Elevated Cardiac Enzymes Research Articles

Incidence and Importance of New Postoperative Right Bundle Branch Block after Pediatric Orthotopic Heart Transplantation

Purpose Studies have shown right bundle branch block (RBBB) to be the most common ECG abnormality after orthotopic heart transplantation (OHT) in adults, correlating it to higher mean pulmonary artery pressures (PAP) and poorer clinical outcomes. This has not yet been evaluated in pediatric heart transplantation. Methods and Materials We hypothesized that development of RBBB following pediatric OHT would be associated with higher postoperative mean PAP. A retrospective review was conducted of paired donor and recipient ECGs (24-72 hours post-OHT) and clinical data of all patients who had undergone OHT at our center from 2/5/2000 to 6/13/2011. Students T-test, Mann-Whitney U, Chi-Square and Kaplan-Meier analyses were used as appropriate. Results Of 97 pediatric OHT patients, 24 (25%) developed new RBBB and were more likely to be older (11.62 yrs [0.11-17.7yrs] vs. 4.87 yrs [0.5-18.6yrs], p=0.002) and have a higher BSA (1.17m² [0.35-2.07m²] vs. 0.65m² [0.21-1.83m²], p=0.001). There was no association with new RBBB and presence of donor downtime (p=0.35), graft ischemic time (p=0.11), cardiopulmonary bypass time (p=0.35), or elevated donor cardiac enzymes (p=0.62). Development of RBBB was not associated with pre-transplant recipient hemodynamics, including cardiac index (p=0.72), RVEDP (p=0.37), mean PAP (p=0.84), mean RAP (p=0.44), PVRI (p=0.89), or PCWP (p=0.68). Those with RBBB had lower mean PAP on post-OHT cath (6-15 days), both within the normal range (16.4±4.5mmHg vs. 20.2±6.7mmHg, p=0.012). No association was found with any other post-transplant hemodynamic data, evidence of rejection (8% vs. 4%, p=0.68) or ischemia on the first post-op biopsy (25% vs. 22%, p=0.78). New RBBB was not associated with in-hospital mortality (p=0.57), graft survival (p=0.25), or overall mortality (p=0.08). Conclusions While the development of RBBB is a common finding in ECGs following pediatric heart transplantation (25%), it is not associated with any known risk factors or clinical outcomes.

Recurrent Myocarditis—An Important Mimic of Ischaemic Myocardial Infarction

Patients presenting with a syndrome of chest pain, elevated cardiac enzyme levels with or without electrocardiogram changes are a common diagnostic and management problem in cardiology. Most commonly, this is due to ischaemic myocardial infarction secondary to coronary artery disease. However, when coronary angiography does not demonstrate any obstructive coronary artery lesion, the diagnosis of myocarditis should be considered. Cardiac magnetic resonance imaging is helpful towards making this diagnosis. Here, we describe the first reported Australian cases of recurrent myocarditis presenting with ischaemic chest pain and elevated cardiac enzyme levels. These cases serve as an important reminder to clinicians that myocarditis is an important mimic of ischaemic myocardial infarction.

