EKG Changes Research Articles

Identifying Factors That Predict for Unplanned Readmissions for Acute Myeloid Leukemia Patients Receiving Consolidation Cytarabine Based Therapies

Background: Younger patients (pts) with acute myeloid leukemia (AML) who enter a remission after intensive induction chemotherapy routinely receive at least one cycle of consolidation therapy with high dose cytarabine (HiDAC). This is commonly administered over a five-day inpatient stay, after which pts are discharged home as their blood counts nadir. It is thus a natural consequence of therapy that readmission for febrile neutropenia (FN) occurs, which can impact measures of quality and value in this population. Precise descriptions of incidence, type, and severity of infection, if identified, are lacking, and thus it is unknown to what standard cancer centers should be held for anticipated readmission. We measured these rates, and attempted to identify predictive factors for readmission. Methods: Adult AML pts ≥ 18 years of age who received at least one cycle of HiDAC consolidation (1000-3000 mg/m2 for six doses) in 2009-2019 were included. Our primary aim was to identify predictive factors for readmission after the first cycle of consolidation chemotherapy. The following pt characteristics and co-morbid conditions were analyzed: age, gender, body mass index (BMI), smoking status, AML cytogenetic risk status, history of diabetes, peripheral vascular disease, cardiovascular disease, chronic pulmonary disease, hepatic impairment, and other cancers. Secondary aims included: estimating rates of all-cause readmissions among all HiDAC cycles, defining the rate of FN readmissions, estimating rates of intensive care unit (ICU) admissions, clinical (e.g., probable pneumonia per imaging) and microbiologically-documented infections, prophylactic (ppx) medications used, and mortality. Statistical analyses interrogated potential risk factors for evidence of association with hospital readmission after the first cycle of consolidation chemotherapy. Results: We identified 182 AML pts who fit inclusion criteria. The median age was 50 years (range 19-73); 55% were female and 45% were male. Statistical analyses revealed no association with readmission after cycle 1 for cytogenetic risk (p=0.85), history of heart failure (p= 0.67), chronic pulmonary disease (p=1), connective tissue disease (p=0.53), cerebrovascular accident (p=0.63), diabetes (p=0.63), gender (p=0.07), history of lymphoma (p=0.53), other solid tumors (p=0.53), liver disease (p=1), myocardial infarction (p=0.71), peripheral vascular disease (p=1), or smoking status (p= 0.52). For 480 HiDAC cycles analyzed (88% at 3000 mg/m2), the overall readmission rate was 50% (242/480), of which 85% (205/242) were for FN. Those readmissions which were not FN were for cardiac complications (chest pain, EKG changes), non-neutropenic fevers or infections, neurotoxicity, bleeding or clotting events, or other symptoms associated with chemotherapy (nausea/vomiting, pain, etc.). Median time to FN hospital admission was 18 days (range 6-27) from the start of HiDAC. Of the 205 FN readmissions, 57% had documented infections. Of these infections, 41% were bacteremia, 23% fungal, 16% sepsis, 12% other bacterial, and 8% viral. Of 480 HiDAC cycles, ppx medications prescribed included: 92% fluoroquinolone (442/480), 81% anti-viral (389/480), 30 % anti-fungal (142/480), and 3% colony stimulating factor (14/480). Only 7% (14/205) of FN readmissions resulted in an ICU admission, and 1% (3/205) resulted in death. Conclusions: Approximately half of patients treated with consolidation therapy following intensive induction therapy can be expected to be readmitted to the hospital. The majority of FN readmissions were associated with clinical or microbiologically documented infections and are not avoidable, however ICU admission and death associated with these complications are rare. Readmission of AML pts following HiDAC is expected, and therefore, should be excluded from measures of value and quality. Disclosures Waldron: Amgen: Consultancy. Hobbs:Amgen: Research Funding; SimulStat Inc.: Consultancy. Advani:Macrogenics: Research Funding; Abbvie: Research Funding; Kite Pharmaceuticals: Consultancy; Pfizer: Honoraria, Research Funding; Amgen: Research Funding; Glycomimetics: Consultancy, Research Funding. Nazha:Incyte: Speakers Bureau; Abbvie: Consultancy; Daiichi Sankyo: Consultancy; Jazz Pharmacutical: Research Funding; Novartis: Speakers Bureau; MEI: Other: Data monitoring Committee; Tolero, Karyopharma: Honoraria. Gerds:Imago Biosciences: Research Funding; Roche: Research Funding; Celgene Corporation: Consultancy, Research Funding; Pfizer: Consultancy; CTI Biopharma: Consultancy, Research Funding; Incyte: Consultancy, Research Funding; Sierra Oncology: Research Funding. Sekeres:Syros: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Millenium: Membership on an entity's Board of Directors or advisory committees. Mukherjee:Partnership for Health Analytic Research, LLC (PHAR, LLC): Consultancy; McGraw Hill Hematology Oncology Board Review: Other: Editor; Projects in Knowledge: Honoraria; Celgene Corporation: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Speakers Bureau; Takeda: Membership on an entity's Board of Directors or advisory committees.

