Diffuse ST Segment Depression Research Articles

Abstract 4119260: Anomalous Origin Of Left Circumflex Artery From Right Pulmonary Artery Resulting In Heart Failure: A Rare Vascular Steal Phenomenon

Background: Anomalous origin of coronary arteries from the pulmonary artery usually presents at a younger age. However, we encountered a case of a 62-year-old female with an anomalous origin of the left circumflex (LCx) artery from the right pulmonary artery. Case summary: A 62-year-old female presented with complaints of dyspnea and angina on exertion for 1 month and had paroxysmal nocturnal dyspnea for the last 4-5 days. She also had an episode of ventricular tachycardia which required DC cardioversion. She had diabetes mellitus type 2 and hypertension. ECG showed diffuse horizontal ST segment depression in precordial, and limb leads and ST segment elevation in aVR suggesting subendocardial ischemia. The echocardiogram showed hypokinesia in basal, mid-inferior and inferolateral segments and LVEF of 42%. There was a marked reduction in global longitudinal strain (average GLPS of -9.2%). Her coronary angiogram revealed extensive collaterals to the left circumflex artery (from the left anterior descending artery and right coronary artery). The left circumflex artery was arising from the pulmonary artery. Exact localization of origin was done by simultaneous contrast injections in the right pulmonary artery and LAD. The anomalous origin of LCx from the right pulmonary artery was hooked using a Tiger catheter. The patient was advised for surgical management; however, the patient has opted for medical therapy. Conclusion: The anomalous origin of coronary arteries from pulmonary arteries is usually detected in childhood e.g. ALCAPA and is associated with other congenital heart diseases. Anomalous origin of LCx from the right pulmonary artery is a rare variant. It can result in a steal phenomenon which may result in angina, heart failure and risk of sudden cardiac arrest.

ST SEGMENT DEPRESSION: MUCH ADO ABOUT NOTHING

Abstract Introduction ST depression in ECG trace is classically used to assess the cardiac ischaemia. Several other causes of ST depression, like hypokalaemia, digoxin therapy, left ventricular hypertrophy, left bundle branch block can be easily excluded. Sometimes the ST segment depression during tachycardia is observed in young healthy people where ischemic background is rare. Case Report We present the case of an asymptomatic and without cardiovascular risk factors 29–years–old man who performed, during occasional sport visit, an ECG showing sinus tachycardia with diffuse ST segment depression. The ECG obtained at the presentation in Emergency Department of our hospital confirmed sinus tachycardia at 140 beats per minute and diffuse ST segment depression. This finding persisted during the following six hours and slowly regressed with normalization of the heart rate. The same ECG alteration was founded during an exercise test when the heart rate rised up to 90 bpm. A coronary angiography showed anatomically normal and angiographically free of stenosis coronaries; the functional study, using Fractional Flow Reserve (FFR), Coronary Flow Reserve (CFR) and Index of Microcirculatory Resistance (IMR), currently gold standard for the functional study of microcirculation, was normal. No alterations were founded at the cardiac magnetic resonance. Due to a previous resting ECG suspected of ventricular preexcitation, an electrophysiological study was performed and showed neither accessory pathways nor inducibility arrhythmias. The asymptomatic and hemodynamically stable patient was discharged and an ambulatorial follow–up was planned. Conclusion This case emphasizes the ever–present difficulty of attributing unequivocal etiological meanings to electrocardiographic alterations.

