine, Zhejiang University, Quzhou, China
- Department of Cardiology, The Second People's Hospital of Quzhou, Quzhou, China
| | - Yinggang Wu
- The Second Affiliated Hospital (Quzhou Campus), School of Medicine, Zhejiang University, Quzhou, China
- Department of Cardiology, The Second People's Hospital of Quzhou, Quzhou, China
| | - Hong Ma
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, China
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Kaichi R, Kawakami S, Tahara Y, Otsuka F, Kataoka Y, Asaumi Y, Noguchi T. Relationship between Earlobe Crease and Anatomical Severity of Coronary Artery Disease in ST-segment Elevation Myocardial Infarction. Intern Med 2024:2997-23. [PMID: 38311426 DOI: 10.2169/internalmedicine.2997-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
Objective Earlobe crease (ELC) is an easily detectable physical sign of cardiovascular risk and coronary artery disease (CAD). However, the relationship between ELC and CAD severity in patients with ST-segment elevation myocardial infarction (STEMI) requiring urgent clinical judgment is unknown. Using the residual synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score, we investigated the relationship between ELC and anatomical severity of CAD. Methods, patients or materials We studied 219 consecutive patients with STEMI (median age, 71 years old) and divided them into 2 groups according to the presence of ELC (ELC group, n=161; non-ELC group, n=58). Results The ELC group had a significantly higher number of diseased vessels than the non-ELC group (≥2 diseased vessels, 79% vs. 46%; ≥3 diseased vessels, 35% vs. 12%; P<0.001). In addition, a higher median residual SYNTAX score was observed after primary percutaneous coronary intervention than the non-ELC group [8 (4-12) vs. 3 (0-8), P<0.001]. Furthermore, a multivariable regression analysis showed that ELC was an independent predictor of the residual SYNTAX score (β=3.620, P<0.001). Conclusions The presence of ELC was significantly associated with the anatomical severity of diseased coronary vessels in patients with STEMI who required emergency clinical judgment and treatment.
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Affiliation(s)
- Ryota Kaichi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
- Department of Cardiology, Aso Iizuka Hospital, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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Liu MH, Li H, Li A, Liu R, Liu HB, Gao LJ, Gu Q, Song L. A patient with acute myocardial infarction with electrocardiogram Aslanger's pattern. BMC Cardiovasc Disord 2024; 24:3. [PMID: 38166569 PMCID: PMC10763094 DOI: 10.1186/s12872-023-03678-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/17/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Aslanger's pattern in electrocardiogram (ECG) indicates that patients may have acute inferior myocardial infarction(AMI) with concomitant critical stenoses on other coronary arteries, which needs to be evaluated the timing of revascularization as risk equivalents of ST elevation myocardial infarction(STEMI). CASE PRESENTATION The patient was a 62-year-old male with chief complaint of intermittent exertional subxiphoid pain for 20 days from 30th June. One day after the last episode (19th July), the 18-lead electrocardiogram showed ST segment elevation of 0.05-0.1mV in lead III, ST segment depression in leads I, avL, and V2-V6, T wave inversion with positive terminal vector in lead V4-V5, and positive T wave in lead V6, which indicated Aslanger's pattern. With increased Troponin I (0.162ng/mL, 0-0.02), The patient was diagnosed as acute non-ST-segment elevation myocardial infarction (NSTEMI) and admitted to coronary ward on 20th July. The coronary angiography showed 95% stenosis in the distal left main coronary artery (LM) to the ostium of the left anterior descending artery (LAD), 90% stenosis in the proximal segment of the LAD, and 80% stenosis in the middle segment of the LAD, and TIMI blood flow was graded score 2. Three drug-eluting stents were implanted at the lesions. The patient's ECG returned close to normal one month after revascularization. CONCLUSION We presented an acute coronary syndrome case whose ECG showed with Aslanger's pattern (i.e., isolated ST-segment elevation in lead III, associated ST-segment depression in lead V4-V6 with positive T wave/terminal vector, and greater ST-segment elevation in lead V1 than in lead V2), and was confirmed severe stenosis of the LM and the proximal segment of the LAD via coronary angiography. In clinical practice, especially in the emergency, patients with ECG presenting Aslanger's pattern should be urgently evaluated with prompt treatment, and the timing of emergency coronary angiography and revascularization should be evaluated to avoid adverse outcomes caused by delayed treatment.
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Affiliation(s)
- Ming-Hao Liu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, CAMS&PUMC. No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Hao Li
- People's Hospital of Bayingoleng Mongolian Autonomous Prefecture, No. 56, Renmin East Road, Korla City, Bayingoleng Mongolian Autonomous Prefecture, Xinjiang Uygur Autonomous Region, China
| | - Ang Li
- Interventional Catheterization Laboratory, Fuwai Hospital, CAMS&PUMC, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Ru Liu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, CAMS&PUMC. No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Hai-Bo Liu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, CAMS&PUMC. No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Li-Jian Gao
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, CAMS&PUMC. No.167 North Lishi Road, Xicheng District, Beijing, China.
| | - Qing Gu
- Department of Emergency, Fuwai Hospital, CAMS&PUMC, No. 167 North Lishi Road, Xicheng District, Beijing, China
| | - Lei Song
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, CAMS&PUMC. No.167 North Lishi Road, Xicheng District, Beijing, China
- Interventional Catheterization Laboratory, Fuwai Hospital, CAMS&PUMC, No. 167 North Lishi Road, Xicheng District, Beijing, China
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7
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Mesa-Maya MA, Duque-Gonzalez L, Franco-Sierra S. Takayasu's arteritis presenting as acute STEMI. J Invasive Cardiol 2023; 35. [PMID: 38108877 DOI: 10.25270/jic/23.00063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
An 18-year-old man with past medical history of secondary arterial hypertension diagnosed at age 15 presented with an abdominal magnetic resonance imaging (MRI) that exhibited left renal artery stenosis.
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Affiliation(s)
| | - Laura Duque-Gonzalez
- AUNA Clínica Las Américas, Medellín, Antioquia, Colombia; Hospital San Vicente Fundación, Rionegro, Antioquia, Colombia.
| | - Sergio Franco-Sierra
- AUNA Clínica Las Américas, Medellín, Antioquia, Colombia; Hospital San Vicente Fundación, Rionegro, Antioquia, Colombia
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Cheng Y, Huang B, Chen M. Respiratory acidosis induced ST-segment elevation. Am J Emerg Med 2023; 73:235.e5-235.e7. [PMID: 37230846 DOI: 10.1016/j.ajem.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Acidosis has been reported to cause ST-segment elevation. We presented a woman with a history of rectal adenocarcinoma experienced cardiac arrest during the contrast-enhanced computed tomography examination. When spontaneous circulation returned, arterial blood gas revealed she had severe respiratory acidosis, and bedside electrocardiogram showed ST-segment elevation in anterior precordial leads. Emergent coronary angiography was normal. Echocardiography revealed no abnormality of cardiac cavity size, segmental wall motion, or pericardial echo. Carcinoma metastasis in the peritoneal cavity and lungs was detected on the contrast-enhanced computed tomography scan while the heart was not involved. The ST-segment regressed and the respiratory acidosis was corrected after she received mechanical ventilation which strongly suggested the association between acidosis and the electrocardiogram changes.
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Affiliation(s)
- Yang Cheng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, PR China
| | - Baotao Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, PR China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, PR China..
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Tsuchida K, Nagai H, Oda H, Kashiwa A, Tanaka K, Hosaka Y, Ozaki K, Takahashi K. Acute coronary syndrome with simultaneous two-vessel occlusion De Winter ST-segment depression or reciprocal change? J Electrocardiol 2023; 81:70-74. [PMID: 37597503 DOI: 10.1016/j.jelectrocard.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/08/2023] [Indexed: 08/21/2023]
Abstract
We discuss a case of acute coronary syndrome (ACS) with simultaneous two-vessel occlusions in a man in his 20s. The serial electrocardiograms (ECG) showed very early dynamic changes of ST-T configuration resulting from ischemic zone depth or area between anterior wall versus inferior wall. The upsloping ST depression along with tall tentorial T waves in the precordial leads, as shown in the index ECG, raises the possibilities of a de Winter pattern. The retrospective assessment of the index ECG identified prominent T waves and a mild degree of ST-segment elevations in the inferior leads, given the electrocardiographic findings previously recorded at his workplace medical examination obtained at a later date. If the subtle ST-segment elevations in leads II, III, and aVF and the tall T waves were not overlooked in the index ECG, the probability of reciprocal ST-segment depressions in the precordial leads should also be taken into account. We recognize our ECG findings as intriguing ST-T deviation patterns that can change depending on the time sequence and anatomical dominancy of two infarct-related arteries. We finally suggest physicians should bear in mind the possibility of simultaneous multiple vessel occlusions when they encounter ACS patients with hemodynamic instability as in this present case.
