EKG Changes Research Articles

Left ventricular dysfunction causing ischemia in patients with patent coronary arteries.

New onset of heart failure (HF) is an indication for the assessment of coronary artery disease. The aim of this study was to clarify the mechanistic causes of new onset HF associated with ischemic electrocardiograph (EKG) changes and chest pain in patients with patent or minimally diseased coronary arteries. Twenty consecutive patients (Group A) were retrospectively reviewed if they had an history of new onset of HF, chest pain, electrocardiographic changes indicating ischemia (ST depression or T wave inversion in at least two consecutive leads and a negative coronary angiogram [CA]) and did not require percutaneous coronary intervention or coronary artery bypass grafting. A 1:1 matched cohort (Group B) was adopted to validate the results. All patients had a negative CA. The majority of subjects in Group A had a higher left ventricular end diastolic pressure (LVEDP) when compared to the control group (p<0.05). Similarly, the aortic diastolic (AOD) pressure was lower in Group A than in Group B (p<0.05). In patients with elevated LVEDP and low AOD, with a coronary perfusion pressure (CPP) <20 mmHg, deep T wave inversion in two consecutive leads were more frequently observed. When the CPP was between 20-30 mmHg, a mild ST depression were more frequently recorded (p<0.05). Conversely, when the CPP was >30 mmHg, only mild non-specific ST-T changes or normal EKG were observed. In patients with HF and EKG changes suggestive of ischemia in at least two consecutive leads, a lower AOD could aggravate ischemia in patients with elevated left ventricular end diastolic pressure.

Feasibility, symptoms, adverse effects, and complications associated with noninvasive assessment of coronary flow velocity reserve in women with suspected or known coronary artery disease.

Microvascular coronary impairment, defined as reduced coronary flow reserve, represents the predominant etiologic mechanism of ischemia in women with chest pain and no obstructive coronary artery disease. Transthoracic echocardiography (TTE) is a noninvasive method for assessing coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD). The purpose of this investigation was to define the safety profile, feasibility, adverse events, and rate of complications of the test in women with suspected CAD. We evaluated CFVR in LAD with TTE during adenosine infusion in 1455 women aged 66.4±11.9years. A complete CFVR study was achieved in 1429 pts (feasibility 98.2%), the test being performed also in the early phase of acute coronary syndrome and on obese patients. Minor symptoms or adverse effects occurred in 43.7% of patients not requiring test termination: hyperpnea (16.7%), flushing (9.4%), atypical chest pain (9.9%), headache (6.6%), minor arrhythmias (2.9%), chest pain with EKG changes (1.5%) were the symptoms reported. No major complications were observed. Noninvasive assessment of CFVR in LAD by TTE is a very feasible method with very low incidence of adverse events and complications in women with suspected or known CAD. It is safe and can be used when evaluating female patients with atherosclerotic LAD disease or with coronary microvascular impairment.

Abstract 451: Beta Blocker Use in Asymptomatic Patients with Sepsis and Elevated Troponin is Associated with Lower Risk of Mortality

Background: In septic patients with elevated Troponin (e-Tn) levels, beta-blockers (BB) are usually avoided to prevent chronotropic incompetence. We examined the unclear association of BB at discharge with mortality in patients with sepsis and e-Tn levels. Methods: We assessed 936 consecutive patients with e-Tn levels and sepsis on admission. Those with septic shock were excluded. BB use was determined by their presence at the time of discharge. Cox proportional hazard models adjusted for demographics and clinical covariates examined the association of BB use with all-cause mortality. Results: 417 (44.6%) were on BB therapy with mean peak Tn level of 1.0 ± 0.09 ng/ml. Over a median follow-up of 5 years, 108 (36.5%) versus 236 (40.3%) deaths were reported in the BB versus the non-BB group respectively. On adjusting the Cox model for demographics, peak Tn, baseline cardiovascular disease risk factors, use of anticoagulants, antiplatelet and statins during hospitalization and discharge, BB use associated with a lower risk of mortality (HR 0.72; 95% CI 0.58-0.90, p = 0.004). In addition, BB use had a significant interaction with ischemic EKG changes (interaction p = 0.049) leading to a lower risk of mortality among patients without ischemic EKG changes (HR 0.66; 0.51-0.84, p = 0.0008 vs. HR 1.33; 0.75-2.36, p = 0.32, Figure 1). Conclusions: In septic patients with e-Tn levels, use of BB on discharge led to a lower risk of mortality and the protective effect was more pronounced in patients without ischemic EKG changes. Future research should focus on its protective mechanism and its use in septic patients with e-Tn in a randomized trial.

