EKG Changes Research Articles

Abstract #1411932: Pseudo-myocardial Infarction in Diabetic Ketoacidosis with Normokalemia

Diabetic ketoacidosis (DKA) is a rare cause of the “pseudo-infarct pattern." It indicates the presence of EKG changes suggestive of myocardial ischemia without a coronary artery lesion. Pseudo-myocardial infarction has been associated with hyperkalemia seen in DKA. We report a case of ST elevation in the absence of a coronary artery lesion in a patient presenting with severe DKA and normokalemia. 41-year-old male with a history of type-1 diabetes mellitus with HbA1c of 13.6%, presented with altered mental status and unresponsiveness. He was intubated in the emergency department. Labs revealed severe DKA with glucose of 1307 mg/dl, non-calculable anion gap metabolic acidosis with bicarbonate level of <10 mEq/L, and B- hydroxybutyrate of 12.38mmol/L. Serum potassium level was normal at 5.1 mEq/L. Other electrolyte derangements include phosphorous at 11.9 mg/dl, magnesium at 4.6 mg/dl, and sodium at 146 mEq/L. Initial EKG revealed bradycardia without ischemic changes. He was started on DKA protocol with insulin drip, resulting in the closure of the anion gap and improvement of blood sugars. The next day, EKG was notable for ST elevations suggestive of anteroseptal infarction. Troponin level was 16.7 ng/ml. Serum potassium remained normal at 3.5 mEq/L. Due to risk factors for coronary artery disease (CAD), he underwent a coronary angiogram and was found to have normal coronaries. EKG changes are thought to be in the setting of DKA, which was subsequently resolved. Several cases have reported ST segment changes in patients with DKA. However, these have been associated with hyperkalemia. The EKG changes in our case were seen in the normokalemia setting and after the anion gap closure. In the absence of metabolic derangements, the etiology of the pseudo-infarct pattern remains unclear. As diabetes is a risk factor for CAD, these patients require ischemic evaluation with a coronary angiogram.

AB-452675-4 CORONARY ARTERIAL SPASM DURING CAVO-TRICUSPID ISTHMUS ABLATION WITH A NOVEL FOCAL PULSED FIELD ABLATION CATHETER: FINDINGS FROM CORONARY ANGIOGRAPHY AND FRACTIONAL FLOW RESERVE MEASUREMENTS

Pulsed field ablation (PFA) has been shown to avoid esophageal damage, PV stenosis and permanent phrenic nerve paralysis. But not studied in these trials was ablation of the cavo-tricuspid isthmus (CTI), a not uncommon adjunct target for ablation during pulmonary vein isolation (PVI) procedures. Indeed, recent studies demonstrated that when PFA is performed adjacent to a coronary artery, there is a susceptibility for vasospasm: in a study of right coronary artery (RCA) angiography during PFA of the cavo-tricuspid isthmus (CTI), there was universally severe RCA spasm, albeit subclinical. However, these studies were performed with a pentaspline PFA catheter designed to create a broad electrical field, not with a focal spot ablation catheter. To evaluate the potential for PFA to cause coronary spasm during CTI ablation, but using a focal PFA catheter. As part of a clinical trial of persistent AF ablation (PersAFOne 3, NCT05272852), after PVI and posterior wall ablation using a 12F commercial pentaspline PFA catheter (Farawave, BSC Inc.), CTI ablation was performed using an investigational 8F deflectable focal catheter (Farapoint, BSC Inc.). PFA was performed at 2kV (2 x 2.5 sec applications per site) with fluoroscopy and ICE guidance. Coronary angiography of the RCA with FFR measurement (Abbott PressureWire X) was performed before, during and after PFA at each application site. Spasm was categorized as mild (<50%), moderate (50-90%) or severe (>90%). At a single center, PFA of the CTI was performed in 8 patients. Bidirectional CTI conduction block was achieved in all patients after a mean of 13.3 lesions/pt (range 8-18). One patient had a left dominant coronary arterial system, and a de minimis RCA; of the remaining, 6 of 7 patients developed moderate (n=5) to severe (n=1) spasm as determined by both angiography and FFR (mean pressure differential 0.60, range 0.31-0.78 among patients developing spasm). There were no EKG changes and no symptoms (albeit sedated patients). The mean time for spasm resolution was 13.8 min. In an additional patient, intracoronary NTG pretreatment (1 mg) was administered before PFA lesions were delivered to the CTI: no coronary spasm was provoked. Focal PFA to the CTI provokes subclinical coronary vasospasm when delivered adjacent to the RCA. Additional investigation is necessary to determine the optimal NTG dosing strategy to prevent this phenomenon.