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Affiliation(s)
- Keiichi Tsuchida
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan.
| | - Hideya Nagai
- Emergency Medical Center, Fukui Prefectural Hospital, Fukui, Japan
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Asami Kashiwa
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Komei Tanaka
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Yukio Hosaka
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Kazuyuki Ozaki
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
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Yue XL, Shi XY, Jiang M, Li RJ. Acute pulmonary embolism presenting with electrocardiographic signs and serum biomarkers of ST-segment elevation myocardial infarction: a case report. J Int Med Res 2023; 51:3000605231197063. [PMID: 37677144 PMCID: PMC10492495 DOI: 10.1177/03000605231197063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
Acute pulmonary embolism (APE) with ST-segment elevation and an upward T-wave is rare, and only a few cases have been reported to date. We herein present a case involving a man in his early 70s with an 8-hour history of dyspnea. Serial electrocardiography (ECG) demonstrated ST-segment elevation in leads V1 to V3 with an upward T-wave, laboratory tests revealed a high serum concentration of high-sensitivity cardiac troponin I, and signs of acute myocardial infarction were present. However, emergency coronary angiography revealed normal coronary arteries. A subsequent computed tomography scan of the pulmonary arteries showed findings consistent with APE. The patient's chest tightness was relieved after catheter-directed thrombolysis. Postoperative ECG showed that the ST-segment in leads V1 to V3 had fallen back and that the T-wave was inverted. The patient was discharged on rivaroxaban therapy. Clinically, the ECG findings of ST-segment elevation and an upward T-wave in APE can be easily misdiagnosed as acute myocardial infarction. Physicians should maintain clinical suspicion through risk stratification to identify APE.
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Affiliation(s)
- Xiao-lin Yue
- Qilu Medical College, Shandong University, Jinan, China
| | - Xue-yun Shi
- Qilu Medical College, Shandong University, Jinan, China
| | - Mei Jiang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China
| | - Rui-jian Li
- Department of Emergency, Qilu Hospital, Shandong University, Jinan, China
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11
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Sawalha K, Gupta S, López-Candales A. Early repolarization: Electrocardiographic cues to distinguish benign from malignant variants. Am J Med Sci 2023:S0002-9629(23)01172-2. [PMID: 37156459 DOI: 10.1016/j.amjms.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 04/10/2023] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
Historically, early repolarization (ER) has been considered a marker of good health as it is more prevalent in athletes, younger persons, and at slower heart rates. However, contemporary reports, largely based on data from resuscitated sudden cardiac arrest patients, suggest an association between ER and an increased risk for sudden cardiac death and the development of malignant ventricular arrhythmias. Therefore, after we present a brief-case presentation, we intend to review a challenging topic in recognition of malignant variants and propose a four-step comprehensive approach to simplify ECG discrimination when assessing ER changes.
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Affiliation(s)
- Khalid Sawalha
- University of Missouri-Kansas City, Nutrition and Metabolism Fellowship, Kansas City, MO, USA
| | - Sanjaya Gupta
- Electrophysiology Division, Saint Luke's Mid-America Heart Institute, University of Missouri-Kansas City, Saint Luke's Blvd, MO, USA
| | - Angel López-Candales
- Section of Cardiovascular Medicine, University Health, Truman Medical Center, University of Missouri-Kansas City, Kansas City, MO, USA.
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12
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Saeed S, Mohamed Ali A, Wasim D, Saeed N, Lunde T, Solheim E, Vegsundvåg J, Imazio M. Natural Course of Electrocardiogram Changes and the Value of Multimodality Imaging in Acute Pericarditis. Cardiology 2023; 148:219-227. [PMID: 36948161 DOI: 10.1159/000530207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/14/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND ECG is the initial diagnostic tool that in combination with typical symptoms often raises the suspicion of pericarditis. Echocardiography remains the first-line imaging modality for assessment of pericardial diseases, particularly effusion/tamponade, constrictive physiology, and assessment of regional wall motion abnormalities as differential diagnoses. However, cardiac CT and cardiac magnetic resonance may be necessary in complicated cases and to identify pericardial inflammation in specific settings (atypical presentation, new onset constriction), as well as myocardial involvement and monitoring the disease activity. SUMMARY In acute pericarditis, the most commonly used ECG criteria recommended by international guidelines are the widespread ST-segment elevation or PR depression. However, the classic ECG pattern of widespread ST-segment elevation or PR depression can be seen in less than 60% of patients. In addition, ECG changes are often temporally dynamic, evolve rapidly during the course of disease, and may be influenced by a number of factors such as disease severity, time (stage) of presentation, degree of myocardial involvement, and the treatment initiated. Overall, temporal dynamic changes on ECG during acute pericarditis or myopericarditis have received limited attention. Hence, the aim of this brief clinical review was to increase awareness about the various ECG changes observed during the course of acute pericarditis. KEY MESSAGES ECG may be normal at presentation or for days after the index episode of chest pain, but serial ECGs can reveal specific patterns of temporally dynamic ST elevation in patients with pericarditis or myopericarditis, particularly during new episodes of chest pain.
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Affiliation(s)
- Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Abukar Mohamed Ali
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Daanyaal Wasim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Nasir Saeed
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Lunde
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Eivind Solheim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | | | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital "Santa Maria Della Misericordia", ASUFC, Udine, Italy
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13
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Escherich T, Mogilansky C, Massoudy P. Case report: postoperative ST-segment elevation caused by mechanical compression of the native right coronary artery by a pericardial drainage tube. Eur J Cardiothorac Surg 2023; 63:7056644. [PMID: 36825837 DOI: 10.1093/ejcts/ezad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 02/25/2023] Open
Abstract
ST-segment elevation is often the first remarkable sign of postoperative cardiac ischaemia. It requires prompt diagnostic measures and an early treatment to improve the patient's outcome. We describe a case of early postoperative ST-segment elevation due to mechanical compression of the native right coronary artery by a pericardial drainage tube in a patient after replacement of the ascending aorta.
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Zhou J, Zhan C, Zhou J, Wei C, Zou C. Case report: Persistent ST-segment elevation due to cardiac metastasis from lung cancer. Front Cardiovasc Med 2023; 10:1001527. [PMID: 36844724 PMCID: PMC9945526 DOI: 10.3389/fcvm.2023.1001527] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/11/2023] [Indexed: 02/11/2023] Open
Abstract
Patients with secondary cardiac cancer occasionally show ST segment elevation that mimics acute coronary syndrome despite the absence of coronary artery occlusion. We herein describe a rare case of secondary cardiac cancer that presented with ST-segment elevation. An 82-year-old Chinese man was admitted to the hospital with chest discomfort. Electrocardiography (ECG) showed ST segment elevation in the precordial leads and low-voltage QRS complexes in limb leads without the development of Q waves. Unexpectedly, emergency coronary angiography showed no significant stenosis of the coronary arteries. However, fortunately, transthoracic echocardiography (TTE) revealed massive pericardial effusion and a mass at the apex of the ventricular myocardium. Coincidentally, contrast-enhanced chest computed tomography showed primary lung cancer in the left lower lobe, pericardial effusion, and myocardial metastasis at the ventricular apex. The pericardiac fluid contained blood with significantly increased CEA levels and exfoliated tumor cells. The lung histopathological report suggested squamous cell carcinoma. Two months later, the patient died. These findings suggested that the persistent ST-segment without the development of Q waves was associated with ventricular invasion by primary lung cancer and may indicate a poor prognosis. In conclusion, physicians should be aware of persistent ST-segment elevation mimicking myocardial infarction due to cardiac metastasis with a poor prognosis.
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Affiliation(s)
- Jiawei Zhou
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China,Department of Echocardiography, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chengchuang Zhan
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Zhou
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chao Wei
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Cao Zou
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China,*Correspondence: Cao Zou,
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15
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Wang X, Wei L, Wu Y, Yan J, Zhao L, Yue X, Gao C. ST-segment elevation predicts the occurrence of malignant ventricular arrhythmia events in patients with acute ST-segment elevation myocardial infarction. BMC Cardiovasc Disord 2023; 23:61. [PMID: 36732698 PMCID: PMC9896671 DOI: 10.1186/s12872-023-03099-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND ST-segment elevation (STE) represents a repolarization dispersion marker underlying arrhythmogenesis in ST-segment elevation myocardial infarction (STEMI); however, its value for predicting malignant ventricular arrhythmia events (MVAEs) remains uncertain. METHODS In total, 285 patients with STEMI and those with or without MVAEs who presented within 6 h of symptom onset were enrolled. The relationships between STE and clinical characteristics of MVAEs (defined as ventricular tachycardia or ventricular fibrillation) were analyzed using t-test, chi-square test, binary multivariate logistic regression, and receiver operating characteristic curve analysis. RESULTS Patients with STEMI and MVAEs had a shorter time from symptom onset to balloon time (p = 0.0285) and greater STE (p < 0.01) than those without MVAEs. The symptom-to-balloon time, age, and STE were associated with MVAEs after stepwise regression analysis in all cases. Only STE was significantly associated with the occurrence of MVAEs (all, p < 0.01). The area under the curve (AUC) of STE for predicting MVAEs was 0.905, and the cut-off value was 4.5 mV. When only infarct-related arteries were included in the analysis, the AUC of the left anterior descending artery was 0.925 with a cut-off value of 4.5 mV, that of the right coronary artery was 0.915 with a cut-off value of 4.5 mV, and that of the left circumflex artery was 0.929 with a cut-off value of 4.0 mV. CONCLUSIONS In patients with STEMI presenting within 6 h of symptom onset, age, symptom-to-balloon time, and STE were the main predictors for MVAEs. However, among these, STE was the strongest predictor for MVAEs and was an index for repolarization dispersion of cardiomyocytes in infarcted and non-infarcted areas.