Prevalence of Cardiac Arrhythmias in Hypothyroid and Euthyroid Patients.

The thyroid functions as a regulator of cardiac function and rhythm through genomic and nongenomic actions of triiodothyronine (T3) in cardiac myocytes. Atrial fibrillation is a common complication of thyrotoxicosis. Hypothyroidism is not considered a risk factor for arrhythmias despite well-known EKG changes in this condition. This case control study was conducted to analyze the differences, if any, in the prevalence of cardiac arrhythmias between hypothyroid patients and euthyroid controls. Three hundred and four consecutive patients admitted at our medical center for a period of one year were included in the study. The study population was divided into 2 groups (age, gender and race matched): patients with hypothyroidism and euthyroid subjects as a control group. Major arrhythmia data were obtained from telemetry recordings and from known past medical history. There were 152 subjects in each arm of the study. The mean age was 61.9 years. Mean TSH in hypothyroid group was 40.4 mIU/l (95% CI 33.3-47.5) (range 10.09-304, SE 3.62) and in euthyroid group was 0.89 mIU/l (95% CI 0.82-0.96). Chi-square analysis revealed a higher prevalence of ventricular tachycardia (p=0.04) and any ventricular arrhythmia in the hypothyroid group (p=0.007). This relatively large case control study revealed a statistically higher prevalence of ventricular arrhythmias in hypothyroidism. Our study has thrown light on the prevalence of arrhythmias in hypothyroidism and the observation of increased ventricular arrhythmias necessitates future large scale prospective studies to better define the risk of such ventricular arrhythmias and the effects of thyroid supplementation on this risk.

Human Electrical Muscular Incapacitation and Effects on QTc Interval.

Human Electrical Muscular Incapacitation (HEMI) is used to subdue combative individuals. Changes in cardiac electrical activity have been proposed as the cause of death in a small fraction of these individuals. The current study sought to determine whether changes in QTc interval occur after HEMI exposure. Twenty-four participants had EKG readings before a 5-second HEMI exposure and within 30 min after exposure. All subject EKGs were read by a data-blinded cardiac electrophysiologist who calculated a QT corrected (QTc) interval. QTc interval was calculated using Bazett method. QTc prolongation was defined as >430 ms and a threshold of 30 ms for identifying QTc lengthening. Five participants experienced QTc prolongation and six had QTc lengthening. One participant developed QTc prolongation exceeding 500 ms, which carries a risk of developing multifocal ventricular tachycardia. These results suggest that HEMI exposure may cause EKG changes with a risk of ventricular tachycardia.

Association of Non-alcoholic Fatty Liver Disease with Conduction Defects on Electrocardiogram.