Design of a Phase 3 Maintenance-of-Effect Trial of Ecopipam in Tourette Syndrome (P12-11.011)

<h3>Objective:</h3> To design an efficient, maintenance-of-effect trial for ecopipam in Tourette Syndrome (TS) while further informing the risk profile. <h3>Background:</h3> Ecopipam is a selective dopamine 1 receptor antagonist in development for TS. A 12-week, parallel group, Phase 2b trial of ecopipam in TS demonstrated a clinically meaningful, statistically significant reduction in tics without inducing weight gain, metabolic syndrome, EKG changes, or drug-induced movement disorders associated with dopamine 2 receptor antagonists. Ideally, a Phase 3 trial should both confirm efficacy and observe safety over a longer duration of exposure. <h3>Design/Methods:</h3> We designed an enriched-enrollment, randomized withdrawal (EERW) clinical trial to best meet maintenance-of-efficacy and safety objectives. All enrolled subjects receive ecopipam for 12 weeks. Those with a ≥25% improvement in the Yale Global Tic Severity Scale-Total Tic Score (YGTSS-TTS) at both weeks 8 and 12 are randomized, double-blinded, 1:1 to continue ecopipam or down-titrate to placebo, for an additional 12 weeks. The primary maintenance-of-effect endpoint is time-to-relapse where relapse is defined as 1. a ≥50% loss of the YGTSS-TTS improvement, 2. required use of tic rescue medication, or 3. hospitalization for TS. The trial completes when the number of relapses has reached the pre-specified target sufficient to differentiate ecopipam from placebo with 85% power. Trial simulations and sensitivity analysis were performed across key variables. <h3>Results:</h3> The number of relapses required is a function of the two relapse rates individually. Previous results suggest, conservatively, that 34% of participants randomized to ecopipam and 65% randomized to placebo will relapse, yielding a target of 49 relapse events for completion. Simulations informed both enrollment and duration requirements. <h3>Conclusions:</h3> This EERW design meets feasibility requirements, provides up to 24 weeks of safety data, and is powered to determine maintenance of efficacy of ecopipam for TS while reducing placebo exposure for this serious disorder. <b>Disclosure:</b> Dr. Cunniff has received personal compensation for serving as an employee of Paragon Biosciences. Dr. Cunniff has stock in Harmony Biosciences. Dr. Cunniff has stock in Emalex Biosciences. The institution of Dr. Gilbert has received research support from NIMH. The institution of Dr. Gilbert has received research support from Emalex. The institution of Dr. Gilbert has received research support from Erydel. The institution of Dr. Gilbert has received research support from PTC Therapeutics. Dr. Gilbert has received publishing royalties from a publication relating to health care. Dr. Gilbert has received publishing royalties from a publication relating to health care. Dr. Gilbert has received personal compensation in the range of $500-$4,999 for serving as a Medical Second Opinion Expert with Teldoc/Advanced Medical. Dr. Gilbert has received personal compensation in the range of $5,000-$9,999 for serving as a Medical Expert with Department of Health and Human Services/Vaccine Injury Compensation Program. Dr. Wanaski has received personal compensation for serving as an employee of Paragon Biosciences. Dr. Wanaski has stock in Paragon Biosciences. Dr. Bittman has stock in IQVIA. Dr. Bittman has received personal compensation in the range of $100,000-$499,999 for serving as a President with Bittman Biostat, Inc.. Dr. Dubow has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Paragon Biosciences. Dr. Dubow has stock in Avadel Pharmaceuticals. Atul Mahableshwarkar has received personal compensation for serving as an employee of Emalex Biosciences. Atul Mahableshwarkar has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ecor1 Capital. Atul Mahableshwarkar has stock in Johnson &amp; Johnson.

Hyperammonemia and First-Degree Atrio-Ventricular Block in Adult Male from Valproic Acid Toxicity

