Chest ECG Research Articles

Assessing myocardial tissue in the acute setting with Photon-Counting CT (PCCT) in comparison with Cardiac Magnetic Resonance (CMR)

Abstract Background Cardiac magnetic resonance (CMR) characterization of myocardial tissue is routinely used in clinical practice. Compared to traditional CT, Photon counting CT (PCCT) uses photon-counting detectors offering higher spatial resolution, elimination of electronic noise and improved contrast-to-noise ratio. A comparison between CMR and PCCT for myocardial characterizazion in an urgent setting, however, has not yet been explored. Purpose The aim of this study was to compare the ability to characterize myocardial tissue between PCCT and CMR in patients presenting with acute chest pain in the emergency department (ED). Methods This single-center prospective study enrolled all consecutive patients presenting to the ED of our hospital from November 2023 to January 2024 with chest pain, ECG alterations and troponin rise consistent with myocardial injury. Patients needing urgent coronary angiography according to guidelines were excluded. PCCT was performed urgently for triple rule-out, but also for tissue characterization through post-iodine-contrast administration images. Within 24 hours, all patients underwent a CMR protocol including T2-weighted and late gadolinium enhancement (LGE) images for tissue characterization. Results Six male patients with a mean age of 20 ± 10 years were enrolled. All clinical, PCCT, and CMR parameters are presented in Table 1. All patients presented with diffuse ST-segment elevation and exhibited T2-weighted images (for edema detection) and LGE distribution (subepicardial and intramyocardial) consistent with acute myocarditis. Mean radiation exposure for PCCT was 0.8±0.1 mSv. A strong linear correlation emerged between PCCT-derived delayed enhancement (DE) volume and CMR-derived late gadolinium enhancement (LGE) volume (r = 0.970; p value 0.001) (Table 1). Similar results were achieved when comparing the number of DE and LGE myocardial segments (r = 0.871; p value 0.026). Significant correlations also emerged between DE, LGE, and high-sensitive troponin (hsTN) at presentation (respectively: PCCT-DE vs hsTN r = 0.951, p value 0.004; CMR-LGE vs hsTN r = 0.918, p value 0.010). CMR showed a much higher signal-to-noise ratio (SNR) for the delayed enhanced myocardium and contrast-to-noise (CNR) ratio between the delayed enhanced and normal myocardium with respect to PCCT in post-contrast images (respectively 7.4 ± 3.9 vs 27.2 ± 17.7, p value 0.024 and 5.5 ± 3.7 vs 38.8 ± 30.2, p value 0.023). In T2-weighted images both SNR for the hyperintense myocardium (30.3 [20.4-122.4]) and CNR between the hyperintense and normal myocardium (26.7 [13.3-60.2]) resulted to be higher compared to PCCT (p value 0.027 and 0.045, respectively) (Table 1). Conclusions PCCT appears to be reliable when compared to CMR for detecting myocardial edema through the acquisition of post-contrast images in the acute setting with an acceptable CNR.

Thrombolysis versus primary percutaneous coronary intervention in patients with suspected ST-elevation myocardial infarction - a SWEDEHEART observational study

Abstract Background Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy in ST-elevation myocardial infarction (STEMI) patients provided time to reperfusion is ≤120 minutes. In patients presenting early with an estimated time to reperfusion >120 minutes, thrombolytic therapy should be considered according to European Society of Cardiology guidelines. However, there is a lack of contemporary data on patients treated with thrombolysis. Aims Our aim was to determine how often thrombolysis was administered in STEMI patients having an estimated time to reperfusion of >120 minutes and to study outcome differences between patients treated with thrombolysis compared to those treated with primary PCI. Methods We calculated transport times to nearest primary PCI centre using three-digit zip codes for each patient enrolled in the SWEDEHEART registry from 2008–2021 in the five geographic areas in Sweden routinely using thrombolysis and included those with >120 min estimated transportation time to reperfusion time. Patients without ST-elevations on prehospital ECG and ongoing chest pain as well as patients with left bundle branch block, pacemaker rhythm and patients with contraindications to thrombolysis were excluded. Patients were grouped by received reperfusion therapy with prehospital thrombolysis or no prehospital thrombolysis and studied with regard to 1- and 3-year mortality using Kaplan-Meier failure estimates and Cox regression adjusted for difference in baseline characteristics. Results A total of 1,840 patients were included of whom 1,381 (75.1%) received thrombolysis. A final diagnosis of STEMI was observed in 92.6% of patients receiving thrombolysis and 80.2% of patients treated with primary PCI. The median transport time estimate to a PCI centre was 153 minutes in both groups. Median time from onset of symptoms to reperfusion therapy was 131 minutes for the thrombolysis group and 255 minutes for the PCI group. Patients who received thrombolysis were on average 2 years younger and had fewer comorbidities such as diabetes, cancer and heart failure. Among patients treated with thrombolysis, a total of 42.7% of patients underwent rescue PCI. There was no significant difference in 365-day mortality (6.7% vs 11.8%, adjusted HR 0.84, 95% CI: 0.59-1.19, p=0.33) or 3-year mortality rates (10.3% vs 16.6%, adjusted HR 0.89, 95% CI: 0.66-1.19, p=0.44) between patients treated with thrombolysis and primary PCI groups. Conclusions In this population-based study of patients where primary PCI cannot be expeditiously used, we observed a commendable adherence rate of 75% to the ESC guidelines for thrombolysis treatment. Moreover, our findings revealed that the administration of thrombolysis was not associated with any discernible benefits or harm.Unadjusted and adjusted Cox-modelKaplan-Meier survival analysis