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Affiliation(s)
- Xianpei Wang
- Department of Cardiology, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou University Central China Fuwai Hospital, No. 1 Fuwai Avenue, Zhengdong New District, Zhengzhou, Henan Province, China.
| | - Lifang Wei
- grid.414011.10000 0004 1808 090XDepartment of Cardiology, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou University Central China Fuwai Hospital, No. 1 Fuwai Avenue, Zhengdong New District, Zhengzhou, Henan Province China
| | - Ying Wu
- grid.414011.10000 0004 1808 090XHenan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Juanjuan Yan
- grid.414011.10000 0004 1808 090XDepartment of Cardiology, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou University Central China Fuwai Hospital, No. 1 Fuwai Avenue, Zhengdong New District, Zhengzhou, Henan Province China
| | - Linwei Zhao
- grid.414011.10000 0004 1808 090XDepartment of Cardiology, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou University Central China Fuwai Hospital, No. 1 Fuwai Avenue, Zhengdong New District, Zhengzhou, Henan Province China
| | - Xinjie Yue
- grid.414011.10000 0004 1808 090XDepartment of Cardiology, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou University Central China Fuwai Hospital, No. 1 Fuwai Avenue, Zhengdong New District, Zhengzhou, Henan Province China
| | - Chuanyu Gao
- grid.414011.10000 0004 1808 090XDepartment of Cardiology, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou University Central China Fuwai Hospital, No. 1 Fuwai Avenue, Zhengdong New District, Zhengzhou, Henan Province China ,grid.414011.10000 0004 1808 090XHenan Provincial Key Lab for Control of Coronary Heart Disease, Zhengzhou University Central China Fuwai Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, Henan Province China
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16
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Javadzadegan H, Separham A, Farokhi A, Applegate C, Nader ND. The critically low levels of vitamin D predicts the resolution of the ST-segment elevation after the primary percutaneous coronary intervention. Acta Cardiol 2023; 78:40-46. [PMID: 35816150 DOI: 10.1080/00015385.2021.2015144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
AIMS To investigate the role of vitamin D2 on the resolution of ST-segment elevation (STE) after a primary percutaneous coronary intervention (PCI), as serum levels of vitamin D have been associated with the severity of coronary artery disease. METHODS AND RESULTS All patients who underwent PCI for STEMI were screened for enrolment. Vitamin D2 levels were measured on admission along with other biochemical and haematologic assays. The electrocardiography (ECG) was recorded upon arrival and 60 min after the completion of PCI. The primary endpoint of the study was a ≥ 50% resolution of ST-segment amplitude (+STR) when compared to the initial ECG. A logistic regression multivariate analysis was performed to examine the association of STR with all confounding variables, including the admission levels of vitamin D. Receiver-operator characteristics analysis was used to determine the cut-off value of vitamin D that was predictive of STR. Although there was no difference in STR based on standard classification of vitamin D sufficiency, critically low levels of vitamin D (<7.5 ng/mL) were significantly associated with the absence of STR after PCI (AUC was 0.65 ± 0.07; p < 0.001). Critical vitamin D deficiency was a moderate predictor of STR in these patients, with a sensitivity of 86% and specificity of 54%. CONCLUSION We concluded that although levels below ten ng/mL were generally accepted as vitamin D deficiency, only critically low levels of this vitamin (<7.5 ng/dL) reliably predicted the resolution of ST-segment after a primary PCI for patients with STEMI.
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Affiliation(s)
- Hassan Javadzadegan
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Separham
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aidin Farokhi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Camille Applegate
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Nader D Nader
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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17
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Zhang J, Zou Y, Chen X, Pan J, Yu H, Wang Y, Wu Y, Zou H. Extremely dangerous hypopituitarism related long QT syndrome and transient ST-segment elevation: A case report. SAGE Open Med Case Rep 2023; 11:2050313X221147194. [PMID: 36636098 PMCID: PMC9829875 DOI: 10.1177/2050313x221147194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 12/07/2022] [Indexed: 01/14/2023] Open
Abstract
Acquired long QT syndrome caused by hypopituitarism and transient ST-segment elevation has not been reported in cardiac arrest patients. We report a case of extremely dangerous acquired long QT syndrome and transient ST-segment elevation. A 44-year-old Chinese woman with renal failure experienced sudden cardiac arrest in the haemodialysis room. Subsequent electrocardiogram showed QT prolongation and transient ST-segment elevation. This patient's medical history, subsequent laboratory results and pituitary magnetic resonance imaging suggested hypopituitarism. Transient ST-segment elevation on the electrocardiogram was considered to be caused by repeated direct current shocks. The patient was diagnosed with acquired long QT syndrome and was not taking any antiarrhythmic drugs. Her corrected QT interval normalized after hormone replacement therapy. This case highlights the importance of the awareness of hypopituitarism; early identification and intervention can prevent the occurrence of this life-threatening arrhythmia. ST-segment elevation is not always due to acute myocardial infarction, and a variety of other causes, especially electrical cardioversion, should be considered.
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Affiliation(s)
- Jia Zhang
- Department of Inspection Medical, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - Yingying Zou
- Digestive System Department, The Third Affiliated Hospital of Qiqihar Medical College, Qiqihar, China
| | - Xiaoshu Chen
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - Jingye Pan
- Department of General and Intensive Care Medical, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haizhu Yu
- Department of General Practice, Zhejiang Hospital, Hangzhou, China
| | - Yi Wang
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - Yanran Wu
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China
| | - He Zou
- Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou, China,He Zou, Department of Cardiovascular Medicine, Wenzhou People’s Hospital, The Wenzhou Third Clinical Institute Affiliated with Wenzhou Medical University, Wenzhou 325035, Zhejiang, China.
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18
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Chrisler O, Sawalha K, López-Candales A. Vasospastic Angina With ST-Segment Elevation Seen During Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring. J Investig Med High Impact Case Rep 2023; 11:23247096231166677. [PMID: 37056197 PMCID: PMC10108419 DOI: 10.1177/23247096231166677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
A 54-year-old man presented with significant ST-segment elevations noted on both channels displayed on the mobile cardiac outpatient telemetry (MCOT). Pertinent cardiac history was remarkable for syncope and episodes of atypical chest pain. The latter were described as infrequent and not associated with exercise intolerance. His syncopal episodes were described as occurring mostly in the mornings after the use of the restroom. Episodes happen 1 or 2 times a year since 2015. Patient had undergone thorough investigation with no significant findings. An MCOT was prescribed since frequency of symptoms has recently increased. Significant ST-segment elevations were noted. The patient described atypical chest pain and a sensation of presyncope during these recordings. He was urgently admitted, and a coronary angiogram revealed no epicardial luminal stenosis. However, the presence of sluggish coronary flow was suggestive of possible vasospastic angina. No ST-segment changes were noted during his coronary angiogram. The remarkable element portrayed by this case hinges in showing the unique utility of MCOT, as the most uncharacteristic diagnostic tool, in identifying transient ST-segment elevations that finally led to the diagnosis.
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19
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Chen L, Fan Y, Fang Z, Liu N. Long-term outcomes and predictors of patients with ST elevated versus non-ST elevated myocardial infarctions in non-obstructive coronary arteries: a retrospective study in Northern China. PeerJ 2023; 11:e14958. [PMID: 36890872 PMCID: PMC9987296 DOI: 10.7717/peerj.14958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/05/2023] [Indexed: 03/06/2023] Open
Abstract
Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous disease entity with diverse etiologies and no uniform treatment protocols. Patients with MINOCA can be clinically classified into two groups based on whether they have an ST-segment elevation (STE) or non-ST segment elevation (NSTE), based on electrocardiogram (ECG) results, whose clinical prognosis is unclear. This study aimed to compare the outcomes and predictors of patients with STE and NSTE in the MINOCA population. Methods We collected the data for 196 patients with MINOCA (115 with STE and 81 with NSTE) in China. Clinical characteristics, prognoses, and predictors of major adverse cardiovascular events (MACE) were analyzed during the follow-up of all patients. Results The proportion of patients with STE was greater than that with NSTE in the MINOCA population. Patients with NSTE were older and had a higher incidence of hypertension. No differences were observed in the outcomes between the STE and NSTE groups during a median follow-up period of 49 (37,46) months. No significant differences were observed in those with MACE (24.35% vs 22.22%, P = 0.73) and those without MACE. The multivariable predictors of MACE in the NSTE groups were Killip grades ≥ 2 (HR 9.035, CI 95% [1.657-49.263], P = 0.011), reduced use of β-blockers during hospitalization (HR 0.238, CI 95% [0.072-0.788], P = 0.019), and higher levels of low-density lipoprotein cholesterol (LDL-C) (HR 2.267, CI 95% [1.008-5.097], P = 0.048); the reduced use of β-blockers during hospitalization was the only independent risk factor of MACE in the STE group. Conclusions There were differences between the clinical characteristics of patients with STE and NSTE in the MINOCA population, even though outcomes during follow-up were similar. Independent risk factors for major adverse cardiac events were not identical in the STE and NSTE groups, which could be attributable to the differences in disease pathogenesis.
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Affiliation(s)
- Lin Chen
- Institute of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu Province, China.,Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Yinghong Fan
- Institute of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu Province, China.,Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Zhen Fang
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China
| | - Ning Liu
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China
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20
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Xenogiannis I, Kolokathis F, Alexopoulos D, Rallidis LS. Myocardial infarction due to left main coronary artery total occlusion: A unique electrocardiographic presentation. J Electrocardiol 2023; 76:26-31. [PMID: 36399954 DOI: 10.1016/j.jelectrocard.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/30/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022]
Abstract
Left main coronary artery (LMCA) total occlusion typically presents as anterolateral ST-segment myocardial infarction with or without right bundle branch block with left anterior fascicular block, and ST-segment elevation in aVR. On the contrary to the previously described electrocardiographic pattern we describe a distinct electrocardiographic presentation in a patient with total LMCA occlusion characterized by the presence of complete LBBB co-existing with upsloping ST-segment depression in precordial leads leading to symmetrical, tall, positive T waves, the so called de Winter's sign.