AbstractIntroductionThe purpose of this case study is to review the clinical presentation and medical work of an adult male who experienced symptomatic hyperammonemia and first-degree atrio-ventricular block in the setting of valproic acid toxicity.MethodThis case involves a 28-year-old African American male with a past psychiatric history of bipolar 1 disorder with psychotic features, antisocial personality disorder, PTSD, and ASD, who was psychiatrically hospitalized for mania and psychosis at a large midwestern university hospital. At the time of evaluation in the emergency department, the patient endorsed suicidal ideation, religious/persecutory delusions, and auditory hallucinations of demons. Zyprexa Zydis was started and titrated to 20 mg every 12 hours, which did not sufficiently improve symptoms. Depakote EC/DR 1000 mg every 12 hours was then added for treatment of mania. Approximately 1 week later, the patient was observed to be somnolent and complained of malaise, nausea, and vomiting.ResultsLabs were collected which showed an elevated ammonia level of 336 umol/L and free valproic acid level of 13.3 mcg/ml. An EKG was performed which showed first-degree atrio-ventricular block with fusion complexes. The patient’s baseline EKG displayed sinus bradycardia with no evidence of atrio-ventricular block. The patient’s CMP was unremarkable except total bilirubin of 1.5 mg/dL and glucose of 104 mg/dL. His lactate was elevated at 1.95 mmol/L. The patient’s troponin and CRP were unremarkable. The patient was medically transferred for management of hyperammonemia and EKG changes. Depakote was discontinued and lactulose 20 g TID was initiated. Patient was placed on telemetry and the first-degree atrio-ventricular block resolved within 24 hours after discontinuation of Depakote. Daily ammonia level, chem 7, and magnesium were collected. Ammonia decreased to 79 and 59 umol/L on consecutive days. Sodium was mildly elevated at 144 on day 2 of medical admission. Poison control was contacted and L-carnitine 990 TID was started for suspected carnitine deficiency. The patient medically recovered after several days and was readmitted to the psychiatric hospital for further psychiatric management.ConclusionsThe patient’s presentation of hyperammonemia and first-degree atrio-ventricular block were likely due to valproic acid toxicity. We suspect that carnitine deficiency contributed to the patient’s valproic acid toxicity at lower-than-expected blood levels. Although antipsychotics can cause prolonged QTc interval, conduction disorders are not typical abnormalities. Caution should be taken when prescribing Depakote to individuals at higher risk of developing toxicity, including those with potential nutritional deficiencies as well as those with limited self-advocacy abilities secondary to psychiatric illness. Rapid identification of side effects, such as valproic acid toxicity, remain crucial for favorable patient outcomes.FundingNo Funding

Left bundle branch area pacing: How to prevent a coronary venous fistula.

Left bundle branch area pacing: How to prevent a coronary venous fistula.

Comparison of electrocardiographic versus echocardiographic detection of left ventricular mass changes over time and evaluation of new onset left ventricular hypertrophy.

We assessed the value of 3 electrocardiographic (EKG) voltage criteria in detecting variations of left ventricular mass (LVM) over time, taking echocardiographic (ECHO) LVM as reference, in the Pressioni Arteriose Monitorate E Loro Associazioni study. In 927 subjects (age 47±13 years on entry, 49.9% men) an ECHO evaluation of LVM and EKG suitable for measurement of EKG-LVH criteria (Sokolow-Lyon voltage, Cornell voltage and R-wave voltage in aVL) were available at baseline and at a 2nd evaluation performed 10 years later. Δ (delta) LVM, Δ LVMI, and Δ EKG parameters values were calculated from 2nd evaluation to baseline. The sensitivity of the EKG criteria in the diagnosis of LVH, poor at baseline, becomes even worse after 10 years, reaching very low values. Only the sensitivity of R-wave amplitude exhibited slight increase over time but with unsatisfactory absolute values. Despite the prevalence of ECHO-LVH at the 2nd evaluation was threefold increased compared to baseline (29.3% and 33.7% for LVM indexed to BSA and height2.7 , respectively), the prevalence of EKG-LVH was unchanged when evaluated by Sokolow-Lyon criteria, significantly reduced when assessed by Cornell voltage index, while significantly increased using R-wave voltage in aVL criteria. Despite an ECHO-LVM increase over the time, mean EKG changes were of opposite sign, except for R-wave amplitude in aVL. Our study highlights the discrepancy between ECHO and EKG in monitoring LVM changes over the time, especially for Sokolow-Lyon and Cornell voltage. Thus, EKG is an unsuitable method for the longitudinal evaluation of LVM variations.

Perioperative outcomes in children with Hashimoto's thyroiditis undergoing total thyroidectomy

BackgroundHashimoto's thyroiditis (HT) affects 1–2 % of the pediatric population. In adults with HT, thyroidectomy is considered challenging and prone to postoperative complications due to the chronic inflammatory process. However, the complications of thyroidectomy among children with HT have not been established. The objective of our study was to evaluate whether children with HT undergoing total thyroidectomy for presumed thyroid cancer have higher complication rates than children without HT. MethodsA retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 2014 and 2021. Results111 patients met inclusion criteria, 15 of these were diagnosed with HT preoperatively. Operative time and length of admission were similar among the groups. Postoperatively, patients with HT were more likely to have low levels of parathyroid hormone (60 % vs 26 %, p = 0.014) and transient hypocalcemia compared to non-HT patients, present with symptomatic hypocalcemia (67 % vs 27 %, p = 0.006), demonstrate EKG changes (20 % vs 6.3 %, p = 0.035) within 24 h of surgery, and to require both oral and intravenous calcium supplements (80 % vs 35 %, p = 0.001 and 60 % vs 22 % p = 0.004 respectively). Persistent hypocalcemia at 6 months follow-up, and recurrent laryngeal nerve paralysis rates were similar between groups. Parathyroid tissue was found in the thyroid specimen of 9 (60 %) HT patients vs 34 (35 %) non-HT patients (p = 0.069). ConclusionsThe risk of permanent complications among children with HT following thyroidectomy is low. However, patients with HT are more likely to develop symptomatic transient hypocalcemia and to require oral and intravenous calcium supplements in the immediate post-operative period compared to non-HT patients. Tailoring a perioperative treatment protocol to optimize calcium levels may be considered for children with HT.