Recurrent Myocardial Infarction Due to Spontaneous Coronary Artery Dissection in a Young Female with Rheumatoid Arthritis: A Case Report

Spontaneous coronary artery dissection (SCAD) is an uncommon but significant cause of myocardial infarction (MI) in young women who do not present with traditional cardiovascular risk factors. This case report details the presentation of a 36-year-old female with recurrent myocardial infarctions, characterized by chest pain, ECG abnormalities, and angiographic evidence of coronary dissection. Concurrently diagnosed with rheumatoid arthritis (RA), her repeated cardiac events were attributed to SCAD. The chronic inflammatory state associated with RA, along with autoimmune vasculitis, connective tissue abnormalities, and possible effects of RA medications, likely contributed to the development of SCAD. This case highlights the critical need to recognize SCAD as a potential diagnosis in young women, particularly those with autoimmune conditions, and underscores the importance of considering autoimmune disorders as a contributing factor in the pathogenesis of SCAD.

Lessons learned from a multimodal sensor-based eHealth approach for treating pediatric obsessive-compulsive disorder.

The present study investigates the feasibility and usability of a sensor-based eHealth treatment in psychotherapy for pediatric obsessive-compulsive disorder (OCD), and explores the promises and pitfalls of this novel approach. With eHealth interventions, therapy can be delivered in a patient's home environment, leading to a more ecologically valid symptom assessment and access to experts even in rural areas. Furthermore, sensors can help indicate a patient's emotional and physical state during treatment. Finally, using sensors during exposure with response prevention (E/RP) can help individualize therapy and prevent avoidance behavior. In this study, we developed and subsequently evaluated a multimodal sensor-based eHealth intervention during 14 video sessions of cognitive-behavioral therapy (CBT) in 20 patients with OCD aged 12-18. During E/RP, we recorded eye movements and gaze direction via eye trackers, and an ECG chest strap captured heart rate (HR) to identify stress responses. Additionally, motion sensors detected approach and avoidance behavior. The results indicate a promising application of sensor-supported therapy for pediatric OCD, such that the technology was well-accepted by the participants, and the therapeutic relationship was successfully established in the context of internet-based treatment. Patients, their parents, and the therapists all showed high levels of satisfaction with this form of therapy and rated the wearable approach in the home environment as helpful, with fewer OCD symptoms perceived at the end of the treatment. The goal of this study was to gain a better understanding of the psychological and physiological processes that occur in pediatric patients during exposure-based online treatment. In addition, 10 key considerations in preparing and conducting sensor-supported CBT for children and adolescents with OCD are explored at the end of the article. This approach has the potential to overcome limitations in eHealth interventions by allowing the real-time transmission of objective data to therapists, once challenges regarding technical support and hardware and software usability are addressed. www.ClinicalTrials.gov, identifier (NCT05291611).

A Comprehensive Review of Cardiovascular Disease Management: Cardiac Biomarkers, Imaging Modalities, Pharmacotherapy, Surgical Interventions, and Herbal Remedies.

Cardiovascular diseases (CVDs) continue to be a major global health concern, representing a leading cause of morbidity and mortality. This review provides a comprehensive examination of CVDs, encompassing their pathophysiology, diagnostic biomarkers, advanced imaging techniques, pharmacological treatments, surgical interventions, and the emerging role of herbal remedies. The review covers various cardiovascular conditions such as coronary artery disease, atherosclerosis, peripheral artery disease, deep vein thrombosis, pulmonary embolism, cardiomyopathy, rheumatic heart disease, hypertension, ischemic heart disease, heart failure, cerebrovascular diseases, and congenital heart defects. The review presents a wide range of cardiac biomarkers such as troponins, C-reactive protein, CKMB, BNP, NT-proBNP, galectin, adiponectin, IL-6, TNF-α, miRNAs, and oxylipins. Advanced molecular imaging techniques, including chest X-ray, ECG, ultrasound, CT, SPECT, PET, and MRI, have significantly enhanced our ability to visualize myocardial perfusion, plaque characterization, and cardiac function. Various synthetic drugs including statins, ACE inhibitors, ARBs, β-blockers, calcium channel blockers, antihypertensives, anticoagulants, and antiarrhythmics are fundamental in managing CVDs. Nonetheless, their side effects such as hepatic dysfunction, renal impairment, and bleeding risks necessitate careful monitoring and personalized treatment strategies. In addition to conventional therapies, herbal remedies have garnered attention for their potential cardiovascular benefits. Plant extracts and their bioactive compounds, such as flavonoids, phenolic acids, saponins, and alkaloids, offer promising cardioprotective effects and enhanced cardiovascular health. This review underscores the value of combining traditional and modern therapeutic approaches to improve cardiovascular outcomes. This review serves as a vital resource for researchers by integrating a broad spectrum of information on CVDs, diagnostic tools, imaging techniques, pharmacological treatments and their side effects, and the potential of herbal remedies.