FULMINANT EOSINOPHILIC MYOCARDITIS TREATED WITH STEROIDS AND INTRA–AORTIC BALLOON PUMP

Abstract Background Hypereosinophilic syndrome (HES) is a hematological disorders characterized by a chronic, unexplained hypereosinophilia (HE) with tissue damage. Cardiac involvement occurs in ∼20% of patients with HES and it carries a poor prognosis.Early detection and treatment of myocardial involvement improves prognosis. Immunosuppressive therapy represents the core treatment in the majority of patients with Eosinophilic Myocarditis. Case Summary 50–year–old man with history of intrinsic asthma and HE was admitted for cardiogenic shock B stage according SCAI classification (heart rate was 130 bpm, systolic blood pressure was 90 mmHg and lactate <2). EKG showed sinus tachycardia and diffuse ST segment depression. Echocardiography revealed severe left ventricular systolic dysfunction and mild pericardial effusion. Blood test showed leukocytosis (33x10^9/L) with HE (47%), mild hepato–renal damage, high TroponinT 3874 pg/mL and NT–proBNP 11060 ng/L. Coronary angiography was unremarkable. Pulmonary artery catheter was placed: IC 1,78 l/min/mq, CPO 0,63, WP 21, SVO2 60%, SVR 17 WU, RAP/WP 0.74. We reclassified patients as SCAI C with “mixed shock” due to inflammatory component and latent right ventricular dysfunction. Intra–aortic balloon pump (IABP) was placed and we performed endomyocardial biopsy (EMB). High dose of intra venous corticosteroids was started obtaining progressive improvement of hemodynamic parameters and reduction of inflammation parameters (Fig.1). EMB confirmed the diagnosis of myocarditis with initial transition into ‘’Loffler’s cardiomyopathy’’. Polymerase chain reaction (PCR) analysis did not detect cardiotropic viruses. After improvement of clinical status we performed cardiac MRI that revealed diffuse biventricular myocardial edema and the presence of subepicardial and mid–wall enhancement with non ischemic pattern,endocardial fibrosis and multiple left ventricular thrombi (Fig. 2). β–blockers and angiotensin–converting enzyme inhibitors were started and the patient was discharged at home with a complete myocardial recovery and immunosuppressive therapy based on corticosteroids and azathioprine. Discussion This case demonstrates the usefulness of myocardial biopsy in fulminant myocarditis. Treatment with corticosteroids resulted in rapid improvement. Early invasive monitoring allowed more precise hemodynamic characterization and mechanical circulatory support with IABP proved feasible and might have helped by unloading the left ventricle.

Abstract 18616: When Stress Strikes the Heart: Developing Takotsubo Cardiomyopathy With Uncommon Complications

Introduction: Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy or "broken heart syndrome," is a rare condition that predominantly affects postmenopausal women. The etiology of TCM is not entirely understood, but it is thought to be related to catecholamine-induced myocardial stunning. Clinical presentation typically mimics acute coronary syndrome. Left ventricular outflow tract obstruction (LVOTO) is an uncommon complication of TCM, with only a few cases reported in the literature. Case Presentation: A 78-year-old lady presented with chest pain that started a week ago. It was associated with exertion and resolved with rest. It was located substernally, pressure-like, and was 7/10 in intensity. EKG revealed diffuse inferolateral ST segment depression. Her initial troponin was 0.2 which climbed up to 5. She was diagnosed with NSTEMI and was started on IV heparin. Cardiac catheterization revealed no significant CAD. Echocardiography revealed wall motion abnormalities suggestive of Takutsubo Cardiomyopathy (apical ballooning syndrome) with apical hypokinesis and hypercontractile basal segment of the left ventricle. She also had LVOTO with a peak and mean gradient of 80 and 48 mmHg respectively. Her LVEF was calculated to be 40 %. There also was accompanied systolic anterior motion of the mitral valve leaflet. Given the above findings, she was started on a beta blocker along with an angiotensin receptor blocker. Patient’s chest pain resolved with this and was discharged in a stable condition on day three. Follow up appointment at the clinic showed complete resolution of her HOCM and LVOTO. Discussion: The key to managing patients with TCM is to identify LVOTO early, and avoid inotropes and vasodilators. Beta blockers are seen as the cornerstone of treatment. Fortunately, this is a self-resolving condition and the prognosis is excellent with resolution of echocardiographic abnormalities and symptoms within a few weeks’ time.

P106 AN INTRIGUING CASE OF INOCA IN THE CATH–LAB

Abstract A 63–year–old woman presented to our Center for a longstanding history of typically radiating oppressive chest pain, with both resting and exertional episodes,mostly occurring early in the morning and exacerbated by cold.Two years before for a treadmill test positive for electrocardiographic (EKG) criteria of exercise–induced ischemia, she underwent coronary angiography which was found negative for epicardial obstructive coronary artery disease.Given the suspicion of coronary microvascular disease,empirical antianginal therapy with Ranolazine was started at that time,with transient improvement of symptoms. She presented to our Center for a 6 month history of recurrence of symptoms. Her antianginal therapy with Ranolazine was up titrated to 750 mg BID and Verapamil (40 mg TID) was added to her usual therapy given the suspicion of coronary vasospasm as additional component in the pathogenesis of her symptoms,as suggested by the anamnestic recall.Moreover a 24–hour–Holter monitoring was performed with subsequent finding of several episodes of horizontal ST–segment depression(up to 3 mm),mainly on awakening,in the absence of significant arrhythmias.The patient underwent coronary angiography for the assessment of coronary physiology. On angiography, the absence of epicardial obstructive coronary artery disease was confirmed, with the finding of extensive coronary fistulas originating from the left coronary system and communicating with the left ventricular cavity.After induction of maximal hyperemia, the clinical suspicion of coronary microvascular disease was confirmed (CFR 1.9).In addition, reduced coronary flow reserve in the left anterior descending (LAD) territory compatible with both microvascular dysfunction and coronary steal was documented (RFR 0.91;baseline FFR:0.94,after systemic adenosine:0.79).Given the clinical suspicion, vasoreactivity test with intracoronary acetylcholine (2–20–100–200 mcg) was also performed,which was positive for epicardial spasm at mid–distal LAD and concomitant onset of chest pain and ischemic EKG changes(diffuse ST–segment depression) with prompt regression after intracoronary nitrate administration.Taken together,clinical and instrumental findings suggested the diagnosis of mixed angina by combination of three mechanisms:microvascular disease,epicardial spasm and coronary steal due to extensive coronary artery fistulas.The patient was discharged with Ranolazine and Diltiazem at maximum tolerated dose with clinical benefit.