INCIDENCE AND IMPORTANCE OF NEW POSTOPERATIVE RIGHT BUNDLE BRANCH BLOCK AFTER PEDIATRIC ORTHOTOPIC HEART TRANSPLANTATION

Purpose Studies have shown right bundle branch block (RBBB) to be the most common ECG abnormality after orthotopic heart transplantation (OHT) in adults, correlating it to higher mean pulmonary artery pressures (PAP) and poorer clinical outcomes. This has not yet been evaluated in pediatric heart transplantation. Methods and Materials We hypothesized that development of RBBB following pediatric OHT would be associated with higher postoperative mean PAP. A retrospective review was conducted of paired donor and recipient ECGs (24-72 hours post-OHT) and clinical data of all patients who had undergone OHT at our center from 2/5/2000 to 6/13/2011. Students T-test, Mann-Whitney U, Chi-Square and Kaplan-Meier analyses were used as appropriate. Results Of 97 pediatric OHT patients, 24 (25%) developed new RBBB and were more likely to be older (11.62 yrs [0.11-17.7yrs] vs. 4.87 yrs [0.5-18.6yrs], p=0.002) and have a higher BSA (1.17m² [0.35-2.07m²] vs. 0.65m² [0.21-1.83m²], p=0.001). There was no association with new RBBB and presence of donor downtime (p=0.35), graft ischemic time (p=0.11), cardiopulmonary bypass time (p=0.35), or elevated donor cardiac enzymes (p=0.62). Development of RBBB was not associated with pre-transplant recipient hemodynamics, including cardiac index (p=0.72), RVEDP (p=0.37), mean PAP (p=0.84), mean RAP (p=0.44), PVRI (p=0.89), or PCWP (p=0.68). Those with RBBB had lower mean PAP on post-OHT cath (6-15 days), both within the normal range (16.4±4.5mmHg vs. 20.2±6.7mmHg, p=0.012). No association was found with any other post-transplant hemodynamic data, evidence of rejection (8% vs. 4%, p=0.68) or ischemia on the first post-op biopsy (25% vs. 22%, p=0.78). New RBBB was not associated with in-hospital mortality (p=0.57), graft survival (p=0.25), or overall mortality (p=0.08). Conclusions While the development of RBBB is a common finding in ECGs following pediatric heart transplantation (25%), it is not associated with any known risk factors or clinical outcomes.

THIN–CAP FIBROATHEROMA CONCOMITANT WITH CALCIUM DEPOSITION IS A POWERFUL PREDICTOR OF PERIPROCEDURAL ENZYME ELEVATION DURING ELECTIVE PCI

Periprocedural cardiac enzyme elevation after percutaneous coronary intervention (PCI) occurs frequently and it is known as a predictor of adverse outcome. In this study, we studied the baseline morphological characteristics of culprit coronary plaques using optical coherence tomography (OCT), and

Troponins in Tako-tsubo Cardiomyopathy

Tako-tsubo cardiomyopathy was first described in Japan in 1990. The clinical presentation of Tako-tsubo cardiomyopathy (TCM) is similar to an acute myocardial infarction with patients having chest pain, ST segment elevations on EKG and elevated cardiac biomarkers. In TCM, however, the elevation in cardiac enzymes is usually mild. We report a case of TCM where the patient had Troponin I elevation up to 42.3 ng/ml. To the best of our knowledge, this is the first case in which such high troponins have been reported in a patient with Tako-tsubo cardiomyopathy.

Impact of Transapical Aortic Valve Replacement on Apical Wall Motion

Recent reports indicate that the transapical approach for transcatheter aortic valve replacement may be associated with elevated cardiac enzymes, poor recovery of left ventricular function, and poor outcomes. The aim of this study was to evaluate whether transapical access is associated with apical dysfunction and to assess consequences on patient outcomes. In patients undergoing transapical aortic valve replacement, apical regional function was retrospectively assessed using the three standard echocardiographic long-axis views. Patients with abnormal baseline apical motion were excluded. Apical regional wall motion abnormality was assessed on preprocedural (baseline), immediate postprocedural (early [6 ± 2 days]), and late postprocedural (late [95 ± 76 days]) examinations. Apical regional wall motion abnormalities were categorized as normal, hypokinesis, or akinesis. A total of 58 patients undergoing transapical aortic valve replacement were included in the present analysis. Of those, 16 (28%) developed early apical dysfunction. There were no differences in baseline characteristics between the patients who developed early apical dysfunction and those who did not. Patients who received 26-mm valves were more likely to develop apical dysfunction (40% vs. 69%, P = .05). In total, 50% of patients with apical dysfunction (eight of 16) had complete recovery of apical function but tended to have lower ejection fractions (50% vs. 60%, P = .045) at long-term follow-up. No difference in short-term or long-term mortality was detected in these small patient cohorts. Myocardial injury during transapical access resulted in apical dysfunction early after the procedure in 28% of patients. This apical dysfunction was transient in half of the patients and was associated with a decrease in left ventricular function but did not affect mortality.