SEPTAL COLLATERAL PERFORATION COMPLICATED BY INTRAVENTRICULAR SEPTAL HEMATOMA: RESOLUTION BY COIL EMBOLIZATION

Abstract A 76–year–old man with effort angina was admitted to our cardiology department for an elective coronary angiography (CA). Diagnostic CA revealed severely calcified three–vessel coronary artery disease (CAD) with chronic total occlusions (CTO) of the right dominant coronary artery (RCA) and left circumflex artery (LCX), and severe calcific stenosis of the left descending artery (LAD). An urgent percutaneous coronary intervention (PCI) to treat the LAD was carried out because of ECG modifications and chest pain immediately after CA. During the procedure a septal collateral perforation occurred leading to abrupt development of a large intraventricular septal hematoma (IVSH). Urgent embolization of the culprit vessel with coils was performed using block and deliver (BAD) technique. Rapid hematoma expansion involved another proximal septal collateral. A prompt second coil embolization was carried out arresting the growth of the septal hematoma. The patient was discharged in stable condition and complete resolution of IVSH was confirmed by transthoracic echocardiogram two months later. Timely management of the septal perforation and close echocardiographic monitoring resulted in complete hematoma resolution and a satisfactory outcome.

EGS P30 Audit on the assessment of upper abdominal pain for cardiac and respiratory differentials (AUPCR)

Abstract Background In multi-morbid ageing population, cardiac and respiratory differentials of upper abdominal pain should be ruled out. In patients presenting to surgical units with upper abdominal pain, we evaluated proportion undergoing chest assessments and in patients older than 40, we identified proportion having Electrocardiograms (ECGs.) We planned to install quality improvement strategies and close the audit loop. Methods According to our trust’s protocol, all patients with upper abdominal pain require chest assessment, and those older than 40, require ECG. We collected data retrospectively from patients’ notes between January and February 2022. We educated healthcare staff to perform chest assessments and interpret ECGs. We circulated the trust protocol as flyers and affixed posters in A&E and SAU. We changed patient’s electronic system so that ECGs can be uploaded. Re-audit happened between May and June 2022. Results 100 patients were included in first cycle and 75 patients in the second. Three-quarters of patients were female and one-quarter were male. Around two-thirds of patients were older than 40. The most common region of pain was the right hypochondrium followed by the epigastrium. Proportion of patients having chest assessments rose from 48% to 85% in re-audit. Number of patients older than 40 having ECGs more than doubled from 28% to 61% in the re-audit. Conclusions We identified that chest assessments and ECGs were not being performed to adequately investigate patients with upper abdominal pain. We trained staff, used visual aids and made changes to electronic systems; which resulted in significant improvement in assessment of differentials for upper abdominal pain. No life-threatening cardiac or respiratory conditions were missed in the re-audit.

Right Ventricular Infarction in Patients with Inferior Wall Myocardial Infarction and its Association with Various Risk Factors

Objectives: This study aimed to evaluate the occurrence of right ventricular infarction among patients with inferior wall MI and the risk factors leading to involvement of the right ventricle.
 Methodology: A prospective study was conducted at Hayatabad Medical complex in Peshawar from December 2022 to July 2023, involving 114 participants aged 40-80 years with inferior wall myocardial infarction. The study confirmed MI by chest pain, ECG changes, and elevated cardiac enzymes, while right ventricular infarction was assessed through specific ECG leads. Patients with specific medical histories were excluded. Ethical approval was obtained to ensure patient rights and data confidentiality.
 Results: Out of 114 patients with inferior wall myocardial infarction (MI), 42 (36.8%) had right ventricular infarction (RVI). RVI and Age: Most participants (59.6%) were aged 40 to 60 years, and the rest (40.4%) were aged 61 to 80 years. RVI occurrence was not significantly associated with age (p = 0.707). RVI and Gender: Among the participants, 61.4% were male, and 38.6% were female. RVI was significantly more common in males (45.7%) compared to females (22.7%) with a p-value of 0.013.
 Hypertension was present in 40.3% of participants, and RVI was significantly associated with hypertension (p < 0.001). RVI occurred in 65.2% of hypertensive patients compared to 17.6% of non-hypertensive patients. Smoking: Smoking was reported by 26.3% of participants, and RVI was significantly more prevalent among smokers (56.7%) compared to non-smokers (29.8%) with a p-value of 0.008. Diabetes Mellitus: Diabetes was present in 21.0% of patients, and RVI was significantly associated with diabetes (p = 0.014). RVI occurred in 58.3% of diabetic patients versus 31.1% in non-diabetics. Dyslipidemias: Dyslipidemia was found in 12.3% of patients, but the association with RVI was not statistically significant (p = 0.092). RVI occurred in 57.1% of dyslipidemic patients and 34.0% of non-dyslipidemic patients.
 Conclusion: The occurrence of RVI is seen in around 33% of instances in conjunction with IWMI. The identification of risk factors is crucial in the assessment of individuals with chronic heart disease. The use of this straightforward method has the potential to streamline the process of identifying and categorizing individuals who may be at a higher risk of developing right ventricular infarction in the context of inferior wall myocardial infarction. The risk variables included in this study consist of hypertension, diabetes mellitus, and smoking. Among these three options, people with hypertension have the greatest likelihood of experiencing RVI. Therefore, it may be inferred that this factor is among the most significant risk factors for respiratory viral infections in individuals with impaired immune systems. The use of timely management strategies for the aforementioned risk factors will lead to a decrease in the occurrence of RVI and therefore mitigate the related complications.