Background: Non-alcoholic fatty liver disease (NAFLD) is a leading cause of liver disease in developed countries. The association of NAFLD with conduction defects is unknown. The aim of our study was to find whether an association exists between conduction defects and NAFLD.Methods: This is a case-control retrospective study of 700 patients admitted to Orange Park Medical Center, Orange Park, Florida from 2009 to 2015. Patients with a history of alcohol use, congenital heart disease, infiltrative malignancy, and myocarditis were excluded from the study. NAFLD was diagnosed by detection of hepatic steatosis on abdominal ultrasound or computerized tomography (CT) scan. Electrocardiograms (EKGs) were performed on all 700 patients and were interpreted by a cardiologist. Univariate logistic regression was used to assess the association between NAFLD and the variables of demographics, clinical characteristics, medicine use, EKG changes, and conduction defects, while multivariate logistic regression with backward elimination method was performed to determine if NAFLD is one of the most important risk factors for conduction defects.Results: The study population included 408 patients with NAFLD and 292 patients with No-NAFLD. A total of 155 conduction defects occurred in 140 patients; conduction defects included 25.7% (36) patients with first degree block, 2.1% (three) patients with Mobitz type 1 block, 41.4% (58) patients with right bundle branch block (RBBB), 17.9% (25) patients with left bundle branch block (LBBB), 11.4% (16) patients with bifascicular block, and 12.1% (17) patients with nonspecific intraventricular block. Multivariate logistic regression with backward elimination method identified six risk factors for conduction defects; these included NAFLD (odds ratio (OR) 2.38; 95% confidence interval (CI) 1.51-3.73, p<0.0001), hypertrophy (OR 2.52; 95% CI 1.57-4.05, p=0.0001), congestive heart failure (CHF) (OR 3.05; 95%CI 1.46-6.38, p=0.0031), male sex (OR 1.79; 95%CI 1.19-2.69, p=0.0051), diabetes mellitus (OR 1.63; 95% CI 1.08-2.47, p=0.02), and age (OR 1.04; 95% CI 1.02-1.06, p<0.0001).Conclusion: NAFLD is associated with conduction defects. Prospective randomized trials are needed to demonstrate that NAFLD causes conduction defects.

Abstract P240: Clinical Outcomes in Patients With Takotsubo’s Cardiomyopathy Who Have Undergone Cardiac Catherterization at Presentation vs. Those Who Have Not: A Two Community Based Hospitals Experience

Background: Diagnosis of Takotsubo’s Cardiomyopathy (TC) remains a challenge due to similar presentation to acute coronary syndrome. Coronary catheterization (CC) proven clean coronaries is important to diagnose TC. However, it is not uncommon that CC is occasionally delayed due to unstable medical condition and/or high risk for CC. We hypothesized that patients with TC had similar outcomes whether they underwent CC at presentation or were diagnosed using non-invasive imaging techniques. Methods: Retrospective chart review of data from Memorial Hospital of Rhode Island and Kent Hospital, two community based hospitals, from June 2008 to March 2016 was done. Thirty nine adult patients &gt; 18 years of age admitted to the intensive care unit or medical floor with chest pain, shortness of breath, elevated troponin, EKG changes, and new non-regional wall motion abnormalities or reduce ejection fraction, with suspected TC were enrolled. Patients were divided into 2 groups based on diagnostic approach of TC: Baseline echo findings suggestive of TC with EF improvement at follow up (non-CC) vs. clean coronaries by CC. Outcomes of the two groups were compared using Chi-square analysis, analysis of variance (ANOVA) and Mann-Whitney Test appropriately. Results: Out of 39 patients, 20 underwent CC while 19 did not. Mean age was not different between the 2 groups (69.1±11.8 vs. 62.4±14.0, p= NS) but CC group had more females (95 %, 19 of 20 vs 68.4%, 13 of 19; p=0.031). Most common chief complaint at the time of admission in both groups was shortness of breath (60.0%, 12 of 20 vs 68.4%, 13 of 19; p=0.548). Admission heart rate was significantly higher in non-CC vs. CC patients (102.3± 19.3 vs 85.4±85.4; p=0.007). Third troponin was higher in non-CC group (1.926 ± 2.667 vs 0.775± 1.378, p=0.017). All other admission and in-hospital findings and drug management in both groups were similar. Both CC and non-CC groups had comparable outcomes: intubation (15%, 3 of 20 vs 21.1%, 4 of 19) , heart failure (21.2 %, 4 of 20 vs 15.8%, 3 of 19), shock (0 %, 0 of 20 vs 5.3% 1 of 19 ), stroke (5 %, 1 of 20 vs 0%, 0 of 19), death (5.3 % 1 of 20 vs 5.3% 1 of 19 ), recovery (65%,13 of 20 vs 52.9 % 10 of 19) p=NS for all. ICU admission (42.1%, 8 of 20 vs 52.6%, 10 of 19; p=NS) and length of stay (8.21±7.82 days vs 5.75±5.67 days; p=NS) was not significantly different between the 2 groups. Both groups showed analogous improvement in ejection fraction (21.92 ± 13.96 vs 20.63 ± 13.21; p= 0.835) on a follow up Echo done within 2 weeks to 6 months. Conclusion: This study shows no difference in outcomes between TC patients diagnosed with CC or TTE on admission. However, CC should still be done on admission for diagnosis of TC until large non-invasive diagnostic imaging modalities (such as myocardial perfusion echocardiogram) trials show high specificity for diagnosis of TC.