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Affiliation(s)
- Iosif Xenogiannis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece.
| | - Fotios Kolokathis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece
| | - Loukianos S Rallidis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece
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21
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Elikowski W, Łazowski S, Fertała N, Zawodna-Marszałek M, Szczęśniewski P, Bolewski A, Żytkiewicz M. Brugada phenocopy in pulmonary embolism - clinicopathological case study and literature review. Pol Merkur Lekarski 2022; 50:378-383. [PMID: 36645685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Brugada syndrome (BrS) is an inherited channelopathy characterized on ECG by coved (type 1) or saddle-back (type 2) ST-segment elevation (STE) of 2 or more mm in the right precordial leads and is associated with an increased risk of malignant ventricular arrhythmias. The term Brugada phenocopy (BrPh) indicates conditions that may reversibly induce Brugada-like ECG pattern in patients without true BrS; e.g.: metabolic abnormalities, mechanical heart compression, ischemia, myocarditis/pericarditis, and pulmonary embolism (PE). Only 9 cases of BPh associated with PE have been described so far. The authors present another case of a 41-year-old-male and analyze the clinical data of all 10 subjects (7 males and 3 females). Type 1 of ECG Brugada pattern was present in 7 patients (including ours), type 2 was found in 2 persons; in 1 case ECG pattern was not defined. In 7 patients STE was prominent (5 mm or more in at least 1 lead). STE was limited to V1-V2 leads in 4 persons, extended to V3 in 3 patients and even to V4 in 3 other patients, which correlated with the significant right ventricular (RV) dilatation. Concomitant left ventricular (LV) systolic dysfunction was reported only in 1 patient, which suggested that paradoxical embolization of coronary artery was not the mechanism of BrS-like STE. Clinical course of PE was usually severe (5 individuals were treated with thrombolysis) and in 3 cases it ended with death. The autopsy was only performed on our patient. It showed diffuse (ischemic) injury of RV and LV secondary to RV overload, decreased cardiac output and severe oxygen deficiency in myocardium, which could have led to BrS pattern in ECG.
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Affiliation(s)
| | | | - Natalia Fertała
- Józef Struś Hospital, Poznań, Poland: Department of Internal Medicine
| | | | | | | | - Marcin Żytkiewicz
- Józef Struś Hospital, Poznań, Poland: Department of Internal Medicine
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22
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Madias JE. Two Electrocardiographic Aberrations Important for All Caring for Patients to Know about. Cardiology 2022; 148:58-61. [PMID: 36404701 DOI: 10.1159/000528173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
Two electrocardiographic (ECG) aberrations encountered daily in ECG interpretation/overreading, which appear to be either unknown or ignored, by all caring for patients, are described herein: the 1st is the transient increase in the amplitude of QRS complexes in the right precordial ECG leads, leading to the erroneous diagnosis of left ventricular hypertrophy, often encountered in patients with episodes of supraventricular tachycardia, rapid sinus tachycardia, and atrial fibrillation; the 2nd is the spurious ST-segment elevations in lateral and/or inferior ECG leads in patients with right bundle branch block, interpreted by the automated ECG diagnostic algorithms as due to "acute myocardial infarction," "ischemic injury," "pericarditis," and "early repolarization," in the absence of such pathologies or electrophysiological explanations.
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Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,The Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York, USA
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23
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Xenogiannis I, Vemmou E, Nikolakopoulos I, Nowariak ME, Schmidt CW, Brilakis ES, Sharkey SW. The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy. J Electrocardiol 2022; 75:60-65. [PMID: 36202658 DOI: 10.1016/j.jelectrocard.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/08/2022] [Accepted: 09/18/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Takotsubo cardiomyopathy (TC) has a variety of electrocardiographic expressions such as ST-segment elevation (STE), T-wave inversion, QTc-prolongation, left bundle branch block, presence of anterior Q waves and rarely ST-segment depression. In contrast to acute myocardial infarction, the impact of STE on the initial electrocardiogram (EKG), on TC outcomes, remains largely unknown. OBJECTIVE To evaluate the significance of STE on the index EKG of patients with takotsubo cardiomyopathy (TC) in terms of prognosis. METHODS We examined retrospectively the data of 436 patients diagnosed with TC who were admitted to the Minneapolis Heart Institute between August 2001 and November 2019. RESULTS Of 436 patients, 145 (33%) presented with STE on the index EKG. Typical apical ballooning pattern was encountered more frequently in the STE group (66% vs 51%; p = 0.005), on the contrary to the mid-ventricular ballooning which was more common in the non-STE group (31% vs 45%; p = 0.005) while initial left ventricular ejection fraction was similar between the two groups (31% ± 9 vs 33% ± 11; p = 0.163). The composite endpoint of TC-related complications, defined as left ventricular outflow tract obstruction (LVOTO), left ventricular (LV) thrombus, hemodynamic instability requiring mechanical or intravenous vasopressor support, cardiac arrest or in-hospital death, was higher for the STE group (37% vs 24%; p = 0.006). Left ventricular outflow obstruction (LVOTO) was more frequent in patients with STE (13% vs 3%; p < 0.001) while there was a trend toward higher rates of LV thrombus formation in the same group (5% vs 1%; p = 0.057). On multivariable analysis, STE remained an independent predictor of TC-related complications. In-hospital mortality (2.8% vs 3.4%; p = 1.000) and five-year mortality were similar between the two groups (23% vs 20%; p = 0.612). CONCLUSION Patients with TC presenting with STE on the initial EKG, were more likely to develop disease related complications, thus, careful in-hospital monitoring including imaging evaluation for LVOTO and LV thrombus may be warranted for these patients. Nevertheless, both groups had similar in-hospital and five-year mortality.
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Affiliation(s)
- Iosif Xenogiannis
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America; Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| | - Evangelia Vemmou
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America; Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, United States of America
| | - Ilias Nikolakopoulos
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America; Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, United States of America
| | - Meagan E Nowariak
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Christian W Schmidt
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Scott W Sharkey
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, United States of America
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24
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Parreira L, Marinheiro R, Carmo P, Chambel D, Mesquita D, Amador P, Marques L, Mancelos S, Reis RP, Adragao P. Validation of an electrocardiographic marker of low voltage areas in the right ventricular outflow tract in patients with idiopathic ventricular arrhythmias. J Cardiovasc Electrophysiol 2022; 33:2322-2334. [PMID: 35971685 DOI: 10.1111/jce.15654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/11/2022] [Accepted: 08/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Previous studies have reported the presence of subtle abnormalities in the right ventricular outflow tract (RVOT) in patients with apparently normal hearts and ventricular arrhythmias (VAs) from the RVOT, including the presence of low voltage areas (LVAs). This LVAs seem to be associated with the presence of ST-segment elevation in V1 or V2 leads at the level of the 2nd intercostal space (ICS). OBJECTIVE Our aim was to validate an electrocardiographic marker of LVAs in the RVOT in patients with idiopathic outflow tract VAs. METHODS A total of 120 patients were studied, 84 patients referred for ablation of idiopathic VAs with an inferior axis by the same operator, and a control group of 36 patients without VAs. Structural heart disease including arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An electrocardiogram was performed with V1-V2 at the 2nd ICS, and ST-segment elevation ≥1 mm and T-wave inversion beyond V1 were assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV were considered LVAs, and their presence was assessed. We compared three groups, VAs from the RVOT (n = 66), VAs from the LVOT (n = 18) and Control group (n = 36). ST-elevation, T-wave inversion and left versus right side of the VAs were tested as predictors of LVAs, respective odds ratio (ORs) (95% confidence interval [CI]) and p values, were calculated with univariate logist regression. Variables with a p < .005 were included in the multivariate analysis. RESULTS ST-segment elevation, T-wave inversion and LVAs were present in the RVOT group, LVOT group and Control group as follows: (62%, 17%, and 6%, p < .0001), (33%, 29%, and 0%, p = .001) and (62%, 25%, and 14%, p < .0001). The ST-segment elevation, T-wave inversion and right-sided VAs were all predictors of LVAs, respective unadjusted ORs (95% CI), p values were, 32.31 (11.33-92.13), p < .0001, 4.137 (1.615-10.60), p = .003 and 8.200 (3.309-20.32), p < .0001. After adjustment, the only independent predictor of LVAs was the ST-segment elevation, with an adjusted OR (95% CI) of 20.94 (6.787-64.61), p < .0001. CONCLUSION LVAs were frequently present in patients with idiopathic VAs. ST-segment elevation was the only independent predictor of their presence.
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Affiliation(s)
- Leonor Parreira
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal.,Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Rita Marinheiro
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Pedro Carmo
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
| | - Duarte Chambel
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Dinis Mesquita
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Pedro Amador
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Lia Marques
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Sofia Mancelos
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
| | | | - Pedro Adragao
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
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25
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Bai L, Wang Y, Chen F, Peng Y. Hypertrophic cardiomyopathy with heart failure and ST-segment elevation of the lateral wall. ESC Heart Fail 2022; 10:705-708. [PMID: 36178133 PMCID: PMC9871721 DOI: 10.1002/ehf2.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/04/2022] [Accepted: 09/19/2022] [Indexed: 01/29/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common cardiovascular disease that is inherited from a single gene. Its clinical manifestations range from asymptomatic mutant gene carriers to patients with severe left ventricular effluent tract obstruction and end-stage HCM with motor restriction. In this case, we present a patient with the main presentation of heart failure and ST-segment elevation of the lateral wall, as determined by electrocardiogram. The patient was finally diagnosed with HCM because of genetic testing and the presentation of extensive myocardial fibrosis with reduced systolic function on cardiac magnetic resonance imaging. The patient's clinical findings, electrocardiogram, and cardiac magnetic resonance imaging were different from those of typical patients with HCM.