Frequency of Contrast Induced Nephropathy in STEMI Patients Undergoing Primry PCI in Patients at Hayatabad Medical Complex Peshawar

Objectives: To determine the frequency of contrast induced nephropathy in STEMI patients undergoing primary PCI in patients at Hayatabad Medical Complex Peshawar.
 Methodology: 178 patients presenting with acute coronary syndrome were enrolled. Confirmation of ACS was based on typical chest pain, ECG findings and imaging findings including angiography. Patients was labelled having contrast induced nephropathy if their serum creatinine ≥25% from the baseline value within the 72- hour period is reported after percutaneous coronary intervention (PCI).
 Results: Age of the patients ranged from 40 to 80 years. Mean age of the patients was 52.80 ± 5.298 years. Male to female ratio was 2.4: 1. Contrast Induced nephropathy was recorded in 30 patients (16.8%). The association of contrast induced nephropathy with age, gender, diabetes mellitus and smoking status was statistically significant.
 Conclusion: CIN after primary PCI is strongly and positively associated with female gender, hypertension, diabetes mellitus and smoking.

Appropriate ischemic criteria for type 4a myocardial infarction: insights from the ALPHEUS trial

Abstract Background Different troponin thresholds have been proposed to define periprocedural myocardial injury based on post percutaneous coronary intervention (PCI) troponin increase only, whereas the definition of type 4a myocardial infarction (MI) needs the association of post procedural troponin and one ischemic criterion. These criteria which evolved from the 3rd to the 4th Universal Definition of Myocardial Infarction (UDMI) are frequently under-reported in studies on periprocedural MI. Purpose We aimed to describe rates of type 4a MI additional diagnostic criteria among the ranges of post PCI troponin elevation in the randomized ALPHEUS trial which compared ticagrelor to clopidogrel in high-risk elective PCI patients. Methods 1698 patients with normal pre-PCI troponin values and centralized core laboratory angiogram analyzes were divided into 4 groups according to maximal post PCI troponin elevations (≤ 1x upper reference limit (URL) for group 1; > 1xURL and ≤ 5xURL for group 2; > 5xURL and < 35xURL for group 3 and ≥ 35xURL for group 4). The type 4a MI additional criteria (ischaemic imaging changes, ischaemic ECG changes, chest pain and angiographic complications) as defined by the 3rd and 4th UDMI were reported and the different angiographic complications were detailed for each group. Results The most prevalent additional ischemic criterion was the presence of angiographic complications detected by the core laboratory. The rate of angiographic complications increased in a stepwise manner with higher post PCI troponin elevation (Figure). Interestingly, we found a similar rate of angiographic complications in patients without any increase in post PCI troponin and troponin elevations below the 5xURL threshold (8.4% and 9.9% respectively). Most angiographic complications were related to transient main branch dissection and/or thrombosis, and transient or permanent side branch occlusions (Table). ECG changes and chest pain ischemic criteria also increased in a stepwise manner and were rarely found below the 5-fold threshold increase, although they might be underreported. Conclusion When using a core laboratory, angiographic complications are found even in patients with no or minor troponin elevation. Above the 5 xURL threshold the rates of angiographic complications are 2 to 3-fold more frequent, and ECG changes and chest pain ischaemic criteria are likely to be present. Our findings support the use of angiographic core laboratory in clinical trial using periprocedural MI as an endpoint; similarly, chest pain -which disappeared from the 4th UDMI- should be reconsidered as a diagnostic ischemic criterion.

Chest pain in patients with cancer: prevalence of myocardial infarction and diagnostic performance of high-sensitivity cardiac troponin T/I