IMPACT OF ELECTROCARDIOGRAM CHANGES ON MORTALITY IN ASYMPTOMATIC PATIENTS WITH SEPSIS AND ELEVATED TROPONIN

Background: The role of EKG changes among septic patients with elevated troponin (e-Tn) without symptoms is not clear. We hypothesized that ischemic changes on EKG are associated with mortality in septic patients with e-Tn. Methods: We examined 936 consecutive patients with e-Tn and sepsis on

Left Ventricular Free Wall Rupture and Contained Pseudoaneurysm Formation in a Patient with Prior Coronary Artery Bypass Graft

An 87-year-old male with prior coronary artery bypass grafts (CABG) presented to hospital with a NSTEMI and peak TnI 7.6 μg/L. A drug-eluting stent was placed in the mid left anterior descending artery beyond the anastomosis of the left internal mammary artery graft. He was discharged at day 5, his echocardiogram showing akinesis of his anterolateral wall. Three days later the patient developed sudden chest pain after heavily exerting himself lawn-mowing. On arrival, his pain had resolved spontaneously, he was haemodynamically stable with no new EKG changes but TnI was 15 μg/L. Repeat coronary angiography excluded in-stent thrombosis, no ventriculogram was performed. He remained asymptomatic but on day 3 repeat echocardiogram revealed a new cavity adjacent to the left ventricle (LV) with bi-directional doppler flow. CT coronary angiogram defined a contained free wall rupture of the LV measuring 10 × 9x4.3 cm. LV free wall rupture is an uncommon but life threatening complication of ST-elevation myocardial infarction. While there are case reports describing ‘oozing’ or sub-acute rupture, we can find no case reports detailing an asymptomatic free wall rupture with an organised cavity in the setting of recent NSTEMI and previous CABG. We hypothesise that chronic adhesions between the epicardium and parietal pericardium from prior CABG formed a pseudoaneurysm preventing haemodynamic compromise. In unstable patients, urgent surgical intervention is usually the only feasible option. Our patient had been haemodynamically stable with no further chest pain following re-presentation. Following detailed multi-disciplinary team discussions with the patient his informed decision was to decline surgery.

PS 05-42 THE USEFULNESS OF HEART RATE AND BLOOD PRESSURE RECOVERY IN DIAGNOSIS OF CORONARY ARTERY DISEASE IN HYPERTENSIVE WOMEN WITH SUSPECTED CORONARY ARTERY DISEASE

Objective: In women, the evaluation for cardiac autonomic dysfunction may improve the diagnostic accuracy of exercise treadmill test (ETT). But cardiac autonomic dysfunction is frequently impaired in hypertension and the diagnostic usefulness in hypertension has not been evaluated. We investigate whether the additional assessment of autonomic functional parameters to ischemic EKG changes on ETT would improve the diagnostic accuracy for coronary artery stenosis (CAS) in female hypertensive patient with suspected CAS. Design and Method: 144 female hypertensive patients (mean age 62.2 ± 9.3) from a KoROSE registry were analyzed. The definition of significant CAS was >50% luminal narrowing of at least one coronary artery by coronary angiography. All patients underwent a symptom-limited treadmill exercise test. Ischemic ST changes were defined as > 1 mm of horizontal or down-sloping depression 80ms after the J point in 2 contiguous leads. Autonomic dysfunction was assessed by heart rate recovery (HRR) and blood pressure response (BPR) after exercise. Delayed HRR was defined as < 18 /min decrease at 1minute after exercise termination. Delayed BPR was defined as systolic blood pressure > 178 mmHg at 2 minute after exercise. Diagnostic accuracy was calculated. Results: Significant CAS was detected in 51 patients (35.4%). Sensitivity, specificity, PPV and NPV of ischemic EKG for prediction of CAD were 44%, 74%, 48% and 71% respectively. But after adding delayed HRR and BP to ischemic ST change, sensitivity and NPV was increased to 73% and 78%, respectively. But specificity and PPV was significantly decreased to 46% and 54%, respectively. And overall diagnostic accuracies were not different between 2 examinations (63.1% and 60.8%). Conclusions: The addition of delayed HRR and BPR after exercise improved the sensitivity but worsened specificity of ETT to detect CAS in hypertension. This findings suggests that impaired cardiac autonomic function was related with decreased myocardial perfusion caused by myocardial fibrosis or diastolic dysfunction, rather than fixed epicardial coronary stenosis