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Affiliation(s)
- Lin Bai
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduChina
| | - Yali Wang
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduChina
| | - Fei Chen
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduChina
| | - Yong Peng
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduChina
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26
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Aslanger EK. Beyond the ST-segment in Occlusion Myocardial Infarction (OMI): Diagnosing the OMI-nous. Turk J Emerg Med 2022; 23:1-4. [PMID: 36818946 PMCID: PMC9930387 DOI: 10.4103/2452-2473.357333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/04/2022] Open
Abstract
The ST-segment elevation (STE) myocardial infarction (MI)/non-STEMI (NSTEMI) paradigm has been the central dogma of emergency cardiology for the last 30 years. Although it was a major breakthrough when it was first introduced, it is now one of the most important obstacles to the further progression of modern MI care. In this article, we trace why a disease with an established underlying pathology (acute coronary occlusion [ACO]) was unintentionally labeled with a surrogate electrocardiographic sign (STEMI/NSTEMI) instead of pathologic substrate itself (ACO-MI/non-ACO-MI or occlusion MI [OMI]/non-OMI [NOMI] for short), how this fundamental mistake caused important clinical consequences, and why we should change this paradigm with a better one, namely OMI/NOMI paradigm.
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Affiliation(s)
- Emre K. Aslanger
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey,Address for correspondence: Prof. Emre K. Aslanger, Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Fevzi Cakmak Mah., Muhsin Yazicioglu Cad. No: 10, Pendik 34899, Istanbul, Turkey. E-mail:
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27
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Du X, Zhang Y. Transient J wave-like ST-segment elevation in intracerebral hemorrhage: a case report. BMC Cardiovasc Disord 2022; 22:255. [PMID: 35672678 PMCID: PMC9172060 DOI: 10.1186/s12872-022-02696-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Certain cerebrovascular events can induce electrocardiography (ECG) abnormalities and cardiac dysfunction. The most frequent patterns reported are nonspecific ST-T change, inverted or broad T wave, prolongation of QT interval as well as ST-segment depression or elevation. Here we present a case of intracerebral hemorrhage (ICH) with transient J wave-like ST-segment elevation accompanied by myocardial lesion. Case presentation A 58-year-old woman was admitted to our hospital and diagnosed with right basal ganglia region cerebral hemorrhage. The ECG recorded on the second hospital day showed transient J wave-like ST-segment elevation accompanied by increased myocardial troponin I and myocardial enzyme. Conclusions The J wave-like ST-segment elevation may be not a specific ECG signs for primary ischemic heart diseases as it also could be found in ICH patients. We believe that the follow-up ECGs can be used in conjunction with repeated myocardial enzyme analysis and echocardiography to differentiate ICH-ralated J wave-like ST-segment elevation from acute myocardial infarction (AMI), thus avoiding unnecessary cardiac catheterization.
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Affiliation(s)
- Xing Du
- Department of Electrophysiology, Yijishan Hospital of Wannan Medical College, 2 Zheshan Road, Wuhu, China
| | - Yongjun Zhang
- Department of Electrophysiology, Yijishan Hospital of Wannan Medical College, 2 Zheshan Road, Wuhu, China.
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28
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Ko H, Kim T, Lee HD, Byun JH, Choo KS. Coronary artery spasm due to acute myocarditis in an adolescent: a case report. BMC Pediatr 2022; 22:304. [PMID: 35610586 PMCID: PMC9128271 DOI: 10.1186/s12887-022-03354-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocarditis refers to the inflammation of the myocardium caused by infection or autoimmune disease that may or may not present with clinical manifestations, such as gastrointestinal symptoms, dyspnea, chest pain, or sudden death. Although myocarditis and coronary artery vasospasm may mimic ST-segment elevation myocardial infarction (STEMI) with normal coronary arteries on angiography, acute myocarditis rarely causes coronary artery spasm. Here, we report a case of coronary artery spasm with reversible electrocardiographic changes mimicking STEMI in an adolescent with acute myocarditis. CASE PRESENTATION A 15-year-old boy present with sudden-onset repeated chest pain following a 3-day history of flu-like illness. Cardiac biomarkers were significantly elevated. Electrocardiography showed ST-segment elevation in the absence of detectable vasospasm on coronary angiography. These findings were consistent with the diagnosis of coronary artery spasm secondary to acute myocarditis. Treatment with immunoglobulin for 2 days improved his condition. The patient was discharged on the 12th day with complete resolution of symptoms and normalization of electrocardiogram findings. CONCLUSIONS We reported a case of coronary artery spasm due to acute myocarditis. This study highlights the importance of considering coronary artery spasm due to acute myocarditis as a differential diagnosis in patients presenting with signs of STEMI as these diseases have different medical management strategies.
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Affiliation(s)
- Hoon Ko
- Department of Pediatrics, Pusan National University Yangsan Hospital, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Taehong Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea.
| | - Hyoung Doo Lee
- Department of Pediatrics, Pusan National University Yangsan Hospital, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Joung-Hee Byun
- Department of Pediatrics, Pusan National University Yangsan Hospital, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan-si, 50612, South Korea
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29
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Cipriani A, D’Amico G, Brunetti G, Vescovo GM, Donato F, Gambato M, Dall’Aglio PB, Cardaioli F, Previato M, Martini N, Perazzolo Marra M, Iliceto S, Cacciavillani L, Corrado D, Zorzi A. Electrocardiographic Predictors of Primary Ventricular Fibrillation and 30-Day Mortality in Patients Presenting with ST-Segment Elevation Myocardial Infarction. J Clin Med 2021; 10:jcm10245933. [PMID: 34945229 PMCID: PMC8703328 DOI: 10.3390/jcm10245933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022] Open
Abstract
Primary ventricular fibrillation (PVF) may occur in the early phase of ST-elevation myocardial infarction (STEMI) prior to primary percutaneous coronary intervention (PCI). Multiple electrocardiographic STEMI patterns are associated with PVF and short-term mortality including the tombstone, Lambda, and triangular QRS-ST-T waveform (TW). We aimed to compare the predictive value of different electrocardiographic STEMI patterns for PVF and 30-day mortality. We included a consecutive cohort of 407 STEMI patients (75% males, median age 66 years) presenting within 12 h of symptoms onset. At first medical contact, 14 (3%) showed the TW or Lambda ECG patterns, which were combined in a single group (TW-Lambda pattern) characterized by giant R-wave and downsloping ST-segment. PVF prior to primary PCI occurred in 39 (10%) patients, significantly more often in patients with the TW-Lambda pattern than those without (50% vs. 8%, p < 0.001). For the multivariable analysis, Killip class ≥3 (OR 6.19, 95% CI 2.37–16.1, p < 0.001) and TW-Lambda pattern (OR 9.64, 95% CI 2.99–31.0, p < 0.001) remained as independent predictors of PVF. Thirty-day mortality was also higher in patients with the TW-Lambda pattern than in those without (43% vs. 6%, p < 0.001). However, only LVEF (OR 0.86, 95% CI 0.82–0.90, p < 0.001) and PVF (OR 4.61, 95% CI 1.49–14.3, p = 0.042) remained independent predictors of mortality. A mediation analysis showed that the effect of TW-Lambda pattern on mortality was mediated mainly via the reduced LVEF. In conclusion, among patients presenting with STEMI, the electrocardiographic TW-Lambda pattern was associated with both PVF before PCI and 30-day mortality. Therefore, this ECG pattern may be useful for early risk stratification of STEMI.
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Affiliation(s)
- Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Gianpiero D’Amico
- Department of Cardiology, Ospedale dell’Angelo, 30174 Venice, Italy; (G.D.); (G.M.V.); (M.P.)
| | - Giulia Brunetti
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Giovanni Maria Vescovo
- Department of Cardiology, Ospedale dell’Angelo, 30174 Venice, Italy; (G.D.); (G.M.V.); (M.P.)
| | - Filippo Donato
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Marco Gambato
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Pietro Bernardo Dall’Aglio
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Martina Previato
- Department of Cardiology, Ospedale dell’Angelo, 30174 Venice, Italy; (G.D.); (G.M.V.); (M.P.)
| | - Nicolò Martini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Luisa Cacciavillani
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
- Correspondence:
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, 35128 Padova, Italy; (A.C.); (G.B.); (F.D.); (M.G.); (P.B.D.); (F.C.); (N.M.); (M.P.M.); (S.I.); (L.C.); (A.Z.)
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30
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Zheng B, Bian F, Li J, Xu H, Wang J. A potential diagnostic pitfall in ST elevation: Acute pulmonary embolism or ST-segment elevation myocardial infarction. Ann Noninvasive Electrocardiol 2021; 27:e12928. [PMID: 34861070 PMCID: PMC9107082 DOI: 10.1111/anec.12928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/28/2022] Open
Abstract
The diagnosis of acute pulmonary embolism (APE) is a great challenge for physicians due to its nonspecific symptoms, and often missed or misdiagnosed as acute coronary syndrome. Electrocardiographic (ECG) abnormalities are seen in majority of patients with APE. Recently, APE with ST‐segment elevation (STE) in leads V1–V3/V4, mimicking ST‐segment elevation myocardial infarction (STEMI), has been described. However, coronary angiography showed that the patient's coronary arteries were mostly normal. Herein, we describe a case of APE presenting with STE in V1–V4, along with severe stenosis of the left anterior descending (LAD) artery.