Abstract Background Among patients with active or past cancer presenting with acute chest discomfort to the emergency department (ED), multiple uncertainties remain regarding the prevalence of acute myocardial infarction (AMI), outcomes, and the diagnostic utility of recommended diagnostic tools. Purpose We aimed to evaluate 1) the prevalence of AMI among consecutive patients with a history of cancer presenting with acute chest pain to the ED; 2) time to discharge from the ED and hospitalization rate; 3) the diagnostic accuracy of 34 predefined chest pain characteristics (CPCs) and ECG signatures; 4) the diagnostic accuracy of hs-cTnT and hs-cTnI concentrations; and 5) the performance of the European Society of Cardiology (ESC) 0/1h-hs-cTnT/I algorithms. Methods Patients presenting with chest pain to the ED were prospectively enrolled in an international multicenter diagnostic study. Cancer status was prospectively assessed. Final diagnosis was centrally adjudicated by two independent cardiologists, applying the 4th universal definition of AMI. Findings were externally validated in an independent, multicenter cohort. Results Among 8267 patients, 711 (8.6%) had cancer. Cancer patients had a higher burden of cardiovascular risk factors and preexisting cardiac disease, and more often a final diagnosis of AMI (184 [26%] patients with cancer vs 1562 [21%, P<0.001] without cancer). This difference was largely due to a significantly higher proportion of NSTEMIs in cancer patients (23% vs 17%; p<0.001). Total length of stay in the ED was significantly longer in patients with cancer versus those without (5.2h versus 4.3h, p<0.001). The hospitalization rate was higher in cancer patients (49.8%) than in non-cancer patients (34.3%, P<0.001), driven by non-AMI diagnoses (36.3% vs 21.3%, P<0.001). All-cause mortality at 5-years was 34.4% in patients with cancer versus 8.9% in patients without cancer (P<0.001). In cancer patients, high-sensitivity cardiac troponin (hs-cTn) T, but not hs-cTnI, concentrations had lower diagnostic accuracy for NSTEMI versus those without cancer (hs-cTnT area under the receiver-operating characteristics curve 0.89 [95%CI 0.86-0.92] vs 0.94 [95%CI 0.93-0.94], p<0.001). In cancer patients, the ESC 0/1h-hs-cTnT/I-algorithms maintained a very high safety but had lower efficacy with significantly more patients remaining in the observe zone (with hs-cTnT: 39.0% vs 20.0%, P<0.001). Similar findings were obtained in the external validation cohort. Conclusions Patients with current or past cancer have a substantially higher prevalence of AMI as the cause of acute chest pain. Time to discharge from the ED and the rate of hospitalization are increased, mainly due to non-AMI causes. The diagnostic performance of hs-cTnT/I and the efficacy of the ESC 0/1-h-hs-cTnT/I-algorithms is reduced.

Abstract 16707: Clinical Validation of a Chest-Worn Personal ECG Device for the Detection of Atrial Fibrillation

Introduction: Novel consumer-focused personal ECG devices have the potential to revolutionise the way that cardiac arrhythmias are diagnosed and managed. These devices can be used remotely to monitor patients for arrhythmias, which could lead to earlier detection and treatment. In this study, we aimed to compare the cardiologist's interpretation of clinical 12-lead ECG recordings to a consumer-focused dry-electrode ECG chest strap device (Fourth Frontier FX+). Methods: We included patients seen in an outpatient cardiology clinic at the Sri Jayadeva Institute of Cardiovascular Science and Research, Bangalore, India. A total of 163 paired ECG recordings were captured from 85 adult patients (50% female, median age 54 years, AF present at the time of recording in 38%). Patients with critical cardiac problems or life support systems were excluded. ECG data from the Fourth Frontier FX+ (Fourth Frontier, Bangalore, India) and a standard 12-lead ECG were obtained simultaneously in the supine position. PDF reports for both devices were then generated, and the cardiologist's interpretation of the Fourth Frontier FX+ ECG was compared to the cardiologist's interpreted 12L ECG. Results: The cardiologist's interpretation of the Fourth Frontier FX+ data matched the cardiologist-interpreted 12L data for all patients. One FX+ ECG was excluded from the analysis due to not enough data being captured by the device. A total of 33 patients were correctly identified as having atrial fibrillation. Conclusion: The results of this study demonstrate that the Fourth Frontier FX+ ECG monitor is comparable to a 12-lead ECG for cardiac rhythm monitoring and that it can be used remotely to monitor patients for cardiac arrhythmias. This has the potential to change the way that arrhythmias are diagnosed and managed and lead to earlier detection and treatment at scale.

A Novel Approach to Fetal ECG Extraction Using Temporal Convolutional Encoder-Decoder Network (TCED-Net).

To extract weak fetal ECG signals from the mixed ECG signal on the mother's abdominal wall, providing a basis for accurately estimating fetal heart rate and analyzing fetal ECG morphology. First, based on the relationship between the maternal chest ECG signal and the maternal ECG component in the abdominal signal, the temporal convolutional encoder-decoder network (TCED-Net) model is trained to fit the nonlinear transmission of the maternal ECG signal from the chest to the abdominal wall. Then, the maternal chest ECG signal is nonlinearly transformed to estimate the maternal ECG component in the abdominal mixed signal. Finally, the estimated maternal ECG component is subtracted from the abdominal mixed signal to obtain the fetal ECG component. The simulation results on the FECGSYN dataset show that the proposed approach achieves the best performance in F1 score, mean square error (MSE), and quality signal-to-noise ratio (qSNR) (98.94%, 0.18, and 8.30, respectively). On the NI-FECG dataset, although the fetal ECG component is small in energy in the mixed signal, this method can effectively suppress the maternal ECG component and thus extract a clearer and more accurate fetal ECG signal. Compared with existing algorithms, the proposed method can extract clearer fetal ECG signals, which has significant application value for effective fetal health monitoring during pregnancy.