673 A CRACK AND A CLOT

Abstract A 74-year-old man with a history of ischaemic heart disease (multiple percutaneous coronary interventions (PCI)), broke his ankle. Therefore, he discontinued dual antiplatelet therapy (DAPT) -acetylsalicylic acid plus clopidogrel- and started enoxaparin sodium 4000 UI/day on medical advice. A few days later, he was admitted to the emergency department for refractory chest pain, vomit and syncope. Twelve-lead electrocardiogram (ECG) showed a sinus rhythm interrupted by frequent premature ventricular contractions in a pattern of trigeminy. The transthoracic echocardiogram revealed a mildly dilated LV with normal wall thickness and marked hypokinesis/ akinesis in apical, infero-lateral and antero-lateral walls, with a 33% ejection fraction. High sensitivity cardiac troponin was increased, and a second ECG showed a diffuse ST segment depression. The patient was loaded with aspirin and emergently taken to the cardiac catheterization lab. Coronary angiography showed a very late stent thrombosis of the left circumflex artery (LCx), with occlusion of the extreme distality of the second obtuse marginal artery and a 50-60% intrastent restenosis of the ostium-proximal tract of the left anterior descending artery (LAD). Given the non-obstructive nature of the thrombus, risk of peripheral embolization, TIMI flow grade 3 and improvement of symptoms, the decision was made to adopt a conservative strategy with loading dose of ticagrelor, heparin and tirofiban infusion. Besides, an optical coherence tomography (OCT) control was scheduled for the next day. OCT of the LCx revealed a well apposed and well expanded stent with a non-obstructive residual thrombus, nevertheless not visible on angiography. Thus, the tirofiban infusion was prolonged up to 48 hours. OCT of the LAD detected a fibro-calcific disease determining a significant restenosis of the distal left main (LM)-LAD ostium. OCT-guided provisional stenting with two drug eluting stents on LM-LAD-LCx was performed successfully. The patient was discharged home on acetylsalicylic acid (lifelong), ticagrelor (for 12 months) and enoxaparin sodium 4000 UI/day (according to specialist indication). DAPT is superior to anticoagulant therapy in preventing stent thrombosis in patients undergoing PCI, and a more informed inter-specialist communication is needed. Intracoronary imaging can help in the management of stent failure and in the guidance of complex PCI, allowing a patient-tailored treatment.