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Affiliation(s)
- Bo Zheng
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou City, Shandong, China
| | - Fei Bian
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou City, Shandong, China
| | - Jingsen Li
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou City, Shandong, China
| | - Huipu Xu
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou City, Shandong, China
| | - Jian Wang
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou City, Shandong, China
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31
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Brown SH, Neuss MJ, Heimlich JB, Kronenberg MW. Reversible, regional ST-segment elevation due to chylothorax. Ann Noninvasive Electrocardiol 2021; 27:e12907. [PMID: 34747075 PMCID: PMC8739594 DOI: 10.1111/anec.12907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022] Open
Abstract
Chylothorax is an uncommon complication of thoracic surgery and, to our knowledge, has never been documented as a cause of dynamic ST-segment elevation (STE). A 63-year-old woman with history of right pneumonectomy presented with chest pain and regional STE on 12-lead electrocardiogram (ECG). Normal troponin-I and a computed tomography (CT) scan showing a large right hemithoracic fluid collection indicated the unique cause of STE, which resolved after thoracentesis, was pericardial inflammation and cardiac compression from chylothorax. This case emphasizes nuances of ECG interpretation in the context of regional STE and explores the pathophysiology that links chylothorax with acute pericarditis.
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Affiliation(s)
- Sarah H Brown
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michael J Neuss
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
| | - J Brett Heimlich
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
| | - Marvin W Kronenberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
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32
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Magdy AM, Demitry SR, Hasan-Ali H, Zaky M, Abd El-Hady M, Abdel Ghany M. Stenting deferral in primary percutaneous coronary intervention: exploring benefits and suitable interval in heavy thrombus burden. Egypt Heart J 2021; 73:78. [PMID: 34499263 PMCID: PMC8429529 DOI: 10.1186/s43044-021-00203-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Deferred stenting, despite being successful in early studies, showed no benefit in recent trials. However, these trials were testing routine deferral; not in patients with heavy thrombus burden. RESULTS This is a prospective, Randomized Clinical Trial that included 150 patients who presented with STEMI, patients were allocated into three equal groups after the coronary angiography ± primary intervention and before stenting of the culprit lesion; group (A) included 50 patients with early deferral of stenting, group (B) included 50 patients with late deferral and group (C) included 50 patients with immediate stenting. No-reflow was significantly higher in group C, while Final TIMI flow grade 3 and MBG grade 3 were significantly higher in group A and B than group C; p = 0.019 and < 0.001 respectively, with no significant difference between groups A and B, only the thrombus resolution in group B was significantly higher than group A; p < 0.001. Finally, 6-months, over-all MACE was significantly higher in group C (34.7% vs. 14.6% and 16.3%, p = 0.029). CONCLUSIONS Stent deferral was proved to be better than immediate stenting after recanalization of IRA, in achieving TIMI III flow, reducing risk of 6 months MACE, and restoration of myocardial function in a subset of STEMI patients presenting with large thrombus burden. While, no significant difference was found between both deferral times in final TIMI flow, or clinical outcomes.
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Affiliation(s)
- Ahmed M. Magdy
- Cardiovascular Medicine, National Heart Institute, Cairo, Egypt
| | - Salwa R. Demitry
- Cardiovascular Medicine, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Hosam Hasan-Ali
- Cardiovascular Medicine, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Mohamed Zaky
- Cardiovascular Medicine, Faculty of Medicine, Assiut University, Asyut, Egypt
| | | | - Mohamed Abdel Ghany
- Cardiovascular Medicine, Faculty of Medicine, Assiut University, Asyut, Egypt
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33
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Bergonti M, Saenen J, Heidbuchel H, Sarkozy A. ST-Segment Elevation: One Sign, Many Shadows. JACC Case Rep 2021; 3:1360-1362. [PMID: 34505070 PMCID: PMC8414421 DOI: 10.1016/j.jaccas.2021.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/29/2022]
Abstract
ST-segment elevation in patients sedated with propofol may be a sign of imminent malignant arrhythmias. Although propofol infusion syndrome-electrocardiographic abnormalities are usually described as Brugada-pattern, in unique cases nearly ubiquitous and extensive J-point and ST-segment elevation may be observed. These patients should undergo an ajmaline test following recovery. (Level of Difficulty: Beginner.)
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Affiliation(s)
- Marco Bergonti
- University of Milan, Cardiovascular Disease Fellowship Program, Milan, Italy.,Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium.,Cardiovascular Research, University of Antwerp, Antwerp, Belgium
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium.,Cardiovascular Research, University of Antwerp, Antwerp, Belgium
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34
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Shrestha NR, Cook S, Goy JJ. Chest Pain and Hemodynamic Instability in a Young Woman. JACC Case Rep 2021; 3:1367-1369. [PMID: 34505072 PMCID: PMC8414420 DOI: 10.1016/j.jaccas.2021.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 12/02/2022]
Abstract
We report the case of an 18-year-old female admitted to the hospital for severe hemodynamic instability and fatal outcome within 6 hours following admission. Significant electrocardiographic modifications were noted and are presented with diagnostic options. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Nikesh Raj Shrestha
- Department of Cardiology, Neuro Cardio, and Multispeciality Hospital, Biratnagar, Nepal
| | - Stéphane Cook
- Cardiology Department, Clinique Cecil, Lausanne, Switzerland
| | - Jean-Jacques Goy
- Cardiology Department, Clinique Cecil, Lausanne, Switzerland
- Address for correspondence: Prof. Jean-Jacques Goy, Clinique Cecil, Av. Ruchonnet 53, 1003 Lausanne, Switzerland.
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35
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Ip JE, Markowitz SM. ST-Segment Changes in Stress-Induced Cardiomyopathy and His Bundle Pacing. JACC Clin Electrophysiol 2021; 7:131-133. [PMID: 33478707 DOI: 10.1016/j.jacep.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/20/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022]
Affiliation(s)
- James E Ip
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA.
| | - Steven M Markowitz
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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36
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Mamiya K, Inden Y, Yanagisawa S, Fujii A, Tomomatsu T, Okamoto H, Riku S, Suga K, Furui K, Nakagomi T, Shibata R, Murohara T. Dynamic Changes in Electrocardiogram Parameters After Epicardial Substrate Catheter Ablation of Brugada Syndrome. Circ J 2021; 85:1283-1293. [PMID: 33692251 DOI: 10.1253/circj.cj-20-1060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Catheter ablation (CA) is effective for recurrent episodes of ventricular fibrillation (VF) in Brugada syndrome (BrS). VF development in BrS is associated with several electrocardiogram (ECG) abnormalities. This study investigated changes in ECG parameters in high-risk BrS patients who underwent epicardial CA.Methods and Results:In all, 27 BrS patients were implanted with an implantable cardioverter-defibrillator (ICD). Patients were divided into 2 groups: (1) an ablation group (n=11) that underwent epicardial CA because of VF recurrence; and (2) a primary prevention (PP) group (n=16) with ICD implantation only. ECG parameters were evaluated before and 12 months after CA and compared with ECG parameters in the PP group. The T wave peak-to-end interval was significantly longer and the number of abnormal spikes in leads V1-V3 at the second, third, and fourth intercostal spaces was greater in the ablation than PP group. After ablation, ST levels and the sum of abnormal spikes in leads V1-V3 were significantly decreased. The mean (±SD) number of ICD shocks decreased markedly during a mean follow-up period of 42.0 months (from 3.8±3.7 to 0.2±0.4/year). Four patients had an ICD shock following the ablation procedure. Greater reductions in ST-segment elevation and abnormal spikes were observed in the group without than with VF recurrence. CONCLUSIONS Improvements in surface ECG parameters appear to be associated with successful ablation in high-risk BrS patients.
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Affiliation(s)
- Keita Mamiya
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroya Okamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Shuro Riku
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kazumasa Suga
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Koichi Furui
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Rei Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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Bai L, Chen F, Peng Y. Widespread ST-segment elevation due to diffuse coronary artery spasm: A case report. Ann Noninvasive Electrocardiol 2021; 26:e12877. [PMID: 34250702 PMCID: PMC8411782 DOI: 10.1111/anec.12877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023] Open
Abstract
Coronary artery spasm (CAS) is considered an important mechanism of acute coronary syndrome but not very common in the clinical setting. We report a case of a 42-year-old woman with chest pain lasting for 4 h due to diffuse CAS, which led to widespread ST-segment elevation in multiple leads of the electrocardiogram and elevated cardiac troponin T. Emergency coronary angiography at admission showed significantly different morphological results from the second angiography during hospitalization, indicating the patient's discomfort was due to CAS rather than stenosis. Our case illustrates that diffuse CAS can cause widespread ST-segment elevation and severe ACS.
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Affiliation(s)
- Lin Bai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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38
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Andreou AY, Christou T, Koskina LE. Electrocardiographic presentation of acute left main coronary artery occlusion misinterpreted as ventricular tachycardia. J Electrocardiol 2021; 68:7-10. [PMID: 34265477 DOI: 10.1016/j.jelectrocard.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/13/2021] [Accepted: 06/27/2021] [Indexed: 10/21/2022]
Abstract
We present a case of acute left main coronary artery (LMCA) occlusion that manifested cardiogenic shock and an ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) pattern comprising "triangular" or "lambda-like" QRS-ST-T complexes. The presenting ECG pattern was misinterpreted as ventricular tachycardia (VT) with resultant delayed emergency percutaneous coronary intervention. The patient died of intractable cardiogenic shock. This case corroborates previous research findings associating the ECG pattern comprising "triangular" or "lambda-like" QRS-ST-T complexes observed in the clinical setting of acute myocardial ischemia with acute LMCA occlusion. Also, we demonstrate how this ECG pattern should be scrutinized for ST-segment elevation in order to avoid misdiagnosing a STEMI for VT.