Armored heart as an image of constrictive pericarditis - a review of the literature

Introduction: Pericarditis is diagnosed among 5% patients hospitalized due to chest pain. It is included in pericardial syndromes together with constrictive pericarditis, pericardial effusion and cardiac tamponade. There are many documented etiological factors leading to pericarditis, most commonly divided into infectious and non-infectious ones. The disease typically presents with chest pain, ECG changes, pericardial rub and pericardial effusion. The diagnosis is made with the results of parameters found in patients’ blood and imaging tests. Treatment is usually based on pharmacological therapy, although in some cases the pericardial surgery is necessary. One of the characteristic changes in imaging diagnostics in patients with pericarditis is thickening of pericardial layers, the so-called armored heart.
 Aim of the study: The aim of the study was to find clear diagnostic criteria for armored heart as a unique type of constrictive pericarditis.
 Materials and methods: Articles available in the databases of medical publications: PubMed, Google Scholar, SCOPUS were analysed using the search phrase: armored heart* AND (pericarditis OR acute pericarditis).
 Results: The search phrase was included in 18 records. After the initial verification, repetitive, unavailable and foreign papers were rejected. Finally, 3 manuscripts were included in further analyses. No clear criteria were found to classify constrictive pericarditis as an armored heart.
 Conclusions: Armored heart is a 'subtype' of constrictive pericarditis. It seems that this term is used subjectively, based on imaging studies.

Clinical profile of congenital heart disease in children with special reference to echo correlation

Background: Congenital heart disease (CHD) is the most frequently occurring congenital disorder responsible for 1/3rd of all congenital birth defects. Diagnostic accuracy of CHD is crucial for timely intervention and optimal patient outcome. So, the study has been done to look for the clinical profile and establishing correlation of clinical diagnosis with echocardiography diagnosis. Methods: This is a prospective cross-sectional study conducted in the department of pediatrics MKCG MCH, Berhampur over a period of 2 years. All children between 1 month to 14 years admitted for suspected CHD were included in the study. Clinical diagnosis was made based on detailed history and physical examination supported by chest X-ray and ECG. Final diagnosis was confirmed by echocardiography and clinico-ECHO correlation was deduced. Results: The 188 patients with CHD were included in this study. The most common age of presentation was 1 month to 1 year with 71.2%, male to female ratio was 1.06:1. Acyanotic CHD (ACHD) was found to be 70.29%, while 29.7% had congenital cyanotic heart disease (CCHD). Clinically specific diagnosis was attributed to 67.1% of cases and no specific diagnosis could be made in 32.9%. Isolated CHD was found to be 66.4% and Complex CHD with multiple defects was found to be 33.6%. Clinic echo correlation was accurate in 39.4% cases, partially correlated in 32% and no correlation in 28.6% cases. Conclusions: So, echocardiography remains the gold standard for diagnosis of CHD and guiding the treatment. Clinical diagnosis alone may not detect associated CHD.

In Hospital Outcome of Patients with Acute St-Elevation Myocardial Infarction Requiring Temporary Pacemaker

Background and Aim: Acute myocardial infarction is a serious public health concern around the globe and temporary pacing is required in a variety of myocardial infarction. The present study aimed to determine the in-hospital outcome of acute ST elevation myocardial infarction patients requiring a temporary pacemaker. Patients and Methods: This descriptive cross-sectional study was carried out on 120 acute myocardial infarction patients in the Cardiology Unit of PIMS Hospital, Islamabad from January 2021 to March 2023. Each individual underwent chest X-ray, ECG and serum markers. A detailed physical history including age, gender, smoking history, occupation, ischemic heart disease, diabetes, and hypertension were noted in specific designed proforma. Inclusion Criteria: Acute myocardial infarction patients who had chest pain, elevated serum markers, New onset ST Elevation and complete heart block on ECG and required pace maker during their hospitalization were enrolled. Exclusion Crieteria: Complete Heart block due to CKD or electrolyte imbalance, beta blocker or calcium channel blocker overdose, congenital heart block were excluded from the study. Results: The overall mean age was 52.64±6.8 years. The incidence of smokers, diabetes, and hypertension was 76 (63.3%), 56 (46.7%), and 52 (43.3%) respectively. The mean duration of symptom’s onset during hospital admission was 7.9±3.8 hours. About 48 (40%) patients had implanted temporary pacemaker at presentation, 66 (55%) on first post MI day, and 6 (5%) on 2nd post MI day. The in-hospital mortality was 8.3% (n=10). The incidence of ventricular tachycardia, ventricular fibrillation, and asystole was 28.3% (n=34), 3.3% (n=4) and 1.7% (n=2) respectively. Conclusion: The present study found that complete heart block is associated with a poorer early prognosis in individuals with ST-Elevation MI who require temporary pacemaker. In these individuals, a more intensive therapy strategy targeted at reducing early death is required. Keywords: Acute myocardial infarction, in-hospital outcome, temporary pace maker

A changing heart in tako-tsubo syndrome.