643 THE HEART WAS MADE TO BE BROKEN: RECURRENT TAKOTSUBO SYNDROME IN AMYOTROPHIC LATERAL SCLEROSIS

Abstract Takotsubo syndrome (TTS) is a rare cardiac disease, characterized by transient regional wall motion abnormalities without evidence of obstructive coronary artery stenoses, mainly triggered by emotion or physical stressors. Reverse Takotsubo syndrome (rTTS), an atypical variant with basal segments involvement, is frequently associated with neurological disorders, including patients with amyotrophic lateral sclerosis (ALS). We reported the case of a 54 years old woman who experienced two consecutive episodes of TTS with different wall motion patterns, complicated by a recurrent episode and arrhythmic events. A Caucasian woman, affected by ALS, was hospitalized in our department due to anemia and recurrent episodes of hematochezia. Following a week of relative clinical stability, the patient experienced acute deterioration with generalized malaise and worsening dyspnea. CT scan excluded pulmonary causes, whereas EKG (ST segment depression in the lower and lateral leads), blood test (increase in high-sensitive cardiac troponins) and TTE (severe impairment of LVEF, with akinesia of basal segments) revealed a cardiac etiology. Coronary angiography and left ventriculography were performed, documenting a wall motion pattern consistent with rTTS. After an initial management in intensive care unit, clinical stability was obtained with a complete recovery of left ventricular systolic function. The patient was discharged but one month later, due to bacterial pneumonia, she was readmitted in our ward and antibiotic therapy was started. Two days later an acute deterioration of clinical status occurred, characterized by dyspnea, altered state of consciousness and marked hypotension. TTE revealed a severe left ventricular systolic dysfunction with apical akinesia and preserved contractility of basal segments, so a diagnosis of typical TTS was made. Three weeks later the clinical scenario became more complicated due to advanced atrioventricular block, with phases of atrioventricular dissociation and ventricular escape-rhythm. Therefore, in light of the increased risk of infectious complications, she underwent implantation of a leadless pacemaker (PMK). This clinical case represents the first report of recurrent episodes of TTS, one of which as rTTS, in a patient affected by ALS. It is worth noting that the first episode of TTS had atypical clinical presentation (dyspnea without chest pain), the EKG showed diffuse ST-segment depression (totally different from classical TTS typical electrocardiographic alterations), and TTE confirmed a different phenotype of segment involvement (unsurprisingly InterTAK Diagnostic Score was low). TTS recurrence is an extremely rare event, even if in this case there were two well defined triggers such as anemia and pneumonia. On the other hand it is reasonable to think that non-use of BBs after the first episode may have contributed to the occurrence of the next event, affecting different segments compared to the previous episode. Furthermore, advanced atrioventricular (AV) block represents a rare complication of TTS, most probably due to catecholamine stress or increased vagal tone, often requiring PMK implantation. In conclusion TTS represents an important frequent cardiac complication in patients affected by ALS, often still underdiagnosed. Therefore clinicians must keep their guard up with TTS, especially in the cases with atypical clinical presentation.

A Case Report of Perimyocarditis as a Rare Complication of Campylobacteriosis

Campylobacter species is one of the most common infections that cause gastroenteritis in developed countries. Although most Campylobacter infections are self-limited, cases can be complicated by extraintestinal presentation, such as myocarditis, pericarditis, or perimyocarditis. We report herein a case of perimyocarditis complicating gastroenteritis in a 24-yearold male. The patient presented with abdominal pain, diarrhea, and dehydration over a couple of days, progressively worsening with substernal chest pain and dyspnea. Troponins were elevated, and ECG showed diffuse concave ST elevation and PR segment depression. Based on the clinical signs and symptoms, the diagnosis of perimyocarditis was made, and he was treated accordingly with a favorable outcome.

A Case Report of Perimyocarditis as a Rare Complication of Campylobacteriosis

Campylobacter species is one of the most common infections that cause gastroenteritis in developed countries. Although most Campylobacter infections are self-limited, cases can be complicated by extraintestinal presentation, such as myocarditis, pericarditis, or perimyocarditis. We report herein a case of perimyocarditis complicating gastroenteritis in a 24-yearold male. The patient presented with abdominal pain, diarrhea, and dehydration over a couple of days, progressively worsening with substernal chest pain and dyspnea. Troponins were elevated, and ECG showed diffuse concave ST elevation and PR segment depression. Based on the clinical signs and symptoms, the diagnosis of perimyocarditis was made, and he was treated accordingly with a favorable outcome.

Multiple Anastomotic Dehiscences After the Bentall Procedure for Aortitis Syndrome.

A 53-year-old man with aortitis was transferred to the current hospital for severe cardiogenic shock. He had undergone the Bentall procedure for annulo-aortic ectasia at the age of 30 years and had received steroid therapy following the diagnosis of aortitis. The preoperative 12-lead electrocardiogram showed ST-segment elevation in lead aVR with diffuse ST-segment depression, suggesting coronary malperfusion. Computed tomography (CT) images demonstrated a retrosternal super-giant pseudoaneurysm (Figure 1A-C) and dehiscence of the distal end of the composite graft from the native aorta (Figure 1B).

Myocardial Infarction Due to Nonvalvular Papillary Fibroelastoma of the Left Coronary Sinus: The Importance of Multimodal Imaging

A 44-year-old woman with a history of type II diabetes and obesity presents, with a two- month history of syncope. In the week prior to presentation, she reported exertional angina. She presented to the emergency department with a 2-hour history of chest pain at rest (intensity 8/10 on the visual analog scale), that radiated to her left arm. Her blood pressure on presentation was 95/60 mmHg and heart rate was 88 bpm. The initial electrocardiogram demonstrated diffuse ST-segment depression and ST elevation in aVR (Figure 1).

Is It ST-Segment-Elevation Myocardial Infarction?