In Vivo Porcine Model of Venous Air Embolism During Pars Plana Vitrectomy

Venous air embolism (VAE) during pars plana vitrectomy (PPV) can occur owing to improper positioning of the infusion cannula in the suprachoroidal space and may lead to sudden compromise of cardiac circulation and death. This was an invivo demonstration of fatal VAE during PPV to show that air can travel from the suprachoroidal space into the central circulation. Experimental invivo surgical study on porcine eyes. Experimental PPV under general anesthesia was performed on porcine eyes (Yorkshire species) at a University Surgical Training & Education Center. Infusion cannulas were placed into the suprachoroidal space and fluid-air exchange (FAE) was started with sequential increases in infusion air pressure. Vital signs of porcine animals were continuously monitored and recorded in real time during the PPV, including end-tidal carbon dioxide (ETCO2), oxygen saturation (SaO2), intra-arterial blood pressure, electrocardiography (EKG), and transesophageal echocardiography (TEE). Intracardiac air was detected on TEE less than 30 seconds after increasing air infusion pressure to 60mm Hg. ETCO2 declined precipitously, followed by hypotension and EKG changes. Oxygen desaturation was a late phenomenon. The animal died within 7minutes of VAE. During autopsy, the heart was open under water and air escaped from the right ventricle. This invivo porcine model confirms that during the FAE in PPV, pressurized air from an infusion cannula malpositioned in the suprachoroidal space can transit through the eye to the central circulation, resulting in fatal VAE.

MY APPROACH to the use of CT in triage of chest pain in the ED

My approach to use of CT in triage of chest pain in the emergency department (ED) centers on selecting patients who would clinically benefit from coronary CT angiography (CTA) and who can undergo this exam safely while having excellent quality images. Patients who present to the ED with chest pain can benefit from coronary CTA if they have no prior history of coronary artery disease (CAD) and there is a clinical concern for a possible acute coronary syndrome (ACS). In such patients, the high-negative predictive value of CTA (495%) can be useful for rapidly ruling out any CAD and identifying individuals who can be sent home immediately and who have a very low risk of future events. However, no test is perfect for everyone. Patients who have a very low risk (ie, young patients and/or when there is a clear alternative diagnosis for their symptoms) or a high risk of an acute coronary syndrome (ie, dynamic EKG changes or elevated troponin) would not be appropriate. In addition, patients who are older (age 470 years) or who have multiple risk factors for CAD may derive greater benefit from functional testing, particularly if they are already on preventive medical therapies, and the main clinical question is if their presenting symptoms are due to ischemia and if they would benefit from coronary revascularization. In such cases, if coronary CTA is performed and a significant amount of plaque is found, it may be difficult to determine the functional significance associated with their anatomical lesions. In addition, if extensive coronary calcifications are present, this may limit the accuracy of CTA to estimate the severity of luminal narrowing.

Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review.