A 63-year-old female presented with acute chest pain and ECG showing T wave inversion in the anterior and inferior leads. Troponin T (TnT) was significantly elevated (peak 1378 ng/L; normal <14 ng/L), as was NT-proBNP (3091 ng/L; normal <400 ng/L). Invasive angiography showed unobstructed coronary arteries with mid-ventricular ballooning and hypokinesia on ventriculography (see Supplementary data online, Video S1) and echocardiography (see Supplementary data online, Video S2), suggesting a mid-ventricular tako-tsubo syndrome (TTS). Cardiac magnetic resonance (CMR) was booked but the patient was unable to attend. Focussed history using the InterTAK diagnostic score assessment revealed no emotional or physical triggers. The patient re-presented six months later with similar symptoms and elevated TnT. Inpatient echocardiography showed a reverse TTS pattern (see Supplementary data online, Video S3) and CMR at 1.5T showed basal hypokinesia with matching elevated native T1 (1220 ms; normal 950–1100 ms) and T2 (69 ms; normal <48 ms) (Panels A–B). Quantitative perfusion maps following adenosine stress perfusion to investigate microvascular disease showed basal to mid circumferential hypoperfusion with normal apical myocardial blood flow, not suggestive of specific coronary artery territory ischaemia (Panel D) and no late gadolinium enhancement (LGE) (Panel C), confirming a reverse TTS. The patient further presented two months later with chest pain and TnT elevation. Repeat inpatient CMR on this occasion showed a classic TTS pattern with apical hypokinesia and elevated T1 and T2 (1261 ms and 81 ms, respectively) at the mid to apical segments with no LGE (Panels E–G). The case was further explored but no triggers, including neurological or psychiatric abnormalities were found. Recurrent TTS with different phenotypes has previously been described but is rare, especially without a trigger. Our case illustrates the utility of multimodality imaging in the investigation of TTS; in particular, multiparametric tissue mapping by CMR. Furthermore, the novel quantitative perfusion maps characterising myocardial blood flow added diagnostic utility.

Pharmacoinvasive Therapy in Treating Acute STEMI Patients in Covid-19 Era

Background: Treating acute ST segment elevated myocardial infarction (STEMI) patients by primary PCI (pPCI) has dramatically fallen globally in covid era as there is chances of potential threat of spreading COVID among the non-COVID patients. Thereby, thrombolysis of acute STEMI patient in grey zone till COVID RT PCR report to come, was the mode of treatment of acute myocardial infarction patient in our hospital. We have carried out this prospective observational study to see the outcomes of thrombolysis and subsequent intervention. Methods: STEMI patient who presented to our emergency department with chest pain and ECG and hs-Troponin-I evidenced acute STEMI, were enrolled in the study. Total 139 patients enrolled (Male:120, Female :54); average age for Male: 54 yrs., female was: 56yrs. All patients were admitted in the grey zone of CCU where thrombolysis was done. COVID-19 patients were excluded from intervention and managed conservatively. Covid Negative patients were kept transferred to CCU green zone. On average 2.1 days after Fibrinolysis, elective PCI carried out. Data analysis from 48 patients who underwent pharmacoinvasive therapy was done. Results: Among the study population, Covid-19 positive was in 11 (7.9%) patients and Covid-19 was negative in 128 (92.1%) patients. Primary PCI was performed in 7 (5.03%) patients. Rest of the patients were managed by Pharmacoinvasive therapy. Thrombolysis by Tenecteplase (TNK) was done in 89 (64%) patients, and by Streptokinase in 25 (17.9%) patients, 18 (12.9%) patients did not receive any thrombolysis due to late presentation. Chest pain to needle time was 7.2 ±12.7hrs., thrombolysis to balloon time was 117.5 ±314.8hrs. More than 50% stenosis resolution observed in 20 (41.6%) patients, chest pain resolution within one hour of thrombolysis observed in 21 (43.8%) patients. Ten (20.8%) patients developed. Door to needle time was 30 mins. Total, 88 stents were deployed in 83 territories. CABG was recommended for 7 (5.03%) patients. Stented territory was LAD 37 (45.7%) and RCA 32 (39.5%) and LCX 12 (14.8%). Conclusion: In the era of COVID-19, in this prospective cohort study, on acute STEMI patient management, we found that Pharmacoinvasive therapy, reduced patients’ symptoms and ST resolution occurred partially. Cardiovasc j 2023; 15(2): 136-143

The Outcome of COVID-19 Patients with Moderate to Severe Disease: A Single Institution Study