A 76-year-old man presented with acute-onset chest pain and dyspnea. He had a history of coronary artery disease, ischemic cardiomyopathy (left ventricular ejection fraction, 25%), recent non-ST-segment-elevation myocardial infarction (NSTEMI), and stenting of the left anterior descending coronary artery (LAD) one month before the current presentation. Soon thereafter, he underwent stenting of the left main coronary artery (LMCA), obtuse marginal branch (OMB), and left circumflex coronary artery. His chest pain subsided soon after arrival at the emergency department. His cardiac troponin I level was 22 ng/mL (normal level, <0.03 ng/mL), and his brain natriuretic peptide level was 841 pg/mL (normal level, <100 pg/mL). Figure 1 shows his electrocardiogram (ECG).What is the diagnosis?C) STEMI due to first OMB or ramus intermedius occlusionThe ECG shows sinus rhythm, mild ST-segment elevation (STE) with T-wave inversion in lead aVL, ST-segment depression with positive T waves in leads II, III, aVF, and V3 through V6, and an isoelectric ST segment in leads I and V1 through V2. The Fourth Universal Definition of Myocardial Infarction1 says, “More profound ST-segment shifts or T-wave inversions involving multiple leads/territories are associated with a greater degree of myocardial ischaemia, and a worse prognosis. For example, ST-segment depression ≥1 mm in 6 leads, which may be associated with STE in lead aVR or lead V1 and hemodynamic compromise, is suggestive evidence of multivessel disease or left main disease” (eliminating answer A). This is considered a high-risk ECG pattern for which invasive intervention within 2 hours is recommended, in accordance with the 2020 European Society of Cardiology guidelines for managing acute coronary syndromes without persistent STE.2 Our patient's ECG shows ST-segment depression in 7 leads but no significant STE in lead aVR or V1. In contrast, STE with negative T waves is seen in lead aVL.Patients with a nonischemic early repolarization pattern can have STE in lead aVL. However, the T waves are usually positive, and there is often a J-point notch. The pattern here suggests a reperfused or more advanced stage of STEMI,3 and the patient's clinical presentation (symptom resolution after hospital arrival) supports this diagnosis.New STE in 2 contiguous leads is necessary for the diagnosis of STEMI.1 However, this is an epidemiologic (not pathophysiologic) criterion, to minimize false-positive diagnosis. Acutely occluded arterial branches may cause STE in only one lead with diffuse ST-segment depression.4 The STE in leads aVL and V2 through V5 is caused by LAD occlusion proximal to the first diagonal branch (eliminating answer B),4 and STE in leads aVL and V2 without STE in leads V3 through V5 suggests an occluded first diagonal branch. The ST-segment depression in the anterolateral and inferior leads is incompatible with the typical presentation of takotsubo cardiomyopathy (answer D). The STE in lead aVL, incompatible with ischemic cardiomyopathy (answer E), is accompanied by ST-segment depression in lead V2, suggesting obstruction of the first OMB. Our patient had an isoelectric ST segment in lead V2, so the differential diagnosis is an occluded OMB or ramus intermedius.4 A coronary angiogram on the second day of admission showed subacute thrombotic occlusion of the first OMB (Fig. 2, arrow), and stenting restored patent flow.Disclosures: NoneFunding/support: None