HEART BREAKS TO BREATHE: RECURRENT TAKOTSUBO CARDIOMYOPATHY IN COPD EXACERBATION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo syndrome (TTS) is defined as reversible stress-induced cardiomyopathy presenting as apical ballooning or mid-ventricular, basal, or focal wall motion abnormalities in the absence of coronary artery disease. It can be provoked by a stressful emotional situation or exposure to catecholamine surge. It’s a rare phenomenon to have a lung-heart axis leading to recurrent TTS. Here we present a rare case of recurrent TTS in the setting of COPD exacerbations also termed as bronchogenic TTS CASE PRESENTATION: 64 years old female with presented with dyspnea secondary to COPD exacerbation due to bacterial pneumonia was noted to have EKG changes with T-wave inversion, mild troponin elevation consistent with an ischemic lesion, elevated BNP 6103, followed by urgent cardiac catheterization noted to have non-significant coronary artery disease. Transthoracic echocardiogram (TTE) reported left ventricular ejection fraction (LVEF) of 25-29% with moderate sized apical, septal, posterior and anteroseptal wall motion abnormalities with akinesis of the segment consistent with TTS. Work up was negative for infective endocarditis, neurological and neuroendocrine tumor. She was treated with guideline-directed medical therapy (GDMT). LVEF normalized to 55%-59% in a follow up TTE. Seventeen months later she got readmitted with another episode of acute hypoxic hypercapnic respiratory failure requiring intubation with cardiac collapse. Patient had similar cardiac Catheterization findings but reduced LVEF of 30-34% consistent with TTS, again treated with GDMT, followed by a return of LVEF to normalization in a repeat TTE DISCUSSION: Recurrent TTS in the setting of COPD exacerbation is an extremely rare phenomenon exact cause of which remains unknown. Catecholamine surge causing microvascular dysfunction leading to cardiac stunning is a leading hypothesis. In COPD exacerbation adding beta 2 adrenergic agonists in management might potentiate worsening of cardiac stunning. Recurrent TTS has 19% overall risk for serious complications such as cardiogenic shock similar to acute coronary syndrome. The first step toward treatment is the removal of precipitating etiology like stress and in our case COPD exacerbation. ACE-inhibitors and angiotensin receptor blockers have a protective effect in reducing recurrent TTS while beta blockers have shown limited benefit. Even after recovery patient with TTS remains at high risk for electrical and mechanical complications CONCLUSIONS: Recurrent TTS in setting of COPD exacerbation has unknown incidence yet it highlights the intricate relationship of heart-lung axis. While TTS might be reversible, underlying pathophysiological insult might be permanent. We encourage physicians to not consider TTS as benign pathology and do every effort to reduce its recurrence. COPD exacerbation with TTS has worse prognosis with higher risk of hypoxic injury warranting improved COPD management. Reference #1: Rennyson, S. L., Parker, J. M., Symanski, J. D., & Littmann, L. (2010). Recurrent, severe, and rapidly reversible apical ballooning syndrome in status asthmaticus. Heart & Lung: The Journal of Acute and Critical Care, 39(6), 537-539. Reference #2: Manfredini, R., Fabbian, F., De Giorgi, A., Pala, M., Menegatti, A. M., Parisi, C., ... & Bossone, E. (2014). Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: a systematic review. World journal of cardiology, 6(5), 338. DISCLOSURES: No relevant relationships by Sreelatha Naik, source=Web Response No relevant relationships by Muhammad Pir, source=Web Response No relevant relationships by najam saqib, source=Web Response