Background and ObjectivesHyperkalemia is a common electrolyte disorder that can result in fatal cardiac arrhythmias. Despite the importance of insulin as a lifesaving intervention in the treatment of hyperkalemia in an emergency setting, there is no consensus on the dose or the method (bolus or infusion) of its administration. Our aim was to review data in the literature to determine the optimal dose and route of administration of insulin in the management of emergency hyperkalemia.Design, Setting, Participants, & MeasurementsWe searched several databases from their date of inception through February 2015 for eligible articles published in any language. We included any study that reported on the use of insulin in the management of hyperkalemia.ResultsWe identified eleven studies. In seven studies, 10 units of regular insulin was administered (bolus in five studies, infusion in two studies), in one study 12 units of regular insulin was infused over 30 minutes, and in three studies 20 units of regular insulin was infused over 60 minutes. The majority of included studies were biased. There was no statistically significant difference in mean decrease in serum potassium (K+) concentration at 60 minutes between studies in which insulin was administered as an infusion of 20 units over 60 minutes and studies in which 10 units of insulin was administered as a bolus (0.79±0.25 mmol/L versus 0.78±0.25 mmol/L, P = 0.98) or studies in which 10 units of insulin was administered as an infusion (0.79±0.25 mmol/L versus 0.39±0.09 mmol/L, P = 0.1). Almost one fifth of the study population experienced an episode of hypoglycemia.ConclusionThe limited data available in the literature shows no statistically significant difference between the different regimens of insulin used to acutely lower serum K+ concentration. Accordingly, 10 units of short acting insulin given intravenously may be used in cases of hyperkalemia. Alternatively, 20 units of short acting insulin may be given as a continuous intravenous infusion over 60 minutes in patients with severe hyperkalemia (i.e., serum K+ concentration > 6.5 mmol/L) and those with marked EKG changes related to hyperkalemia (e.g., prolonged PR interval, wide QRS complex) as an alternative to 10 units of short acting insulin. Because the risk of hypoglycemia is increased with using large insulin doses, sufficient glucose (60 grams with the administration of 20 units of insulin and 50 grams with the administration of 10 units) should be given to prevent hypoglycemia, and plasma glucose should be frequently monitored.

Nutritional therapy leads to complete recovery of left ventricular dysfunction in anorexia nervosa: A case report

&lt;p&gt;This case highlights the cardiac complications associated with anorexia nervosa and how early recognition and treatment significantly affects overall prognosis. A few cases have been reported in literature where cardiomyopathy associated with anorexia nervosa was reported but this is the first case where adequate medical management and metabolic support lead to complete recovery&lt;/p&gt;&lt;p&gt;A young female presented to our hospital with lethargy and dehydration with EKG changes notable for T wave inversions in precordial and inferior leads. Echocardiogram showed severely reduced left ventricular (LV) function. Patient was diagnosed with anorexia nervosa and started on high calorie diet as per metabolic recommendations, ace inhibitor, beta-blockers and statin. 10 month follow up showed a significant improvement in heart function showing the reversible nature of anorexia nervosa induced cardiac dysfunction&lt;/p&gt;&lt;p&gt;Cardiac abnormalities, specifically cardiomyopathy are known in patients with Anorexia nervosa and have been attributed to the deficiency of multitude of minerals, vitamins and electrolytes. It is important to recognize that patients with anorexia can develop cardiac dysfunction and early nutrition along with medical optimization can lead to complete reversal of cardiac dysfunction. Multi-disciplinary team approach involving cardiologist, metabolic support, internist, and psychiatrist is required for appropriate care of these patients.&lt;/p&gt;

Stress Cardiomyopathy: A Case of Apical Ballooning Syndrome followed by Mid-ventricular Ballooning Syndrome as Recurrence

Stress cardiomyopathy has an association with emotional or physical stressors and is found to be more common in postmenopausal women. It has a similar presentation as acute myocardial infarction. Involvement of apex at the initial presentation and recurrence at the mid ventricular segment is rare. We describe a case of a 46 year old female with apical involvement at the initial presentation but mid ventricular involvement at the recurrence. 46 year old woman developed sharp chest pain while giving awards at an honors assembly. She was brought to the ER and was found to have a troponin level elevation without any EKG changes. Cardiac cath did not show coronary artery disease. ECHO revealed a low EF of 30 % with apical ballooning. Patient's symptoms resolved and her EF normalized on repeat ECHO. 2 years later patient developed similar symptoms. She had a troponin elevation without EKG changes. ECHO revealed mid-ventricular ballooning with a low EF. Patient's symptoms again resolved and repeat ECHO showed a normalized EF. Our patient had two different episodes of stress cardiomyopathy. Recurrence rate has been reported up to 11.4 percent in previous studies (5). This case is unique as recurrence was at different anatomic locations i.e apex followed by the mid ventricular segments. Further research is needed to understand the underlying mechanisms associated with the stress cardiomyopathy as current hypothesis do not completely explain the disease.