272 Combined rotational atherectomy and intravascular lithotripsy for heavy calcified coronary artery

Abstract Aims Percutaneous coronary intervention (PCI) of heavily calcified coronary lesions still represents a challenge for interventional cardiologists, with higher risk of immediate complications, late failure due to stent underexpansion or malapposition and consequent poor clinical outcome. Rotational atherectomy (RA) is a well-known calcium debulking modality. However, when coronary plaques present a significant amount of circumferential deep calcium, RA alone may not be able to achieve adequate lesion preparation. The combined use of intravascular lithotripsy (IVL) and RA, a technique called ‘Rotatripsy’, can be an effective approach in order to enable optimal stent implantation. We present a case of a calcific right coronary artery (RCA) PCI successfully treated by ‘Rotatripsy’ technique. Methods and results A 78-years-old man presented to our emergency department complaining of acute chest pain and dyspnoea. The electrocardiogram revealed ST-segment elevation in aVR and a diffuse ST-segment depression. Transthoracic echocardiography showed left ventricular anterior, septal, and apical walls akinesia. An urgent coronary angiography showed a critical distal left main (LM) stenosis involving the left anterior descending (LAD) artery ostium and a heavy calcified dominant RCA with two tandem sub-occlusive stenosis in the mid segment (Figure 1A). An immediate PCI with two drug eluting stents (DES) in the LM and LAD was performed. The patient was scheduled two days later for RCA PCI. RCA was engaged via left radial approach with a 6-Fr AL1 guiding catheter and the lesions were crossed with a Sion Blue wire. Using a Finecross MG microcatheter, an extra-support Rotawire was placed distally in the RCA. However, after multiple rotablation with 1.5 mm burr (Figure 1B), the mid segment lesion (Figure 1C) was still undilatable with a 3.5 mm non-compliant balloon (NCB) at 22 atm showing a partial dog bone effect (Figure 1D). We decided to attempt adjunctive IVL for calcium debulking. Using a Finecross MG and the trapping technique, a Gran Slam wire was placed distally; a 4.0 mm IVL balloon was delivered at the undilatable lesion and 80 pulses were applied (Figure 1E). Once the IVL treatment was completed (Figure 1F), a 4.0 mm NCB was inflated to 20 atm to further dilate the segment with an optimal expansion (Figure 1G). Finally, a DES Synergy 4.0 × 48 mm was implanted (Figure 1H) and it was post-dilated with a 4.5 mm NCB inflated to 22 atm (Figure 1I) with a perfect angiographic result (Figure 1J). Conclusions Coronary calcifications can lead to stent underexpansion, which is related to a higher rate of future complications, such as restenosis or thrombosis. If conventional lesion dilatations are not effective, alternative techniques should be considered (cutting balloon, scoring balloon, RA, orbital atherectomy, IVL). In case of circumferential deep calcium plaques, RA may not be able to achieve an adequate lesion preparation. RA allows the treatment of intimal calcium and permits to cross balloons or stents through severe lesions. However, when adequate expansion of the balloons is not achieved after RA, Shockwave IVL, that is not usually able to cross critical stenosis due to its bulky profile, represents an optimal complementary device, in order to fracture deep calcium and facilitate stent delivery and optimal expansion. In this case, we have successfully used the hybrid approach called ‘Rotatripsy’, which combines RA and IVL, in order to avoid more aggressive RA, which would have required the use of 7-Fr guiding catheter setting and may have increased the risk of complications.

Web Exclusive. Annals for Hospitalists Inpatient Notes - Myocarditis After Vaccination for SARS-CoV-2.

Web Exclusive. Annals for Hospitalists Inpatient Notes - Myocarditis After Vaccination for SARS-CoV-2.

A life-threatening reverse Takotsubo syndrome in a young breastfeeding woman: a case report

BackgroundTakotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction and is usually triggered by emotional, physical, or combined stress. This syndrome has been increasingly recognized, although it remains a challenging and often misdiagnosed disorder.Case summaryA 36-year-old breastfeeding woman was admitted with sudden dyspnoea and oppressive chest pain. On admission, she was lethargic, hypotensive, and tachycardic. The electrocardiogram showed rapid atrial fibrillation and diffuse ST-segment depression. The transthoracic echocardiogram (TTE) revealed severe LV systolic dysfunction, with midventricular and basal akinesis, compensatory apical hyperkinesia, and without intraventricular gradient. Emergent coronary angiogram showed normal coronary arteries. A presumptive diagnosis of reverse TTS with cardiogenic shock (CS) was made. The patient was transferred to the intensive care unit after intubation and inotropic and vasopressor support was initiated. During hospitalization, rapid clinical improvement was observed. In 3 days, the patient was weaned from haemodynamic support and extubated. Furthermore, β-blocker and angiotensin receptor blocker were initiated and tolerated. Cabergoline was also administered to inhibit lactation. The presumptive diagnosis was further strengthened by cardiac magnetic resonance and all triggering factors were excluded. At hospital discharge she was asymptomatic and the follow-up TTE was normal, which confirmed the diagnosis of reverse TTS.DiscussionWe present a case of a young woman, 8 months after delivery, which developed a life-threatening reverse TTS without triggering factor identified. Reverse TTS is a rare variant of TTS with different clinical features and is more likely to be complicated by pulmonary oedema and CS.

FOLLOW THE HEART OR THE GUT?