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Affiliation(s)
- Andreas Y Andreou
- Department of Cardiology, Limassol General Hospital, Limassol, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus.
| | | | - Lida Efstathia Koskina
- University of Nicosia Medical School, Nicosia, Cyprus; St George's University of London MBBS Programme, University of Nicosia Medical School, Nicosia, Cyprus
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Madias JE. On the nonpathological nature of ST-segment elevation in lateral leads in patients with CRBBB. Pacing Clin Electrophysiol 2021; 44:755-757. [PMID: 33565606 DOI: 10.1111/pace.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/18/2021] [Accepted: 01/31/2021] [Indexed: 11/29/2022]
Abstract
Stable ST-segment elevation (STSE) in the lateral electrocardiogram (ECG) leads (i.e., I, II, aVL, V5, and V6) are frequently encountered in association with stable and transient complete right bundle branch block (CRBBB). These STSE in the lateral ECG leads in patients with CRBBB, represent parallel changes to the ST-segment depression seen in the V1-V3 leads, and both represent secondary ECG changes expected in patients with intraventricular conduction delays, and they are opposite in polarity to the latter part of the QRS complexes. Proprietary automated ECG interpretation algorithms provided by the different electrocardiographs associate such ECG changes in the lateral leads in the presence of CBBB to "lateral myocardial infarction, ischemia, or injury," "pericarditis," or "early repolarization," which results in inappropriate concern among clinicians, and leads to costly unnecessary diagnostic testing. This piece strives to reassure clinicians about the nonpathological nature of lateral STSE in ECGs with CRBBB.
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Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York, USA
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40
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Meizinger C, Klugherz B. Focal ST-segment elevation without coronary occlusion: myocardial infarction with no obstructive coronary atherosclerosis associated with COVID-19-a case report. Eur Heart J Case Rep 2021; 5:ytaa532. [PMID: 33768195 PMCID: PMC7982125 DOI: 10.1093/ehjcr/ytaa532] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/15/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND While it is understood that coronavirus disease 2019 (COVID-19) is primarily complicated by respiratory failure, more data are emerging on the cardiovascular complications of this disease. A subset of COVID-19 patients present with ST-elevations on electrocardiogram (ECG) yet normal coronary angiography, a presentation that can fit criteria for myocardial infarction with no obstructive coronary atherosclerosis (MINOCA). There is little known about non-coronary myocardial injury observed in patients with COVID-19, and we present a case that should encourage further conversation and study of this clinical challenge. CASE SUMMARY An 86-year-old man presented to our institution with acute hypoxic respiratory failure and an ECG showing anteroseptal ST-segment elevation concerning for myocardial infarction. Mechanic ventilation was initiated prior to presentation, and emergent transthoracic echocardiography reported an ejection fraction of 50-55%, with no significant regional wall motion abnormalities. Next, emergent coronary angiography was performed, and no significant coronary artery disease was detected. The patient tested positive for COVID-19. Despite supportive management in the intensive care unit, the patient passed away. DISCUSSION We present a case of COVID-19 that is likely associated with MINOCA. It is crucial to understand that in COVID-19 patients with signs of myocardial infarction, not all myocardial injury is due to obstructive coronary artery disease. In the case of COVID-19 pathophysiology, it is important to consider the cardiovascular effects of hypoxic respiratory failure, potential myocarditis, and significant systemic inflammation. Continued surveillance and research on the cardiovascular complications of COVID-19 is essential to further elucidate management and prognosis.
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Affiliation(s)
- Casey Meizinger
- Department of Internal Medicine, Abington Hospital, Jefferson Health Abington, 1200 Old York Road PA, 19118, USA
| | - Bruce Klugherz
- Department of Cardiology, Abington Hospital, Jefferson Health Abington, 1200 Old York Road, PA, 19118, USA
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41
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Fontes A, Dias-Ferreira N, Tavares A, Neves F. Cerebral embolism due to left atrial myxoma in a patient presenting with chest pain and ST-segment elevation: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33442627 PMCID: PMC7793160 DOI: 10.1093/ehjcr/ytaa272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/31/2020] [Accepted: 07/22/2020] [Indexed: 11/14/2022]
Abstract
Background Myocarditis is an uncommon, potentially life-threatening disease that presents with a wide range of symptoms. In acute myocarditis, chest pain (CP) may mimic typical angina and also be associated with electrocardiographic changes, including an elevation of the ST-segment. A large percentage (20-56%) of myxomas are found incidentally. Case summary A 62-year-old female presenting with sudden onset CP and infero-lateral ST-elevation in the electrocardiogram. The diagnosis of ST-elevation myocardial infarction was presumed and administered tenecteplase. The patient was immediately transported to a percutaneous coronary intervention centre. She complained of intermittent diplopia during transport and referred constitutional symptoms for the past 2 weeks. Coronary angiography showed normal arteries. The echocardiogram revealed moderate to severe left ventricular systolic dysfunction due to large areas of akinesia sparing most of the basal segments, and a mobile mass inside the left atrium attached to the septum. The cardiac magnetic resonance (CMR) suggested the diagnosis of myocarditis with concomitant left atrial myxoma. The patient underwent resection of the myxoma. Neurological evaluation was performed due to mild vertigo while walking and diplopia in extreme eye movements. The head magnetic resonance imaging identified multiple infracentimetric lesions throughout the cerebral parenchyma compatible with an embolization process caused by fragments of the tumour. Discussion Myocarditis can have various presentations may mimic acute myocardial infarction and CMR is critical to establish the diagnosis. Myxoma with embolic complications requires emergent surgery. To the best of our knowledge, this is the first case reported in the applicable literature of a myxoma diagnosed during a myocarditis episode.
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Affiliation(s)
- António Fontes
- Department of Cardiology, Hospital do Divino Espírito Santo de Ponta Delgada, Avenida D. Manuel I, 9500-370 Ponta Delgada, Azores, Portugal
| | - Nuno Dias-Ferreira
- Department of Cardiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
| | - Anabela Tavares
- Department of Cardiology, Hospital do Divino Espírito Santo de Ponta Delgada, Avenida D. Manuel I, 9500-370 Ponta Delgada, Azores, Portugal
| | - Fátima Neves
- Department of Cardiothoracic Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
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Wang A, Singh V, Duan Y, Su X, Su H, Zhang M, Cao Y. Prognostic implications of ST-segment elevation in lead aVR in patients with acute coronary syndrome: A meta-analysis. Ann Noninvasive Electrocardiol 2020; 26:e12811. [PMID: 33058358 PMCID: PMC7816815 DOI: 10.1111/anec.12811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/26/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND ST-segment elevation (STE) in lead aVR is a useful tool in recognizing patients with left main or left anterior descending coronary obstruction during acute coronary syndrome (ACS). The prognostic implication of STE in lead aVR on outcomes has not been established. METHODS We performed a systematic search for clinical studies about STE in lead aVR in four databases including PubMed, EMBASE, Cochrane Library, and Web of Science. Primary outcome was in-hospital mortality. Secondary outcomes included in-hospital (re)infarction, in-hospital heart failure, and 90-day mortality. RESULTS We included 7 studies with a total of 7,700 patients. The all-cause in-hospital mortality of patients with STE in lead aVR during ACS was significantly higher than that of patients without STE (OR: 4.37, 95% CI 1.63 to 11.68, p = .003). Patients with greater STE (>0.1 mV) in lead aVR had a higher in-hospital mortality when compared to lower STE (0.05-0.1 mV) (OR: 2.00, 95% CI 1.11-3.60, p = .02), However, STE in aVR was not independently associated with in-hospital mortality in ACS patients (OR: 2.72, 95% CI 0.85-8.63, p = .09). The incidence of in-hospital myocardial (re)infarction (OR: 2.77, 95% CI 1.30-5.94, p = .009), in-hospital heart failure (OR: 2.62, 95% CI 1.06-6.50, p = .04), and 90-day mortality (OR: 10.19, 95% CI 5.27-19.71, p < .00001) was also noted to be higher in patients STE in lead aVR. CONCLUSIONS This contemporary meta-analysis shows STE in lead aVR is a poor prognostic marker in patients with ACS with higher in-hospital mortality, reinfarction, heart failure and 90-day mortality. Greater magnitude of STE portends worse prognosis. Further studies are needed to establish an independent predictive role of STE in aVR for these adverse outcomes.
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Affiliation(s)
- Aqian Wang
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Vikas Singh
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yichao Duan
- School of Clinical Medicine, Ningxia Medical University, Ningxia, China
| | - Xin Su
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Hongling Su
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Min Zhang
- Department of Pathology, Gansu Provincial Hospital, Lanzhou, China
| | - Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China.,Department of Cardiology, Shanxi Cardiovascular Hospital affiliated With Shanxi Medical University, Taiyuan, China
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Raza M, Ikram S, Williams N, Otero D, Barry N, Kelsey N, Kahlon T, Singh V. Cardiac Lymphoma Presenting with Recurrent STEMI. Methodist Debakey Cardiovasc J 2020; 16:158-161. [PMID: 32670477 DOI: 10.14797/mdcj-16-2-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The incidence of primary cardiac tumors is exceedingly rare, whereas secondary cardiac tumors are more common in the global population. Cardiac involvement is seen in approximately 18% of patients with non-Hodgkin's lymphoma at the time of autopsy. Clinical manifestations of cardiac involvement are subtle and often go unrecognized until advanced stages of the disease. We present a rare case of metastatic cardiac lymphoma that presented as an ST-segment elevation myocardial infarction complicated by left ventricular free wall rupture and cardiogenic shock due to transmural myocardial necrosis from malignant cell infiltration.