1283. Safety, Tolerability, and Pharmacokinetics of BRII-778, A Modified-Release Oral Formulation of Rilpivirine in Healthy Adult Subjects

Abstract Background BRII-778 is a modified release (MR) formulation of rilpivirine for once-weekly (QW) oral administration. BRII-778 aims to prolong oral absorption, lower Cmax, relatively, and reduce peak to trough ratio achieved with a MR formulation of rilpivirine, within the known efficacy and safety bounds established by once daily oral administration of rilpivirine. QW BRII-778 dosing may have advantages over once daily rilpirvirine in terms of patient convenience, and treatment adherence. Multiple MR formulations of rilpivirine were evaluated in healthy adult subjects in this Phase 1 study. Methods This was a Phase 1, randomized, double-blinded, placebo-controlled, study of single ascending dose (SAD) and multiple ascending dose (MAD) cohorts, evaluating the safety, tolerability, and PK of BRII-778. Three MR formulations of rilpivirine, BRII-778-A1, -A2, and -A3, were evaluated in this study. Rilpivirine PK profiles after single or multiple doses of the three BRII-778 formulations were characterized under the fed state over the dose range of 150 mg to 750 mg. Food effect was assessed after a single oral dose of BRII-778-A3 750 mg. Exploratory concentration-QTc (C-QTc) analysis was conducted using combined SAD and MAD data. Results BRII-778 as single dose or multiple doses was generally safe and well-tolerated when administered to healthy adult subjects. There were no Grade ≥3 AEs, SAEs or AEs leading to withdrawal in BRII-778 dosing arms. PK profiles of BRII-778 were consistent with slower oral absorption with MR formulation. The increase in exposure was less than dose proportional. Mild accumulation in plasma was observed after 3 QW BRII-778-A3 doses. BRII-778-A3 750 mg under the fed state enhanced bioavailability by improving gastric dissolution and/or subsequent absorption. Exploratory C-QTc analysis confirmed a concentration-dependent effect on the QTc interval with escalating doses of BRII-778, but the interpretations are limited by small sample size. There were no clinically significant EKG changes and no individual subject met QTc stopping criteria. Conclusion SAD and MAD administration of BRII-778 formulations were generally safe and well tolerated. Rilpivirine PK profiles post BRII-778 dosing supports further evaluation of BRII-778 for potential QW regimen. Disclosures David A. Margolis, MD MPH, Brii Biosciences: Stocks/Bonds Ji Ma, PhD, Brii Biosciences: Stocks/Bonds Michael Watkins, PharmD, Brii Biosciences: Stocks/Bonds Yujin Wang, M.Sc., Brii Biosciences: Stocks/Bonds Chetana Trivedi, B.A., Brii Biosciences: Stocks/Bonds Xuelian Wei, PhD, Brii Biosciences: Stocks/Bonds Lijie Zhong, PhD, Brii Biosciences: Stocks/Bonds Kamlesh Patel, PhD, Brii Biosciences: Stocks/Bonds Li Yan, MD PhD, Brii Biosciences: Stocks/Bonds Zhi Hong, PhD, Brii Biosciences: Ownership Interest Jean-Luc Girardet, PhD, Brii Biosciences: Stocks/Bonds Lianhong Xu, PhD, Brii Biosciences: Stocks/Bonds.

POSSIBLE CORONARY SYNDROME IN A CHILD WITH AORTIC ENDOCARDITIS DURING CARDIAC SURGERY.