Abstract Objective: This case underlines the importance of thoroughly investigating alternative causes for hypertension in patients with atypical presentations, regardless of their age and risk factors. Design and method: Clinical case. Results: We present the case of a 68 year old woman without known cardiovascular diseases who came to the ER complaining of headaches, palpitations and chest pain of two hours duration. Upon admission, her blood pressure was 300/150 mmHg - overlapping values in all limbs with no asymmetric pulse. Heart rate was 140 bpm, rhythmic and without heart murmurs, abdomen without murmurs or palpable masses. Her ECG showed diffuse ST segment depression and high sensitivity troponin level at 0 h was 258 ng/L. Cardiac echo showed no wall motion abnormalities and no hypertrophy of the left ventricle. Her BP was acutely controlled with ACEi and iv nitroglycerin. Two hours after admission her BP returned to normal and remained within normal range without medication. Her ECG showed normal sinus rhythm with no other pathological findings. Coronary angiography was performed the next day and showed no atherosclerotic lesions. At this stage, her diagnosis was type 2 MI caused by severely elevated BP. Blood and urine tests revealed high levels of serum catecholamines and urinary normetanephrines - over 4000 micrograms/24 h. Abdominal ultrasound found a mass near her right kidney. Abdominal CT confirmed the presence of a nodular 5 × 3 cm mass in the right adrenal gland, compatible with a pheochromocytoma. She was submitted to laparoscopic adrenalectomy with normalization of her BP after the surgery. During follow-up, the patient presented with persistently normal blood pressure and normal ECG aspect without any chronic medication. Conclusions: Pheochromocytoma is a rare neuroendocrine tumour originating in the adrenal gland medulla. Sustained or paroxysmal arterial hypertension is sometimes associated with the classic triad: episodic headaches, profuse sweating and tachycardia. A timely diagnosis and an effective therapeutic strategy are important, as this is a potentially fatal disease with a very good prognosis if discovered and treated early. It should be excluded in patients with high paroxysmal BP, especially if under 20 or over 50 years old.

EXTREME ECG AND TROPONIN ABNORMALITIES IN DIABETIC KETOACIDOSIS IN THE ABSENCE OF AN ACUTE CORONARY SYNDROME

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Although troponin I (TnI) elevation indicates myocardial injury, the majority of instances are not due to an acute coronary syndrome (ACS). CASE PRESENTATION: A 57 year old female presented with diabetic ketoacidosis (DKA) 5 months after CABG. She was hemodynamically stable with mild tachycardia and a normal cardiopulmonary examination. Serum glucose was > 1250, pH= 7.16, K+ =8.3. CXR and sepsis evaluation was negative. The ECG revealed ST elevation in V1-2 and aVR with diffuse ST segment depression and peaked T-waves (Figure 1A). Initial TnI (4th generation) was 0.079 and peaked at 63.2 ng/mL (Figure 1B). The patient had no cardiopulmonary complaints and an echocardiogram revealed hyperdynamic function with an LVEF of 70% without wall motion abnormalities. Treatment with IV fluid and insulin normalized K+ and pH, as the ECG returned to baseline. Myocardial infarction commonly causes death in the first 24 hours of DKA. This patient had known CAD, a markedly abnormal ECG and marked troponin elevation, but no clinical or imaging evidence of ACS. Cardiac catheterization was not pursued. DISCUSSION: Various metabolic derangements accompany DKA including hypo and hyperkalemia, hyponatremia and metabolic acidosis. Hyperkalemia is well known to present with ECG pseudoinfarct pattern including ST elevations and peaked T waves in the setting of severe academia. Likewise, hypokalemia can depress ST segments and cause T wave inversion. Free fatty acid elevation itself can disrupt cell membranes and release troponin. Our patient lacked other findings typically seen in demand ischemia. Such isolated troponin elevation has been seen in up to 27% of patients with DKA in the absence of ACS1. CONCLUSIONS: With the dawn of more sensitive troponin assays, caution will need to be taken interpreting troponin in non-ACS settings, as specificity for ACS may be reduced. Reference #1: Al-Mallah, M., Zuberi, O., Arida, M., & Kim, H. E. (2008). Positive Troponin in Diabetic Ketoacidosis without Evident Acute Coronary Syndrome Predicts Adverse Cardiac Events. Clinical Cardiology,31(2), 67-71. https://doi.org/10.1002/clc.20167 DISCLOSURES: No relevant relationships by Gilead Lancaster, source=Web Response No relevant relationships by Craig McPherson, source=Web Response No relevant relationships by Tony Roy, source=Web Response No relevant relationships by Kristin Stawiarski, source=Web Response No relevant relationships by stuart zarich, source=Web Response