A BUNDLE IN THE HEART: WOLFF-PARKINSON-WHITE SYNDROME PRESENTING AS CARDIAC ARREST

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Ventricular fibrillation (VF) is a rare complication of Wolff-Parkinson-White (WPW) Syndrome. We present a case of WPW presenting as VF arrest. CASE PRESENTATION: A 21-year-old man with no past medical history was brought to emergency department after he experienced an out of hospital VF cardiac arrest after having a cold slushy. Post arrest electrocardiogram revealed atrial fibrillation with rapid ventricular rate. Patient achieved return of spontaneous circulation after 30 minutes of advanced cardiac life support. Patient was admitted to Intensive Care Unit for post cardiac arrest care which included targeted temperature management. During his hospitalization, elevated troponin and EKG changes in the inferior leads (II, III and aVF) prompted left heart catheterization. No evidence of coronary artery disease was found. Patient was successfully extubated with good neurological status after rewarming. On review of EKG patient was noted to have shortened PR interval and delta waves in the setting of normal sinus rhythm, thus fulfilling the criteria for WPW syndrome. The morphology of delta waves in the inferior leads was noted to be of pseudo-Q waves. Electrophysiology was consulted and patient underwent successful ablation of the left posterolateral accessory pathway. It was hypothesized that he had an acute vasovagal episode in response to the cold slushy which lead to conduction of atrial fibrillation through accessory pathway into ventricular fibrillation. EKG (figure 1) showing pseudo Q waves in leads II, III and aVF which represent Delta waves. Pathognomic Delta waves seen in precordial leads. DISCUSSION: WPW is a pre-excitation syndrome involving an accessory pathway called bundle of kent. AV nodal blockade in the setting of atrial fibrillation in patients with WPW syndrome leads to pre-excitation of ventricles which can induce ventricular arrythmias. Therefore drugs or conditions leading to AV nodal blockade should be avoided in patients with WPW syndrome as ventricular arrythmias are associated with high morbidity and mortality. CONCLUSIONS: VF accounts for many sudden cardiac deaths (SCD) in WPW syndrome. SCD is more common in patients symptomatic with WPW. AV nodal blockade should be avoided in patients with WPW syndrome. Guidelines and treatment strategies need to be established to screen patients for WPW syndrome. Reference #1: Centurion OA. Atrial Fibrillation in the Wolff-Parkinson-White Syndrome. J Atr Fibrillation. 2011;4(1):287. Published 2011 May 4. https://doi.org/10.4022/jafib.287 DISCLOSURES: No relevant relationships by Anandbir Bath, source=Web Response No relevant relationships by Syed Sami Haider, source=Web Response

AN UNUSUAL CASE OF NON SMALL CELL LUNG CANCER PRESENTING AS NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Non-ST-elevation myocardial infarction (NSTEMI) is a mismatch in the myocardial oxygen demand and consumption. Common causes include poor coronary flow, unmet increased oxygen demand, and cardiac inflammation. We present a case of NSTEMI as a result of a cause not yet reported in the literature. CASE PRESENTATION: An 84-year-old man with a history of coronary artery disease (CAD), coronary artery bypass grafting, hypertension, 10 pack-year smoking history presented with a 1-week history of typical chest pain. Review of systems was otherwise non-contributory. He reported medication adherence and denied illicit drug use. Initial vitals were stable. Electrocardiogram (EKG) was unchanged from prior with no dynamic ST changes. Cardiac enzymes showed a troponin of 0.720 ng/ml, CKMB of 72.50 ng/ml and CK of 585 IU/L. Heparin drip was started for presumed NSTEMI. Troponins subsequently rose to 22.530 ng/ml and peaked at 49.160 ng/ml after which they trended downwards. Serial EKGs were unchanged. His chest pain resolved with the initiation of heparin drip. Given the downtrend in troponins and lack of EKG changes, cardiac catheterization was not performed. The echocardiogram revealed a right ventricular mass obstructing the right ventricular outflow tract (RVOT) without evidence of right ventricular strain. As the position of the mass was unclear a CT chest and cardiac MRI were done which showed an anterior mediastinal mass 5.0 cm x 5.5 cm x 6.5 cm effacing the right ventricle and pulmonary artery and also encasing the left main coronary artery, the left internal mammary artery and left anterior descending artery graft with invasion of the superficial epicardial margin of the left ventricle basal anterior segment. The heparin drip was discontinued at this point given the risk of hemorrhagic conversion of the mass. Biopsy of the mass revealed a non-small cell lung cancer (NSCLC). Further imaging revealed no metastatic lesions. Due to the size of the mass and cardiac invasion, he was not a candidate for cardiothoracic surgery. Given that he was stable from a cardiac standpoint, he was discharged with followup with hematology-oncology. DISCUSSION: Cardiac metastasis has been reported in 9% of NSCLC cases. It typically presents as dyspnea and pleuritic chest pain. While myocardial metastasis has been reported to be associated with acute STEMI [2], its presentation as NSTEMI has not been previously reported [1]. We hypothesize that this unusual presentation may have resulted from the encasement of the coronary vessels by the tumor, which led to disruption and stasis of blood flow promoting a prothrombotic state. This may have resulted in a thrombus causing ischemia which responded to heparin as treatment. CONCLUSIONS: Cardiac metastasis should be considered as a differential diagnosis for NSTEMI in patients with CAD presenting with typical chest pain given the potential to alter treatment Reference #1: Chiles, C., Woodard, P., Gutierrez, F., Link, K. (2001). Metastatic involvement of the heart and pericardium: CT and MR imaging. Radiographics, 21(2), 439-449. Reference #2: Suga, T., Akuzawa, N., Hatori, T., Imai, K., Kitahara, Y., & Kurabayashi, M. (2015). ST segment elevation in secondary cardiac cancer: a case report and review of the literature. International journal of clinical and experimental medicine, 8(5), 7719-27. DISCLOSURES: No relevant relationships by Hassaan Arshad, source=Web Response No relevant relationships by Aishwarya Bhardwaj, source=Web Response No relevant relationships by Dayna Panchal, source=Web Response no disclosure on file for Kumar Satya; No relevant relationships by Umar Jamshed Sharif Khawaja, source=Web Response No relevant relationships by Rehan Umar, source=Web Response No relevant relationships by Jun Chih Wang, source=Web Response