Infective endocarditis (IE) in children it is serious condition and has a hospital mortality rate 10-20 % with medical treatment. Although, surgical management is the last chance for severely ill patients and has been associated with a mortality rate of 50 %. This is a case report of a child 10 years old with aortic IE who developed coronary syndrome intraoperatively. A 10-year-old boy with history of aortic valve repair 6 years ago was recently diagnosed with aortic endocarditis. He was transferred to the cardiac center for treatment. Clinically, he was unwell, pale and complaining of chest pain days before the surgery. He was admitted with electrocardiography changes, ST depression DI-II, V5 and V6.Echocardiogram revealed a mobile mass on the aortic valve which prolapsed into the left ventricle during diastole causing severe aortic regurgitation. Heparin anti-coagulation was instituted upon arrival. He received meropenem and teicoplanin for 5 days and was transfused before surgery. He underwent urgent aortic replacement due to the mobile mass on the aortic valve, unresolved EKG changes and increasing heart failure. Intraoperatively during repeat sternotomy and lysis of adhesions he developed worsening coronary syndrome (increase of previous ST depression DI-II and more III). Hypotension and bradycardia developed which did not responded to atropine. Pulseless electrical activity ensued, and open cardiac massage and paediatric advance life support was performed for 25 minutes before establishing cardiopulmonary by-pass (CPB). During CPB he developed increasing of metabolic acidosis, lactate and decreased of urine output less than 0.9 ml/kg/h. Aortic valve replacement with 19 mm mechanical valve was done during hypothermia 28 degrees. Following release of the cross-clamp no electrical activity occurred and was connected to the pacemaker VVI for 3 hours and worsening of lactic acidosis (lactate 17),urine output decreasing and creatinine increasing. Disconnection from CPB was done and the patient died. Surgery was performed in a resource restricted low- and middle-income country Figure 1.Mid esophageal AV Long Axis View (ME AV LAX) 110 degrees: significant size mass attached to right size of aortic valve, moving, creating severe insufficiency. Figure 2.Deep Transgastric Long Axis view (Deep TG LAX) 120 degrees, showed opening of aortic valve, thickened and dysplastic. Significant jet from aortic regurgitation with significant size vegetation and showed LV severe dilated with moderate to severe impairment.

Abstract 15178: Impact of Anemia on Mortality Among Patients With Type 2 Myocardial Infarction

Introduction: Anemia, a common precipitant of Type 2 Myocardial Infarction (T2MI), is well studied in Acute Coronary Syndrome (ACS), but its impact on mortality in T2MI population is lacking. We evaluated the association of hemoglobin (Hgb) levels on all-cause mortality within 60 days in patients with T2MI. Methods: In this single-center retrospective study, we evaluated 812 patients with Hgb &gt; 7g/dl and troponin &gt;0.04 ng/L (&gt;99 th percentile) presenting to a tertiary ED from 08/2016-08/2018. Exclusion criteria included patients with ischemic EKG changes, ACS treatment, cardiac catheterization showing intervenable lesions. Adjusted confounding variables are included in the figure. Iterative code was created to test each possible Hgb cut-off, from 7.1 to 15.2, to maximize the area under the curve while also looking for the smallest p-value and largest odds ratio. Five Hgb categories were then created, and mortality was calculated across groups. A multivariate-adjusted logistic regression model was used to predict mortality using Hgb category 13+ as the reference group. Results: Cut-off analysis showed Hgb of 9.9 as an inflection point of maximal mortality benefit (p&lt;0.0001). Thus, our Hgb categories were 7-9.9, 10-10.9, 11-11.9, 12-12.9, and 13+. 60-day mortality rate for the above respective groups were 45.4% (n=216), 40.0% (n=135), 36.5% (n=104), 34.8% (n=115), and 26.9% (n=242) respectively. The overall 60-day mortality was 36.3% (295/812). In comparison with the reference group, multivariate analysis showing ORs for 60-day mortality for the above Hgb categories were 1.92 (95% CI: 1.28-2.96, p-0.003), 1.42 (0.87-2.32, p-0.16), 1.46 (0.86-2.49, p0.16), and 1.46 (0.88-2.42, p-0.15) respectively. Conclusions: Hospitalized patients with T2MI have an exceptionally high mortality rate that independently correlate with anemia severity. Those with Hgb &lt; 9.9 had significantly higher mortality compared to Hgb &gt; 9.9.

Abstract 9710: Prevalence of Ekg Criteria Suggestive of Fabry’S Disease in Heart Failure Patients

Introduction: Cardiac disease is the most important cause of morbidity and mortality in Fabry disease, an X-linked genetic condition caused by a defect in alpha-galactosidase A. Diagnosis of Fabry’s disease requires high index of suspicion and includes EKG assessment. Prevalence of EKG changes consistent with Fabry disease in patients admitted with heart failure has not been well investigated. Methods: Clinical, EKG and echocardiographic data were collected in 460 non-V paced consecutive CHF patients enrolled over 2 years in the Get with The Guidelines Heart failure (GWG-HF) registry at a single academic center. Fabry disease EKG features including shortened PR intervals, AV block, LVH criteria, QRS prolongation, left atrial enlargement (LAE), atrial fibrillation (AFIB), and bradycardia were recorded. Results: Of the studied criteria, shortened PR was noted in only 1.85% (6/324) of patients in sinus rhythm. Of the 460 non-V-paced rhythms patients, LVH was noted in 19% (87/460), QRS&gt;120 ms in 20% (96/460), LAE in 21% (98/460), AFIB in 21% (100/460), and HR &lt;60 bpm in 8% (37/460). Overall, 15% (70/460) of patients with non-V-paced rhythms had a combination of LVH/QRS and LAE/AFIB; this combination of ECG findings is potentially suggestive of Fabry disease. There were no significant differences in gender, age, BMI, BNP, GFR, or Hgb levels, degree LV dysfunction, histories of HTN, CAD, diabetes in these 70 patients vs. the rest of the cohort. However, patients with these criteria had significantly increased prevalence of HFrEF (55.7%, 39/70, vs. 42.8% in the rest of the cohort, 167/390, p=0.031). There was no difference in re-admission and/or mortality rates during the 70.7+/-25.2 month follow-up according to these ECG criteria. Conclusions: In our study of unselected patients with ascertained CHF diagnosis, many manifested with multiple EKG features associated with Fabry’s disease. While these patients had increased prevalence of HFrEF, there were no clinical or demographic characteristics separating these individuals from the rest of the cohort. Given poor prognosis and treatable nature of Fabry’s disease, these patients may benefit from additional clinical and laboratory evaluation directed at Fabry’s disease diagnosis