A CURIOUS CASE OF MYOCARDITIS WITH ELEVATED ANTISTREPTOLYSIN O TITERS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Acute rheumatic fever can cause a spectrum of rheumatic heart disease, including myositis, pericarditis, or valvulitis. It is mostly seen in children and is considered a disease of poverty. Here, we present a case of a 24 year-old with myocarditis secondary to rheumatic fever. CASE PRESENTATION: A 24 year-old male presented to the emergency department because of chest pain that started 2 nights prior. His pain was rated 8/10, nonradiating, worse with inspiration and associated with nausea. It was the first time he had experienced chest pain. The patient was recently discharged from the the hospital because of acute tonsillitis, where he experienced throat pain, fever, nausea, vomiting, cervical and submandibular lymph node swelling. He was discharged with improvement of his tonsillitis after treatment with clindamycin. He has no significant past medical history. On physical examination, the patient’s temperature was 38.2*C and heart rate was 103 bpm with the rest of physical examination being unremarkable. Chest X-ray showed bilateral pulmonary congestion with cardiomegaly but no infiltrates or consolidation. EKG revealed diffuse ST segment depression. Laboratory studies showed an elevated white count with normal neutrophil and lymphocyte counts. Troponin levels were elevated from 0.359 ng/mL and peaked to 0.447 ng/mL. Urine toxicology was negative. Blood cultures were taken but returned negative. He was admitted to the telemetry unit with elevated troponin levels to rule out acute coronary syndrome. Cardiology performed an echocardiogram, showing no structural or functional abnormalities; a cardiac catheterization showed the patient had nonobstructive CAD. Throughout his hospital stay, he had fluctuating temperatures, with a Tmax of 38.9*C and developed right knee pain and then pain in the left knee two days later. X-rays were taken of both knees, demonstrating moderate effusion of the right knee. Infectious disease was consulted and recommended ASO titers, influenza Ag, stool culture, and gonorrhea and chlamydia urine PCR. All results of the laboratory test were negative except for the ASO titer of 1:200, CRP of 309.1 mg/dL, and ESR of 114 mm/hr. He was started on naproxen as well as benzathine penicillin G with a diagnosis of myocarditis secondary to rheumatic fever. The patient showed much improvement throughout the course of hospital stay and was discharged to follow up with cardiology and infectious disease clinics. DISCUSSION: The differential diagnosis for a young adult with chest pain is usually secondary to drugs or chest wall pain. It is very unusual for a young adult to present with myocarditis secondary to rheumatic fever, which is more commonly seen in children. It is pertinent to consider acute myocarditis associated with GAS tonsillitis as a differential. CONCLUSIONS: An early diagnosis and treatment can significantly improve the prognosis of the patients. Reference #1: Jose L. Aguirre, MD, Margarita Jurado, MD, Mateo Porres-Aguilar, MD, Cristina Olivas-Chacon, MD, Mateo Porres-Muñoz, MD, Debabrata Mukherjee, MD, and  Juan Taveras, MD. Acute nonrheumatic streptococcal myocarditis resembling ST-elevation acute myocardial infarction in a young patient. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Hung-I Liao, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response

A case of left circumflex artery stenosis involving ST segment depression in multiple leads with ST elevation in lead augmented vector right

Electrocardiography (ECG) patterns of ST-segment elevation in lead aVR with or without diffuse ST segment depression may predict either left main coronary artery or triple vessel stenosis. Here, we have presented the case of a 56-year-old female involving such an ECG pattern with ST-segment depression in more than eight leads and ST Segment elevation in lead aVR, however, showing stenosis of the mid-segment of the left circumflex artery (LCX). She was scheduled to undergo percutaneous coronary intervention with implantation of a drug-eluting stent with respect to mid LCX stenosis. The patient was asymptomatic post procedure and was discharged on beta blockers. To conclude, the ECG pattern of ST depression in multiple leads with ST-elevation in aVR lead can occur in LCX obstruction as well.

Diffuse ST-segment depression despite prior coronary bypass grafting: An electrocardiographic-angiographic correlation

The standard 12‑lead electrocardiogram (ECG) has become a mainstay diagnostic tool in patients suspected to have myocardial ischemia. The identification of hallmark electrocardiographic abnormalities, such as ST-segment deviation or serial T wave changes, not only helps identify the presence of myocardial ischemia but also may help localize myocardial territories with an ongoing injury. Widespread ST-segment depression is commonly attributed to diffuse subendocardial ischemia precipitated by severe multivessel or left main coronary artery disease. However, among patients with prior coronary revascularization, clear electrocardiographic-angiographic relationships responsible for widespread ST-segment depressions have not been well defined. We report a case in which diffuse ST-segment depression emerged from a patient with prior coronary artery bypass grafting. In this report, we examine the patient's presenting ECG pattern as to (1) establish causal inferences which align with the distribution of myocardial ischemia supported by angiography and (2) provide an accompanying analysis of the relevant scientific literature.