Objective: To determine the outcome of COVID-19 positive patients with moderate to severe disease.Study Design: A cross-sectional study.Place and Duration of Study: This study was conducted at the Department of Medicine of Combined Military Hospital, Malir Karachi, Pakistan, from 1st Jun 2020 to 31st Jul 2020.Materials and Methods: Total 67 SARS-CoV-2 positive cases, including males and females, were studied. All patients were admitted with presenting complaints such as fever, cough, arthralgia, or shortness of breath. Investigations including complete blood count, serum ferritin, quantitative CRP, liver function tests, renal function tests, blood sugar fasting, and random chest radiographs and ECG were performed. Critical patients were admitted to COVID ITC and managed with high-flow oxygen and assisted ventilation. Patients with moderate disease were admitted to a high-dependency unit and managed with oxygen, intravenous dexamethasone, intravenous antibiotics, anticoagulants, and antiviral therapy patients accordingly. Supportive treatments, including zinc, vitamin C and vitamin D, were given to all patients.Results: Out of total 67 patients, 56 were suffering from comorbidities. Eighteen patients have died. Forty-nine patients have recovered with uneventful recovery.Conclusion: All over the world advanced age and comorbidities such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease remain a major health hazard for an increased likelihood of adverse clinical outcomes in patients with COVID-19 infections outcomes. Early diagnosis and prompt treatment of moderate to severe COVID-19 cases could only be possible with good clinical acumen to prevent a catastrophic outcome.

Cardiac dysfunction in active pulmonary tuberculosis: Mysterious facts of TB’s pandora

&lt;b&gt;Introduction&lt;/b&gt;: Cardiac dysfunction in pulmonary tuberculosis is relatively more common and underestimated due to lack of suspicion. We have studied prevalence of cardiac dysfunction in pulmonary tuberculosis with special emphasis on echocardiography, serum cortisol and its correlation in cases with unstable cardiorespiratory parameters.&lt;br /&gt; &lt;b&gt;Methods:&lt;/b&gt; Prospective, observational, complete workup, and one year follow up study conducted during January 2016 to December 2020 included 800 cases of active pulmonary tuberculosis with specified inclusion criteria of disproportionate tachycardia, tachypnea with or without hypoxia and shock. Cases with known risk factor for cardiac disease and taking cardiac medicines, and cases with pericardial effusion were excluded from study. All study cases were undergone protocolized analysis such as chest radiograph, pulse oximetry, ECG, sputum examination, cardiac enzymes (CPK-MB, NT-Pro-BNP, and cardiac troponins), serum cortisol, and echocardiography at entry point, at two and six months of treatment with anti-tuberculosis medicines as per NTEP. Statistical analysis was carried out by Chi-square test.&lt;br /&gt; &lt;b&gt;Observations and analysis: &lt;/b&gt;In a study of 800 pulmonary tuberculosis cases, 56.00% (448/800) cases were males, and 44.00% (352/800) cases were females. Cases with BMI&amp;lt;18 was 41.62% (333/800) and BMI&amp;gt;18 was 58.37% (467/800). Radiological patterns as unilateral disease in 33.62% (269/800) &amp;amp; bilateral disease in 66.37% (531/800). Hemoglobin less than 10 gm% were documented in 85.12% (681/800) and above 10 gm% were in 14.87% (119/800) cases. Serum albumin less than 3.5 gm% and more than 3.5 gm% were observed in 48.12% (385/800) and 51.12% (415/800) cases respectively. Hypoxia was documented 26.12% (209/800) cases and normal oxygen saturation in 73.87% (591/800) cases. cases with normal and abnormal serum cortisol were 61.37% (491/800) &amp;amp; 38.62% (309/800) respectively. Sputum examination for AFB observed in 30.00% (240/800) and gene Xpert MTB/RIF documented in 51.37% (411/800) cases respectively. Bronchoscopy guided techniques were used in 149 cases and BAL smear AFB in 44.96% (67/149) cases, gene Xpert MTB/RIF in 97.31% (145/149) cases and MGIT culture in four cases (positive in 100% cases subjected to MGIT culture). We have observed global hypokinesia is predominant cardiac dysfunction documented in 82.21% (171/208) cases, followed by left heart systolic dysfunction in 16.34% (34/208) cases and left heart diastolic dysfunction in 75% (156/208) cases. Right heart dysfunction as dilated right atrium and right ventricle documented in 52.88% (110/208) cases and pulmonary hypertension in 40.38% (84/208) cases. Covariates such as age, gender, hemoglobin, BMI, serum cortisol, serum albumin, oxygen saturation and radiological involvement has significant association with cardiac dysfunction. (p&amp;lt;0.00001) Response to treatment with antituberculosis medicines and steroids has documented as improved in 77.40% cases (161/208) cases, persistent in 13.46% (28/2028) cases and progressive in 9.13% (19/208) cases. Final outcome of cardiac dysfunction in Pulmonary tuberculosis cases has significant association with serum cortisol level (p&amp;lt;0.00086).&lt;br /&gt; &lt;b&gt;Conclusion:&lt;/b&gt; Cardiac dysfunction is active pulmonary tuberculosis needs prompt workup in presence of disproportionate tachypnea, tachycardia with or without hypoxia and shock. Echocardiography is basic tool to evaluate these cases and global hypokinesis is most common abnormality. Serum cortisol abnormality documented in fair number of cases and very well correlated with left ventricular dysfunction abnormalities. Steroids with antituberculosis treatment backup is mainstay protocol during management of these cases. Cardiac dysfunction is reversible in majority of cases and proportionate number shown complete improvement in cardiac dysfunction.