ODP133 Rare Case of Primary Hyperparathyroidism Causing Hypercalcemic crisis in Systemic Lupus Erythematosus (SLE)

Abstract Introduction Hyperparathyroid crisis is a rare endocrine emergency with a high mortality. Primary hyperparathyroidism (PHP) can present as severe hypercalcemia. There are very few cases documented in literature of patients with concomitant SLE and PHP. We present a case of hypercalcemic crisis in a patient with untreated primary hyperparathyroidism with a history of SLE. Case description A 46 year old woman was found to have hypercalcemia of 12.9 mg/dl on routine lab work. Her medical history is significant for SLE (diagnosed 9 years prior) and osteoarthritis. She had no physical complaints. Further workup confirmed primary hyperparathyroidism with PTH of 322.8 pg/ml and findings consistent with parathyroid adenoma on Sestamibi scintigraphy. Parathyroidectomy was strongly recommended however the patient refused. She was then offered medical management but did not show up for any follow up appointments. Two years later, she presented to the emergency department with altered mentation, lethargy, poor oral intake and abdominal pain for 2 days. She was found to have severe hypercalcemia with a serum calcium of &amp;gt; 24.8 mg/dl and was in acute renal failure. On admission, EKG changes suggestive of pseudoinfarct pattern from severe hypercalcemia were present. She was managed in the intensive care unit with intravenous hydration, calcitonin, zoledronic acid and hemodialysis. Shortly after initiation of hemodialysis, the patient succumbed to a cardiac arrest. Conclusion Hyperparathyroid crisis when untreated has a 100% mortality rate. Early management with surgical intervention is the only confirmed cure for PHP. There are only 18 cases reported in literature of hypercalcemia in SLE. Mechanisms involved are believed to be stimulatory PTH antibodies, PTHrP and osteoclastic activity due to inflammatory cytokines. To our best knowledge this is the 6th case report of a patient with concomitant SLE and PHP. A prospective study by Norman et. al 1 done in 10000 PHP patients demonstrated a Gaussian distribution with the average calcium concentration being 10.9 ± 0.6 mg/dL and the average parathyroid hormone concentration being 105.8 ± 48 pg/ml . Her baseline calcium at diagnosis was 13mg/dl and intact PTH was 322.8 pg/ml which is higher than seen in the normograms as per the study. In our patient, we believe SLE could have exacerbated the hypercalcemia caused by PHP. It is important to perform further studies to identify if any association exists between the two conditions. Physicians must recognize their concomitant occurrence as prompt management of hypercalcemia becomes even more crucial in these cases.

CORONARY VASOSPASM FROM COMBINATION CAPECITABINE AND OXALIPLATIN THERAPY

CORONARY VASOSPASM FROM COMBINATION CAPECITABINE AND OXALIPLATIN THERAPY

DELAYED-ONSET CORONARY VASOSPASM FOLLOWING RADIOFREQUENCY CATHETER ABLATION OF ATRIAL FIBRILLATION

DELAYED-ONSET CORONARY VASOSPASM FOLLOWING RADIOFREQUENCY CATHETER ABLATION OF ATRIAL FIBRILLATION

ACUTE PERICARDITIS CAUSED BY COVID-19 INFECTION AND ITS MANAGEMENT

ACUTE PERICARDITIS CAUSED BY COVID-19 INFECTION AND ITS MANAGEMENT

S2264 A Case of Progressive Untreated Eosinophilic Gastrointestinal Disorder Complicated by Eosinophilic Myocarditis