THE GREAT IMITATOR: TENSION PNEUMOTHORAX MIMICKING STEMI IN A PATIENT WITH BI-VENTRICULAR TAKOTSUBO CARDIOMYOPATHY

There are many causes of ST elevation beyond acute coronary syndrome. Although uncommon, pneumothorax can present with EKG changes concerning for acute myocardial infarction (AMI). A 66-year old female with HTN and COPD was admitted for work up of newly discovered mediastinal mass. Post

Regadenoson-induced asystole and ischemic EKG changes in the setting of underlying coronary disease

Regadenoson-induced asystole and ischemic EKG changes in the setting of underlying coronary disease

Carbon Monoxide: A Rare Cause of Myocardial Ischemia

In an acute care setting, chemical asphyxiants (CA) are a vice which cause debilitating injury. Carbon monoxide (CO) is one well known CA which causes hypoxic injury to cardiovascular and neurological tissue. CO poisoning is one of the leading causes of death in USA. As many as 6% of patients who get admitted with CO poisoning in the USA have acute myocardial infarction. A strong positive correlation of CO Hb concentration has been established with increased incidence of MIs. We present a case of a 75-year-old male with complaints of chest discomfort, dyspnea, diaphoresis that was attributed to CO poisoning. Over the course of his stay he had two sets of positive serial troponins and was diagnosed with a non-ST elevation MI. Most of the recent literature focuses on ST elevation and T wave inversions in patients with CO poisoning. Contrary to this, our patient did not exhibit any EKG changes at any point during his hospital course. CO poisoning can cause fatal complications including an MI.

Nurses Are Key in Preventing Deadly Diagnostic Errors in Cardiovascular Diseases.

Nurses Are Key in Preventing Deadly Diagnostic Errors in Cardiovascular Diseases.

CATHETER DIRECTED THROMBOLYSIS FOR MASSIVE PULMONARY EMBOLISM IN A PREGNANT PATIENT

SESSION TITLE: Critical Care 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary embolism (PE) is a leading cause of maternal mortality in the United States [1]. CASE PRESENTATION: We report a 27-year-old female at 13 weeks gestation who presented with massive PE and circulatory shock and was successfully treated with catheter directed thrombolysis. History of syncope prior to arrival combined with EKG changes and findings on bedside ultrasound led to a high clinical suspicion for PE with diagnosis confirmed by computed tomography. The patient was admitted to the intensive care unit on systemic anticoagulation with unfractionated heparin. Subsequent circulatory shock led to the decision for catheter directed thrombolytic therapy. The advantage of our treatment choice was rapid clot lysis, return of normal hemodynamics, and avoidance of the risk of complications associated with higher doses of thrombolytic agents [2]. The patient remained hospitalized for 5 days without complication and was discharged on low-molecular weight heparin injections. DISCUSSION: The morbidity and mortality associated with PE during pregnancy demands prompt diagnosis and treatment. In general, thrombolytic agents are relatively contraindicated during pregnancy because of the presumed risk of maternal bleeding and fetal loss. The teratogenicity for these agents in humans is also uncertain [3]. CONCLUSIONS: Ultimately, all life-saving measures must be considered in the face of hemodynamic collapse. Our case demonstrates a positive outcome from catheter directed thrombolytic therapy and contributes to the growing literature in outcomes of treatment in massive PE in pregnancy. Reference #1: 1 Creanga, Andreea A., et al. “Pregnancy-Related Mortality in the United States, 2006-2010.” Obstetrics & Gynecology, vol. 125, no. 1, Jan. 2015, pp. 5–12., https://doi.org/10.1097/aog.0000000000000564. Reference #2: 2 Brandt, Kimberly, et al. “Low-Dose Systemic Alteplase (TPA) for the Treatment of Pulmonary Embolism.” Annals of Pharmacotherapy, vol. 49, no. 7, Sept. 2015, pp. 818–824., https://doi.org/10.1177/1060028015579988. Reference #3: 3 Ahearn GS, Hadjiliadis D, Govert JA, Tapson VF. Massive Pulmonary Embolism During Pregnancy Successfully Treated With Recombinant Tissue Plasminogen ActivatorA Case Report and Review of Treatment Options. Arch Intern Med. 2002;162(11):1221–1227. https://doi.org/10.1001/archinte.162.11.1221 DISCLOSURES: No relevant relationships by daniel goldbach, source=Web Response