High frequency irreversible electroporation (H-FIRE) as a novel method of targeted cell death.

277 Background: Irreversible electroporation unlike ablation is excellent in inducing cell death via apoptosis. It, however, has disadvantages of electrical conduction via cardiac and nervous tissue. This results in requiring cardiac monitoring and general anesthesia and paralytics while performing electroporation. We hypothesized a novel high-frequency IRE (H-FIRE) system employing ultra-short bipolar pulses would obviate the need for cardiac synchronization and paralytics while maintaining measurable effect on cell death. Methods: Female swine (55-65Kg) were used. Two H-FIRE electrodes were inserted into the liver (1.5-cm spacing). In the absence of paralytics H-FIRE pulses were delivered (2250V, 2-5-2 pulse configuration) at different on times (100 vs. 200μs) or number of pulses (100 vs. 300). Next electrodes were placed across major hepatic vascular structures and H-FIRE performed. At conclusion tissue was resected and analyzed histologically. Results: 24 H-FIREs were performed (mean ablation time 275 secs). No EKG abnormalities or changes in vital signs were measured during H-FIRE procedures. In 1/24 H-FIREs minor twitching of the rectus abdominis was recorded coinciding with pulse delivery. Histologically, tissues had effective electroporation as evidenced by cell death and caspase activity. Blinded scoring was performed for necrosis and apoptosis. Areas of cell death were predictable. No significant vascular damage or coagulated/thermally-desiccated blood was detected within major vessels following H-FIRE. Conclusions: H-FIRE is a novel way of liver electroporation. It produces predictable cell apoptosis without the requirement of paralytics and alteration of electrocardiographic signals as compared to traditional electroporation, while preserving underlying vascular integrity. Its application in cancer cell death needs to be further studied, but it has a potential for clinical use in targeting tumors with minimal morbidity and associated cardiac and neurologic side effects.

ST Segment Elevation with Normal Coronaries.

Noncardiac causes should be kept in the differential while evaluating ST elevation on EKG. Rarely abdominal pathologies like acute pancreatitis can present with ST elevation in the inferior leads. Once acute coronary syndrome is ruled out by emergent cardiac catheterization alternative diagnosis should be sorted. Abdominal pathologies, like acute pancreatitis and acute cholecystitis, can present with ST elevation in the inferior leads. Treating the underlying condition would result in resolution of these EKG changes.

Abstract 20133: Not All ST Elevations Mandate Emergent Catheterization: A Case Report of Brugada Syndrome Induced by Severe Hyponatremia

Introduction: Brugada syndrome is a rare channelopathy, which is familial or sporadic in occurrence. Typical ECG findings of Brugada pattern consist of a pseudo-right bundle branch block and persistent ST segment elevation in leads V1 to V2. While fever, stressors and sodium channel blockers have been implicated in unmasking the underlying rhythm, only 2 cases of hyponatremia precipitating Brugada Syndrome have been reported to date. Here in, we report a case of a 61 y/o woman who underwent emergent cardiac catheterization after her EKG demonstrated ST elevation in the anterior leads. Eventual work up revealed Brugada Syndrome induced by hyponatremia. Case: A 61 y/o woman with a known medical history of hyponatremia from chronic alcohol abuse was found to be unresponsive at home. EKG performed by paramedics revealed ST elevation in anterior leads. Based on the EKG and the patient’s presentation, a probable diagnosis of cardiac arrest from ischemic heart disease was made and a decision for emergent cardiac catheterization was made. Catheterization revealed, mild non-obstructive coronary artery disease. The patient was transferred to ICU for further care where she continued to remain unresponsive. Initial work up revealed severe hyponatremia, with a serum sodium of 103. The rest of her electrolytes were within normal limits. Detailed review of her presenting EKG revealed that she had “coved” pattern of ST elevation in the anterior leads. Her severe hyponatremia was corrected with hypertonic saline. Subsequent EKG’s after partial correction of hyponatremia demonstrated resolution of abnormal EKG changes. Conclusion: The patient described in this case had a cardiac arrest most likely from sustained ventricular tachycardia secondary to a brugada pattern. Hence, hyponatremia should be recognized as an important etiology in the list of causes that unmask a Brugada pattern in patients with this channelopathy.