Introduction: Eosinophilic gastrointestinal diseases (EGID) are immune-mediated conditions characterized by GI dysfunction and histological evidence of eosinophilic infiltration. While usually confined to the GI tract, severe inflammation can involve multiple organ systems, typically under the umbrella term of hypereosinophilic syndrome (HES). Patients can present with cardiac involvement such as eosinophilic myocarditis which results in an uncommon, but potentially lethal complication. We present a case of a patient with prior history of eosinophilic esophagitis (EoE) subsequently presenting with diffuse EGID complicated by eosinophilic myocarditis. Case Description/Methods: A 63-year-old female with a history of EoE and breast cancer post mastectomy presented with acute epigastric and chest pain. The patient had biopsy-proven EoE which was managed with PPI in the past. On physical examination, she had diffuse abdominal tenderness. Labs were remarkable for peripheral eosinophilia peaking at 57%. Initial high sensitivity troponin I was 300 ng/L without EKG changes, and ultimately peaked at 7821 ng/L. CT of the abdomen and pelvis showed thickening of the stomach, duodenum, and jejunum. Left heart catheterization revealed LAD disease without obstructive disease. EGD demonstrated severe inflammation, erythema, and eosinophilic infiltration in the gastric body, antrum, and throughout the duodenum. High dose steroids were initiated with subsequent improvement in symptoms, serum troponin, and complete resolution of peripheral eosinophilia. Patient followed up as an outpatient, where cardiac MRI confirmed eosinophilic myocarditis, and she was started on Mepolizumab for maintenance therapy and prevention of relapse. Discussion: EGID are increasingly prevalent disorders that can result in significant morbidity and mortality without prompt diagnosis. This patient had a history of EoE and developed diffuse GI involvement and subsequent eosinophilic myocarditis. Her presentation as atypical chest pain suggestive of NSTEMI resulted in delay of initiation of steroids until after heart catheterization. Our case suggests that without glucocorticoid suppression, eosinophilia can cause widespread tissue infiltration and damage. The majority of these patients have chronic disease that require long term maintenance therapy. Mepolizumab has been demonstrated to be an effective agent for hypereosinophilic disorders. When managing EGID, it is pertinent to recognize early involvement of systemic eosinophilic infiltration.Figure 1.: EGD.

Abstract P254: Effect Of Covid-19 Infection On Qtc Prolongation

Background Objective: What is the association between COVID-19 infection and QTc changes? Coronavirus SARS-COV2 uses angiotensin-converting enzyme receptors 2 (ACE2) on host cells to enter into human cells. These receptors are expressed on the heart cells among other major cells. This is one of the most accepted theories for direct cardiac cell injury of COVID-19disease and associated cardiorespiratory manifestations. COVID-19 infection leads to unstable myocardial cell membranes, by causing hypoxia, myocarditis, myocardial ischemia, and abnormal host immune response. This is the main reason behind Arrhythmia and EKG changes during COVID19 infection. But the specific effect on QTc has not been studied well so far, so our research try to study this connection. Method: This is an observational retrospective hospital chart review involving 320 adult participants diagnosed with COVID-19 infection at our facility. After applying the exclusion criteria, 130 participants remained, who were distributed into two groups. One group with long QTc and one group with normal QTc. Data was collected and demographics were recorded using Excel and SPSS, then compared using a student’s t-test for independent groups. The quantitative data are summarized by the mean and standard deviation (SD). Statistical significance was taken as P &lt;0.05. Result: A total of 63 participants (48.4% of total 130 participants) met the criteria for long QTc, and a total of 67 participants(51.5%) had normal QTc (P &lt; 0.001). There was no statistically significant mortality outcome (0.8% vs. 3.8%, P = 0.21). Conclusion: Our study showed 48.4% participants having an increase in QTc during COVID-19 infection, (20% of 320 total admissions). This observation is very important to help healthcare providers to gaina better understanding of this disease.

A UNIQUE CASE OF PURE ASYMPTOMATIC PERICARDITIS IN COVID-19

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Acute pericarditis in COVID-19 pneumonia (PNA) can present during PNA, after PNA, or even as the main presentation. Chest pain and EKG changes should raise suspicion for pericarditis and be immediately addressed. CASE PRESENTATION: A 43 y/o male with no relevant medical history, presented with respiratory symptoms 20 days with COVID RT-PCR positive 17 days before admission. He was admitted for COVID PNA due to persistent productive cough, increasing dyspnea and decreased exercise tolerance. No chest pain with normal vitals, sat 98% on RA but complained of orthopnea. Labs: Troponin negative x4, potassium 5.1, and D-dimer 2388. He was started on therapeutic enoxaparin and given sodium zirconium cyclosilicate. EKG: diffuse ST segment elevations across precordial leads and lead I with reciprocal ST segment depression in aVR. TTE: small pericardial effusion. This would indicate 2/4 pericarditis diagnosis criteria. CXR and CTPE: b/l patchy and scattered ground-glass opacities. Ibuprofen 600 mg was started; however, colchicine was not initiated. ST segment elevations improved and he was discharged with ibuprofen and apixaban without complications. DISCUSSION: There are few reports on patients who developed pericarditis and pericardial effusions with COVID-19 infection. Most have been associated with myocardial involvement with increasing troponin. Treatment is an on-going debate, but consensus is that corticosteroids and colchicine are safe. CONCLUSIONS: This is a unique case of COVID-19 PNA complicated with troponin negative pericarditis. DISCLOSURE: Nothing to declare. KEYWORD: covid pericarditis