Cardiac Toxicity Due to High-Dose Loperamide Therapy

Introduction: There has been a tragic increase in the adverse events seen with the use of loperamide owing to abuse by opiate addicted individuals. Loperamide is a peripherally acting Mμ-opioid agonist which binds receptors in the digestive tract slowing intestinal transit, and does not cross the blood-brain barrier at prescribed doses owing to an efflux transporter. However, when used at extremely high doses, euphoric effects similar to opiate use may occur as the drug overwhelms the efflux transporter, crossing the blood-brain barrier. Only two cases have been reported in the literature of the cardiac effects of loperamide overdose in IBD, although both individuals had a history of substance abuse, and the overdoses were attributed to its euphoric rather than anti-diarrheal effects. We present a case of a life-threatening EKG changes in the setting of excess loperamide use for its anti-diarrheal properties in the setting of IBD. CASE: Our patient is a 27 year-old Caucasian man with Crohn's disease and no history of substance abuse. He was managed in a step-up approach, eventually requiring adalimumab five years after diagnosis. He then developed obstructive symptoms requiring an ileocecectomy. He did well after surgery and resumed adalimumab. Unfortunately, the patient was lost to follow-up, and later revealed that he stopped adalimumab therapy because he felt well and did not want to continue this medication. Nineteen months later, he presented to the emergency room with pre-syncopal symptoms. He had markedly prolonged QT intervals and a wide QRS, resembling a sine wave at only 100 beats per minute with normal electrolytes. He underwent extensive evaluation and ultimately was diagnosed with an arrhythmia due to loperamide toxicity. He revealed that he had been ingesting 80-90mg of loperamide daily to help control his diarrhea after discontinuing adalimumab. On follow up his QT intervals and QRS improved after discontinuation of loperamide. DISCUSSION: This demonstrates one of the dangerous consequences of loperamide toxicity. Our case represents the first reported case of cardiac-related loperamide toxicity as a consequence of anti-diarrheal management in a patient with uncontrolled IBD. Typically this toxicity is seen in opioid addicted individuals; however, our case highlights the fact that providers must be cognizant of loperamide abuse in all settings.2063 Figure 1. The initial EKG showed a very wide QRS complex that fuses with QT, producing what looks like a sine wave. This is illustrated best by the red arrows. Given normal electrolytes, this is a result of loperamide toxicity and can predispose to torsades de pointes.

Survival Outcome of Patients in Acute Variceal Bleeding With Acute Coronary Syndrome Discharged on Anti-Platelet Agents

Introduction: Acute variceal bleeding is one of major and killing complication of advanced liver disease, and these patients are not immune from developing acute coronary syndrome. Data regarding outcome of patients with acute variceal bleeding with acute coronary syndrome is scarce. The aim of this study was to look for survival outcome of those patient who were discharged on anti-platelet agents. Methods: All the patients diagnosed with acute variceal bleeding based on gastroscopy along with acute coronary syndrome based on troponin leak with or without EKG changes, presented at The Aga Khan University Hospital, from February 2002 to February 2017 were included in the study. The medical records were reviewed to evaluate the survival outcome for 1 year. Results: Out of 39 files that were coded (ICD-9) with acute variceal bleeding and acute coronary syndrome, only data of 27 patients could be retrieved, out of them, 3 patients had no active bleeding at the time of acute coronary syndrome and 1 patient had ulcer bleed so excluded from study. So only 23 patients were included in the study. The mean age of patient 59.22 ± 11 years, 17 (74 %) of the patients were males. 10 (44 %) patients had child pugh C liver disease, followed by 8 (35 %) with child pugh B liver disease. Overall 7 (30%) had also underlying hepatocellular carcinoma. 12(52 %) patient had underlying ischemic heart disease. Out of 23, 7 (30 %) patients died during same admission, and out of 7 patients only one patient was on dual antiplatelet agents. Out of remaining 16 (70 %) patients, 4 (18 %) patients lost to follow up after discharge. Only 12 patients followed for 1 year survival and out of them only 3 patients were started on single antiplatelet agents (2 patients discharged on asprin and one patient on clopidogrel). 9/12 patients survived over 1 year and those patients with antiplatelet agent didn't developed re-bleeding. Still results are pre-liminary, final result may have little change. Conclusion: Survival outcome in patients with variceal bleeding with acute coronary syndrome is not good, and fear of re-bleed stops to offer antiplatelet agents in this setting, which is other wise, standard treatment for acute coronary syndrome. Comparing risks versus benefit, single antiplatelet agent looks relatively safer option, which can be offered cautiously in such dilemmas, after achieving hemostasis. For validation, large scale prospective studies should be considered.