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Affiliation(s)
- Munis Raza
- UNIVERSITY OF LOUISVILLE, LOUISVILLE, KENTUCKY
| | | | | | - Diana Otero
- UNIVERSITY OF LOUISVILLE, LOUISVILLE, KENTUCKY
| | - Neil Barry
- UNIVERSITY OF LOUISVILLE, LOUISVILLE, KENTUCKY
| | | | | | - Vikas Singh
- UNIVERSITY OF LOUISVILLE, LOUISVILLE, KENTUCKY
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44
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Aslanger EK, Yıldırımtürk Ö, Şimşek B, Bozbeyoğlu E, Şimşek MA, Yücel Karabay C, Smith SW, Değertekin M. DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study). Int J Cardiol Heart Vasc 2020; 30:100603. [PMID: 32775606 PMCID: PMC7399112 DOI: 10.1016/j.ijcha.2020.100603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/07/2020] [Accepted: 07/18/2020] [Indexed: 12/28/2022]
Abstract
Background Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy. Methods A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database. Results In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality. Conclusions We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.).
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Affiliation(s)
- Emre K Aslanger
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey
| | - Özlem Yıldırımtürk
- University of Health Sciences, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Barış Şimşek
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Division of Cardiology, Istanbul, Turkey
| | - Emrah Bozbeyoğlu
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Division of Cardiology, Istanbul, Turkey
| | | | - Can Yücel Karabay
- University of Health Sciences, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Stephen W Smith
- University of Minnesota, Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States
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Loghin C, Chauhan S, Lawless SM. Pseudo-Acute Myocardial Infarction in a Young COVID-19 Patient. JACC Case Rep 2020; 2:1284-1288. [PMID: 32342049 PMCID: PMC7183966 DOI: 10.1016/j.jaccas.2020.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022]
Abstract
A 29-year-old man tested positive for COVID-19 and developed acute respiratory distress syndrome. While mechanically ventilated, his electrocardiogram showed inferior ST-segment elevations, with normal serial cardiac troponin I and transthoracic echocardiograms. He was treated conservatively, with complete clinical recovery and resolution of his electrocardiographic abnormalities. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Catalin Loghin
- Division of Cardiology, Department of Internal Medicine, University of Texas McGovern Medical School–Houston, Houston, Texas
| | - Siddharth Chauhan
- Division of Cardiology, Department of Internal Medicine, University of Texas McGovern Medical School–Houston, Houston, Texas
| | - Sean M. Lawless
- Division of Cardiology, Department of Internal Medicine, University of Texas McGovern Medical School–Houston, Houston, Texas
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Xu B, Abdu FA, Liu L, Mohammed AQ, Yin G, Luo Y, Xu S, Lv X, Fan R, Che W. Clinical Outcomes and Predictors of ST-Elevation Versus Non-ST-Elevation Myocardial Infarction with Non-Obstructive Coronary Arteries. Am J Med Sci 2020; 360:686-692. [PMID: 32736830 DOI: 10.1016/j.amjms.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/19/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myocardial infarction with nonobstructive coronary arteries (MINOCA) can be clinically categorized as ST-segment elevation (STE) and non-ST-segment elevation (NSTE), whose clinical prognosis are poorly understood. The aim of this study was to compare the clinical outcome and their predictors of patients with STE and NSTE in MINOCA population. METHODS A total of 265 patients with MINOCA (102 with STE, and 163 with NSTE) were consecutively collected. Clinical profile, prognosis, and predictors of all patients were assessed. RESULTS The proportion of patients with NSTE was greater than patients with STE in MINOCA population. Patients with NSTE were older and more likely to be female and had a higher incidence of atrial fibrillation. Both high density lipoprotein (HDL) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were higher in the NSTE group. Patients with STE were more likely to have a history of smoking and a higher diastolic blood pressure. During the 1-year follow up, there were no differences in the outcomes between the STE and NSTE groups, with no significant differences in mortality and a similar rate of major adverse cardiovascular events (MACE) (20.9% vs 19.3%, P = 0.767). The multivariable predictors of MACE in the NSTE groups were age, lower level of total cholesterol, hypertension, and smoking history, whereas reduced left ventricular ejection fraction, and diabetes mellitus were the multivariable predictors of major adverse cardiac events in the STE group. CONCLUSIONS There were differences in the clinical profile between STE and NSTE in the MINOCA population, whereas the outcomes during the 1-year follow up were similar. The STE and NSTE groups had different predictive factors for major adverse cardiac events.
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Affiliation(s)
- Bin Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Medical College of Soochow University, Suzhou, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yanru Luo
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Siling Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xian Lv
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Fan
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Department of Cardiology, Shanghai Tenth People's Hospital Chongming branch, Shanghai, China.
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Celik AI, Karaaslan MB, Ikikardes MF, Meral F, Cagliyan CE. Acute Anterior Myocardial Infarction in a Patient With Dextrocardia and Situs Inversus: An Unusual Coexistence. JACC Case Rep 2020; 2:1220-1221. [PMID: 34317453 PMCID: PMC8311727 DOI: 10.1016/j.jaccas.2020.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 06/13/2023]
Abstract
Situs inversus totalis is a rare disorder. In addition, acute coronary syndromes, especially ST-segment elevation myocardial infarctions, are rarely detected in this group. We demonstrate the electrocardiographic features and discuss the interventional challenges of acute anterior myocardial infarction in a patient with dextrocardia. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Aziz Inan Celik
- Department of Cardiology, Gebze Fatih State Hospital, Kocaeli, Turkey
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Affiliation(s)
- Jason Lee Winter
- Yorkshire Ambulance Service National Health Service Trust, Wakefield, United Kingdom
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Aslanger E, Yıldırımtürk Ö, Şimşek B, Sungur A, Türer Cabbar A, Bozbeyoğlu E, Karabay CY, Smith SW, Değertekin M. A new electrocardiographic pattern indicating inferior myocardial infarction. J Electrocardiol 2020; 61:41-46. [PMID: 32526537 DOI: 10.1016/j.jelectrocard.2020.04.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/11/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND We identified a specific pattern that does not display contiguous ST-segment elevation (STE), indicating acute inferior myocardial infarction (MI) with concomitant critical stenoses on the other coronary arteries. We sought to define the frequency, underlying anatomic substrate, diagnostic power and prognostic implications of this pattern. METHODS One thousand patients with a diagnosis of non-STEMI were enrolled as the study group. Within the same date range, all patients with inferior STEMI and 1000 patients, who had been excluded for MI (no-MI), were also enrolled. The coronary angiograms were reviewed by two interventional cardiologists, who were blinded to the ECGs. Echocardiographic wall motion bullseye displays and coronary angiography maps were constructed for each group. The dead or alive status was checked from the electronic national database. RESULTS The final study population consisted 2362 patients. The prespecified ECG pattern was observed in 6.3% (61/966) of the non-STEMI cohort and 0.5% (5/1000) of no-MI patients. These patients had a larger infarct size as evidenced by 24-hour troponin levels, higher frequency of angiographic culprit lesion, and higher frequency of composite acute coronary occlusion endpoint compared to their non-STEMI counterparts. On the other hand, they had a similar in-hospital (5% vs. 4%, respectively; P = 0.675) and one-year mortality compared to the patients with inferior STEMI (11% vs. 8%, respectively; P = 0.311). CONCLUSION We here define a new ECG pattern indicating inferior MI in patients with concomitant critical lesion(s) in coronary arteries other than the infarct-related artery. Patients with this pattern have multivessel disease and higher mortality.
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Affiliation(s)
- Emre Aslanger
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey.
| | - Özlem Yıldırımtürk
- Health Sciences University, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Barış Şimşek
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Division of Cardiology, Istanbul, Turkey
| | - Azmi Sungur
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Division of Cardiology, Istanbul, Turkey
| | - Ayça Türer Cabbar
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey
| | - Emrah Bozbeyoğlu
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Division of Cardiology, Istanbul, Turkey
| | - Can Yücel Karabay
- Health Sciences University, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Stephen W Smith
- University of Minnesota, Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
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Scarsini R, Terentes-Printzios D, De Maria GL, Ribichini F, Banning A. Why, When and How Should Clinicians Use Physiology in Patients with Acute Coronary Syndromes? ACTA ACUST UNITED AC 2020; 15:e05. [PMID: 32577130 PMCID: PMC7301203 DOI: 10.15420/icr.2019.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022]
Abstract
Current data support the use of coronary physiology in patients with acute coronary syndrome (ACS). In patients with ST-elevation MI, the extent of myocardial damage and microvascular dysfunction create a complex conundrum to assimilate when considering clinical management and risk stratification. In this setting, the index of microcirculatory resistance emerged as an accurate tool to identify patients at risk of suboptimal myocardial reperfusion after primary percutaneous coronary intervention who may benefit from novel adjunctive therapies. In the context of non-ST-elevation ACS, coronary physiology should be carefully interpreted and often integrated with intracoronary imaging, especially in cases of ambiguous culprit lesion. Conversely, the functional assessment of bystander coronary disease is favoured by the available evidence, aiming to achieve complete revascularisation. Based on everyday clinical scenarios, the authors illustrate the available evidence and provide recommendations for the functional assessment of infarct-related artery and non-culprit lesions in patients with ACS.
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Affiliation(s)
- Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | | | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona Verona, Italy
| | - Adrian Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals Oxford, UK.,Division of Cardiovascular Medicine, BHF Centre of Research Excellence, University of Oxford Oxford, UK
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