P415 NEUROGENIC STRESS CARDIOMYOPATHY

Abstract Case Report Caucasian 84–years–old woman was found on the floor at her house and was brought to the ED of Policlinico Umberto I with the diagnosis of cranial trauma following a syncope. A head CT showed right paramedian fracture of the occipital bone, left frontal subarachnoid hemorrhage and left frontal subdural hemorrhage. The neurosurgeon gave no indication to urgent evacuation of the hemorrhage. Then elevation of cardiac enzymes and ST–segment elevation at the EKG were found but due to the state of the patient a coronary angiography was not performed and the patient was transferred to the CCU. The patient was hemodynamically stable with right hemiplegia. The EKG showed rapid ventricular rate atrial fibrillation with ST segment elevation in inferior and lateral leads with T wave inversion in the same leads and elevated serum troponin levels. ETT showed: EF 30% with a global reduction of left ventricular systolic function with diffuse akinesis. Intravenous therapy with mannitol and corticosteroids for perilesional oedema was started. Beta blockers and a class III antiarrhythmic drug were also started, but hemodynamic conditions declined and acute kidney failure occurred with progressive hypotension followed by cardiogenic shock. The patient had an episode of nonsustained ventricular tachycardia treated with antiarrhythmic drugs and magnesium sulfate. The EKG started to show a normalization of the repolarization phase with regression of ST segment elevation and persistent T wave inversion.The patient’s neurological conditions were complicated with epileptic seizures.On the fifth day of hospitalization the TTE revealed a slight improvement of global systolic function and the presence of an apical thrombotic apposition.The patient’s clinical conditions worsened and led to exitus. Discussion The interpretation of this patient’s history was made more difficult by the lack of witnesses of the trauma.The patient’s age, her history of hypertension and the presence of regional wall motion abnormalities at the TTE suggested the presence of CAD. On the other side the atrial fibrillation could hint a primitive cerebral event. This case report shows the potentially severe cardiac manifestations of cerebral hemorrhage and the necessity to consider cerebrovascular events as the cause of EKG changes mimicking a myocardial infarction, cardiac enzymes elevation and ventricular wall motion abnormalities, in order to avoid inappropriate or delated therapies.

P381 A CHALLENGING PACEMAKER IMPLANTATION IN THE PRESENCE OF A GIANT RIGHT CORONARY ANEURYSM COMPRESSING THE RIGHT ATRIUM

Abstract Giant coronary artery aneurysm is an uncommon disease, treated with surgerical intervention or percutaneous coil embolization. A thrombosed aneurysm can cause extrinsic compression on the cardiac chambers, with potential haemodynamic effects and may cause problems when we need to implant a cardiac device. We present a 85–year–old patient, with a previous myocardial infarction and double coronary artery bypass graft in 1995. In 2013 he was hospitalized for heart failure and severe mitral insufficiency, with cardiac surgery indication. Preoperative coronary angiography revealed a giant right coronary aneurysm (65x75mm). The aneurysm was partially thrombosed and in close contact with the posterior sternal wall; it was decided to treat it by coil embolization in order to avoid damage during the initial stages of cardiac surgery (sternotomy and isolation of the pericardium). Subsequently, the replacement of the mitral valve with a bioprosthesis was performed without complications. In 2019 a chest CT scan, in an asymptomatic patient, showed an enlarged coronary aneurysm (85x90mm), completely thrombosed, compressing the right atrium, for which a conservative approach was maintained. The patient was hospitalized in May 2021 following 3 syncopes, with cranial trauma. The EKG shows sinus rhythm with first degree AV block and complete left bundle branch block. Chest CT confirmed the aneurysm, unchanged from 2019 (Fig 1). Transthoracic and transesophageal echocardiography confirmed compression of the mass on the right atrium, reduced to a very small cavity (Fig 2). A stress echocardiogram with dobutamine, performed to evaluate a possible hemodynamic effect of atrial compression, showed no changes in diastolic ventricular filling, arrhythmias, pressure drops, or significant symptoms. Based on these assessments, the syncopes and EKG changes, we implanted a VVIR ventricular pacemaker. The procedure was hampered by the difficulty of passing the lead through the compressed right atrium in order to reach the tricuspid plane and then enter the right ventricle; only after numerous attempts, and with the help of simultaneous echocardiographic and fluoroscopic guidance, was it possible to complete the procedure without complications (Fig 3). This case demonstrates the usefulness of the echocardiogram, in particular contexts, in cardiac electro–stimulation procedure