Mexiletine Usage in a Chronic Pain Clinic: Indications, Tolerability, and Side Effects

Intravenous lidocaine has multiple applications in the management of acute and chronic pain. Mexiletine, an oral lidocaine analogue, has been used in a number of chronic pain conditions although its use is not well characterized. To report our experience using mexiletine in a chronic pain population, specifically looking at tolerability, side effects, and EKG changes. Retrospective, cohort study. Three chronic pain clinics within a hospital system in Detroit, MI. All patients who had a mexiletine prescription between August 2015 and August 2016 were queried via the electronic medical record. Each chart was examined for demographics, QTc changes on EKG, length of use, and reasons for stoppage. There were 74 total patients identified in the chronic pain management clinics as receiving at least 1 mexiletine prescription over the 1-year time period. Twice as many women as men received mexiletine prescriptions. Neuropathic pain was the most common primary diagnosis (64%) which included diabetic neuropathy, radiculopathy, and others. Fibromyalgia was the next most common primary diagnosis (28%). A QTc change on the EKG showed a mean decrease of 0.1 ms and median increase of 1.5 ms. At 6 months (180 days), approximately 30% of the patients remained on mexiletine therapy, and 28% remained on the therapy at 1 year (360 days). Median duration of use was 60 days and the mean was 288 days. Neurologic and gastrointestinal side effects were the most commons reason for stoppage. All side effects were mild and resolved with stoppage. After side effects, lack of response, or loss of efficacy, were the next most common reasons for stoppage. Pain relief and outcomes were not specifically examined due to confounding factors including interventional treatments and multiple treatment modalities. This was a retrospective, cohort study limited to our specific clinic population with a relatively high loss to follow-up rate. Mexiletine is rarely a first line option for chronic pain management and is often used when multiple other modalities have failed. By reporting our experience, we hope other clinicians may have more familiarity with the drug's use in a chronic pain practice. It appears reasonably tolerable, may not require frequent EKG monitoring, and can be an appropriate adjunct in the chronic pain population. More research is needed regarding efficacy and dose titration for mexiletine in chronic pain. Chronic pain, mexiletine, IV lidocaine, pain, neuropathic pain, neuropathy, fibromyalgia, QTc, tolerability.

Abstract 174: Clinical Redesign Project to Improve Troponin Utilization at a University affiliated Community Hospital

Background: Cardiac troponin (CTn) is central to the diagnosis of acute coronary syndromes (ACS), however, in patients with low pre-test probability, the specificity of a positive CTn assay diminishes significantly. Overutilization of CTn assay is a rather prevalent problem and doctors often order further expensive testing for non-specific elevation in CTn. Methods: A clinical redesign team, formed in October 2015, defined four appropriate indications for ordering CTn assays, namely, chest pain, new EKG changes, cardiac arrest and angina equivalents such as shortness of breath and fatigue. We started by administering anonymous questionnaires, pertaining to CTn ordering practices, to different groups of healthcare providers at our hospital. Upon obtaining results of the questionnaire we executed a multifaceted intervention, including educational seminars and insertion of prompts in the electronic medical record system. We divided our study period into pre- and post-intervention periods of 1-year duration each and included a 17-week post-intervention interim analysis. We used Pearson’s correlation to test the null hypothesis that the pre- and post-intervention CTn assay volumes were not correlated and we used ANOVA to compare mean CTn assay volumes in the 38-week pre- and 17-week post-intervention period. Result: Overall: there was a 4% increase in ED patient volume and a 14% decrease in the total cTn order volume. Average cTn assays per ED patient decreased by 19%, from 0.26 to 0.21. The proportion of appropriate cTn assays increased post-intervention (45 vs 40% p=0.03). Interim analysis revealed a statistically significant decrease in weekly cTn order volume (r=0.903, p=0.0001). Percentage of cTn assays associated with a discharge diagnosis of ACS increased from 5.1% to 5.8% post-intervention (p= 0.001). Conclusion: cTn utilization can be effectively addressed by an organized multifaceted step-wise approach. Inappropriate utilization of cTn assays comes with associated cost implications due to the cost of the assay (nearly $50,000 cost savings in a year alone). It is quintessential to understand cTn ordering attitudes among different groups of healthcare providers. Our study also highlights the relevance of pre-test probability of ACS in any given patient before ordering cTn.