Abstract 11417: Drug Abuse and Abdominal Pain: A case of Cocaine Induced Renal and Cardiac Infarction

Introduction: A 35 year old man presented with sudden onset left-sided chest pain and left flank pain. He had known non-ischemic cardiomyopathy (EF of 40-45%), non compliant with treatment. He was in severe pain with left costovertebral angle tenderness. Initial investigations showed a WBC count of 12,000, troponin of 3.72 and a urinalysis significant for 2+ proteins but no RBCs. Initial ECG showed &lt;1 mm ST segment elevations with T wave inversions in inferior leads. Cardiac catheterization, did not demonstrate any flow limiting disease. Serial ECGs demonstrated a resolution of the aforementioned changes and his troponins trended down. Further review revealed an extensive history of cocaine use confirmed with a positive urine drug screen. Due to worsening abdominal pain, a CT abdomen with contrast was done which showed an acute segmental infarct on the upper pole of left kidney, but a CT angiogram did not show any evidence of obstructing vascular lesion or dissection. He was discharged on oral oxycodone, diltiazem and lisinopril.The patient returned in one week with exertional chest pain that was relieved with sublingual nitroglycerin. ECG on admission showed diffuse T wave inversions which improved in 6 hours. A repeat urine drug screen was positive for cocaine. Troponins peaked at 5.03. He then complained of persistent right flank pain and a repeat CT angiogram showed a new moderate-sized segmental infarct in the mid-pole of the right kidney. His pain was managed with oxycodone and he was eventually discharged home with isosorbide mononitrate, amlodipine and lisinopril. Conclusions: Renal infarcts may be sometimes missed in the absence of imaging, but must be suspected in drug users with flank pain and inferior EKG changes. In this case, it was hypothesized that renal arterial vasospasm led to the infarct; an extension of the known effect of cocaine on coronary vessels. This case highlights the importance of ruling out renal infarction as a cause for persistent abdominal pain. Identification of the cause of infarction is important, so as not to subject patients to long term anticoagulation. Guidelines for the treatment of drug induced renal infarction are lacking and the approach to such patients, as with all substance abusers, is abstinence.

Abstract 18043: Factors That Influence the Decision for Ischemic Work-up in Hypertensive Emergency

Background: Hypertensive emergencies (HE) account for 3% of emergency room hospitalizations and it is estimated that 1-2% of America’s 50 million hypertensive patients will have at least one occurrence of HE in their lifetime. Recent studies have shown that cardiac troponin-I is elevated in a third of patients with HE, however the pathophysiology and significance of this elevation is still being explored. We tried to look at different factors that influence the decision to do ischemic work up in patients with HE. Method: Patients admitted to Albert Einstein Medical Center from 01/01/2005 to 08/30/2014 with a diagnosis of HE were included in this retrospective study. Patients were divided into two groups: those who had either cardiac catheterization or stress test, and those who had no ischemic work up. Demographic and clinical variables were collected. A cumulative risk score for coronary artery disease was calculated by assigning 1 point for each risk factor. Results: There were total of 187 patients with HE of which only 37 had ischemic work up. 20 out of the 37 patients who had ischemic work up had chest pain. Of the 20 patients only 3 were found to have significant coronary artery disease. Comparisons between the demographics and clinical predictors in both groups are shown in the table. Multivariate analysis shows chest pain to independently predict which patients were more likely to receive an ischemic work up (OR=4.7; 95% CI 1.6 to 7.6; p=0.001). Conclusion: In the setting of HE, our study shows that chest pain was the only single factor that independently predicts which HE patients are more likely to receive an ischemic work up. Elevated troponins or EKG changes alone were not found to independently predict the decision to perform an ischemic work up. This may reflect the pattern of clinical practice at our center. Large multi-center studies might be needed to explore this further and also assess the clinical outcomes of this decision making process.