03: Utility of EKG for preoperative evaluation in benign hysterectomy

Preoperative electrocardiogram (EKG) is commonly utilized in work up for benign hysterectomy. No standard of care exists to guide gynecologists in its use to optimize patients for surgery. Our institutional guidelines, developed by consensus opinion by the anesthesia department, recommend EKG for patients who meet the following criteria: age >60 years, type 2 diabetes, renal disease, alcohol/drug use, radiation/chemotherapy in the last 3 months, or digoxin use. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guidelines recommend EKG for age > 65 years and an American Society of Anesthesia (ASA) classification of 2 or more. Our objective was to assess guideline compliance and utility of preoperative EKG for benign hysterectomy. Medical records of 182 patients who underwent EKG for preoperative evaluation for benign hysterectomy at a single institution from January 1 to December 31, 2016 were reviewed. Each EKG was evaluated for indication, compliance with institutional and NICE guidelines, effect on management, result, and association with perioperative complications. Data was analyzed with descriptive statistics. For 587 benign hysterectomies, 182 (31%) preoperative EKGs were performed. EKG was indicated in 166 (28%) patients according to institutional criteria and 177 (30%) patients per NICE criteria, with 91% institutional and 97% NICE guideline compliance. Of institutional criteria, obesity was the most common indication in 124 (68%) patients (median BMI 33 kg/m2; SD ± 6.8), followed by hypertension in 120 (66%) and hyperlipidemia in 33 patients (18%). Additional indications were: age 60 or above (20; median age 46 years; SD ± 8.6), type 2 diabetes (40), renal disease (4), and alcohol/drug use (42). No patients had radiation/chemotherapy in the last 3 months or used digoxin. EKGs indicated per NICE criteria included those for age 65 or above (8), ASA 2 (145), and ASA 3 (28). Findings were normal in 93 (51%) and abnormal in 89 (49%) of 182 EKGs. Of 17 patients with an abnormal review of systems or cardiac exam, 10 (59%) were found to have EKG abnormalities. Positive results included: 42 (47%) voltage (i.e., ventricular hypertrophy, heart blocks), 35 (39%) ischemic (i.e., S and T wave changes), 22 (24%) rate (i.e., tachycardia, bradycardia), and 12 (14%) rhythm (i.e., sinus arrhythmia, ectopic foci) abnormalities. Further work up was pursued in 16 of 89 patients (18%) with abnormal EKGs through repeated EKG (6), additional cardiac testing (7), and specialist consultation (7). Two surgical delays of 1 and 4 months occurred as a result of additional work up ordered for abnormal EKG. Two perioperative complications were noted. Surgery was aborted after post-induction ischemic EKG changes in a patient with minimal ventricular hypertrophy voltage criteria on preoperative EKG. A second patient with airway edema failed extubation, with preoperative EKG showing a non-acute inferior infarct. Despite excellent compliance with guidelines, preoperative EKG offers little clinical utility in terms of modifying perioperative risk. Preoperative EKG, regardless of result did not change management nor impact perioperative complications.

Takotsubo Cardiomyopathy Mimicking Stent Thrombosis After Percutaneous Coronary Intervention.

Takotsubo cardiomyopathy, also known as “broken heart syndrome,” is a transient left ventricular dysfunction associated with stress (usually emotional) induced myocardial injury and stunning. It often presents as myocardial infarction on surface electrocardiogram (EKG). Diagnosis is made by coronary angiography, which rules out coronary artery disease and shows pathognomonic apical ballooning. In this article, we present a case of a 72-year-old woman who initially presented with an ST segment elevation myocardial infarction on EKG. Coronary angiography showed severe left anterior descending artery and diagonal lesions requiring percutaneous coronary intervention. Post–percutaneous coronary intervention, EKG changes resolved. The next day, the patient developed recurrent chest pain and her EKG showed diffuse T-wave inversion in precordial leads with reemerging ST segment elevations concerning for stent thrombosis. The patient underwent repeat emergent coronary angiography, which showed patent stents and findings consistent with takotsubo cardiomyopathy.

Simultaneous Massive Coronary Air Embolism and Intraprocedural Stent Thrombosis

Massive coronary air embolism and intraprocedural stent thrombosis are a very infrequent but live-threatening complications of coronary interventions. The simultaneous occurrence of both have never been published yet. In this case report, 50-years-old male, with prior history of dyslipidemia is presented. Coronary air embolism is a rare complication of cardiac catheterization with a known incidence of 0.1% to 0.3% of all the procedures. This case exemplifies that the strategy of using directly a guiding catheter previous the contralateral diagnostic angiography if the EKG changes are manifest, is valid.

When an arterial blood gas analysis can save an unnecessary cardiac catheterization

Introduction: Diabetic Ketoacidosis can mimic electrocardiogram (EKG) changes of myocardial ischemia or infarction. The EKG changes of myocardial ischemia or infarction usually disappear after resolution of metabolic and electrolyte changes of DKA. We present a case in which a timely arterial blood gas analysis (ABG) prevented an unnecessary cardiac catheterization.

A Rarer Case of Spontaneous Coronary Artery Dissection causing Acute Coronary Syndrome in a Puerperal Woman: Case Report

Chest pain is one of the most common complaints of patients presenting to the emergency room department. There are many causes of chest pain and providers must always consider acute coronary syndrome (ACS). Spontaneous coronary artery dissection is a very rare cause of ACS but providers must consider this possibility in younger patients without risk factors or a history of coronary artery disease. This rare phenomenon is commonly associated with pregnant women or those in the postpartum period. This is a case report study describing a classic scenario of a postpartum female in her early 30s who presented with spontaneous coronary artery dissection. Providers obtained the usual tests of an electrocardiogram (EKG) and blood work. She then had a heart catheterization performed. The patient was conservatively managed through use of medications without any use of invasive measures. The patient also had other images of the chest taken to rule out other causes of chest pain such as pneumothorax and pulmonary embolism. There were EKG changes noted, as well elevated troponin levels suggestive of heart damage. The heart catheterization results showed coronary artery dissection involving the artery that correlated with the EKG changes. Spontaneous coronary artery dissection is a rare phenomenon that can present as ACS. Pregnant and postpartum women are at higher risk to develop this condition. It is essential to consider this condition along with other causes of chest pain.

Fluoropyrimidine-induced cardiac toxicity: challenging the current paradigm.

Fluoropyrimidine chemotherapy [5-fluorouracil (5-FU) and capecitabine] are commonly used agents in the treatment of various solid malignancies. However, their use has been limited by cardiac toxicity, presenting as a wide spectrum of asymptomatic (e.g., EKG changes) and symptomatic (e.g., chest pain) manifestations related to coronary vasospasm leading to myocardial ischemia. Historically, patients with suspected coronary vasospasm have been treated with traditional acute ischemic workup and various combinations of anti-anginal therapies. In addition, most patients typically are not rechallenged with fluoropyrimidine after experiencing initial cardiovascular side-effects with resulting interruption of planned chemotherapy regimens. We report a case series of 11 consecutive patients in a single-center with suspected fluoropyrimidine-induced coronary vasospasm who were successfully rechallenged with the culprit drug to allow for planned chemotherapy completion. Our protocol utilized rechallenge with bolus infusional regimen of intravenous fluoropyrimidine chemotherapy and oral capecitabine with cardioprotective pretreatment with two calcium blockers and long-acting oral nitrate therapy. We were successfully able to continue and complete the previously planned first-line chemotherapy regimen for all 11 patients with minimal therapeutic interruption. There have been no cardiac events or evidence of recurrent coronary spasm after completion of therapy with discontinuation of prophylactic medications upon therapy completion. We report a single-institution experience of successful rechallenge with fluoropyrimidines with careful cardiac monitoring and the combined use of calcium channel blockers and long-acting nitrates. With further study, this algorithm can be used to safely continue fluoropyrimidines, a potentially curative regimen in the treatment of many solid tumors.

Evaluating the Risk of Viral Myocarditis following Influenza Infection among Hospitalized Patients during 2014–2015 and 2015–2016 Influenza Seasons

BackgroundMyocarditis is a severe cardiovascular complication of influenza infection that is often fatal and underdiagnosed. We evaluated the epidemiology of influenza myocarditis (IM) among inpatients at one institution.MethodsWe performed a retrospective cohort study of inpatients harboring influenza virus by reverse transcription-polymerase chain reaction from respiratory specimens between 2014 and 2016. We collected demographic, treatment, strain-typing, and hospitalization data for all patients. Definitive IM was proven by histopathology or viral isolation from myocardial tissue. Probable and possible IM were based on CDC and predefined clinical criteria, respectively. We used the chi-squared test to compare characteristics between 2014–2015 and 2015–2016 influenza seasons and the subset of patients with cardiovascular complications.ResultsWe identified 757 patients with influenza in 2014–2015 (n = 453) and 2015–2016 (n = 304). Baseline characteristics including gender, influenza type, and co-morbidities were similar between seasons except for more white and cardiovascular disease (P <0.005) in 2014–2015. Overall, five (0.7%) (2014–2015 = 4, 2015–2016 = 1) had probable IM. Median age was 65 years (range 29–87) and median length of stay was 4 days (range 4–15). All had EKG changes, one had increased heart size without effusion requiring ICU stay and intubation. Four received oseltamivir, and all survived.Possible IM occurred in 39 patients (5%) based on new EKG changes (58%), troponin elevation (38%) and pericardial effusion (2%). These patients were older (median 81 years, range 29–91) with longer length-of-stay (median 8 days, range 1–41). Oseltamivir was given to 30/39 (77%). Death occurred in 5/23 patients with EKG changes and 3/15 with troponin elevation.ConclusionIM was rare during the past two influenza seasons with no attributable mortality at our institution. Eight-fold more patients with IM were detected using a priori criteria when compared with CDC criteria with substantially higher mortality. This may represent a high-risk subset for whom future studies are needed to improve IM diagnosis and prevent morbidity and mortality.Disclosures All authors: No reported disclosures.