Can family history of premature coronary artery disease be a risk factor for clinical outcomes in patients with acute myocardial infarction?

Can family history of premature coronary artery disease be a risk factor for clinical outcomes in patients with acute myocardial infarction?

Acute myocardial infarction

Organophosphorus compounds are used as pesticides and represent a common cause of poisoning in developing countries including India due to their widespread availability and use. Toxicity due to these agents can affect many organs including heart. Here, we report a case of acute organophosphorus poisoning (parathion), followed by acute myocardial infarction; documented by clinical features, electrocardiographic changes, and elevated cardiac enzymes. Myocardial infarction has been rarely reported with organophosphorus compounds exposure, thus awareness of this complication can reduce morbidity and mortality.

Isolated Left Main Coronary Artery Stenosis after Thoracic Radiation Therapy: To Operate or Not to Operate

Radiation therapy of neoplasms involving the chest or mediastinum results in a wide spectrum of cardiac complications including coronary artery disease, which can present in patients with few or no traditional cardiac risk factors. We report a case of radiation induced coronary artery disease in a 60-year-old female with a history of stage IIIA nonsmall cell lung carcinoma which was diagnosed eight years earlier and treated with chemotherapy and radiotherapy. She presented to the hospital with atypical chest pain that had occurred intermittently over the preceding week. Her initial electrocardiogram and cardiac enzymes were within normal limits. However, following an indeterminate exercise nuclear stress test, she developed chest pain and elevated cardiac enzymes. Coronary angiography demonstrated 90% stenosis of the left main coronary artery ostium, without any evidence of atherosclerotic disease or stenosis in other coronary arteries. She underwent surgical revascularization, which revealed dense adhesions surrounding the heart. During surgery, she developed severe bleeding and died. Coronary artery disease can present within years of radiation exposure, and ostial lesions are typical. Treatment is often challenging because of the effects of radiation on other tissues and the risks of revascularization procedures. Therefore, a multidisciplinary team approach should be considered.

Coronary Flow Assessment in Unstable Angina/non ST-segment Elevation Myocardial Infarction Patients via Thrombolysis in Myocardial Infarction Frame Count in Angiography.

Background:TIMI Frame Count (TFC) is one of the methods to estimate the coronary blood flow velocity. This is a simple, inexpensive, quantitative, reproducible, and continuous variable method. Many studies have been conducted on TFC assessment in ST elevation myocardial infarction (STEMI) patients.Objectives:The present study is aimed to measure the TFC in the coronary arteries of UA/NSTEMI patients to find abnormalities in diseased or patent vessels and compare with the normal values.Patients and Methods:The participants were 105 consecutive UA/NSTEMI patients who underwent coronary angiography in Shahid Rajaie Cardiovascular Medical and Research Center, Tehran, Iran in 2009. Exclusion criteria were history of CABG, PCI, or STEMI or presence of occluded arteries in angiography. We measured the coronary TFC in these patients. We examined also 55 stable patients without coronary lesions and with TIMI 3 flow to have an estimation of normal TFCs.Results:From a total of 105 patients, 25 (23.8%) had no significant coronary lesion (> 60%); 35 (33.3%) were diagnosed with single vessel disease; 22 (21%) were 2VD; and 23 (21.9%) were 3 VD.). In overall, mean TFC in UA/NSTEMI group was 28.7 (± 14) frames compared to 23.8 (± 7.8) frames in the normal group (P < 0.05). In the vessels with significant lesions, TFC was significantly higher than normal (30.84 vs. 23.8; P < 0.001) and also significantly higher than patent vessels of the same patients (30.84 vs. 26.10; P = 0.029). In these patients, patent vessels had higher TFC values compared to normal coronaries (26.10 vs. 23.8), but the difference was not significant (P = 0.12). In the patients with significant lesions, mean TFC was higher than the same value in acute coronary patients without significant lesions (29.3 vs. 27.2), but the difference was not significant (P = 0.114). In the patients who underwent PCI and stenting, TFC changed significantly after PCI toward the normal value (P = 0.001). In the patients with elevated cardiac enzymes, TFC was higher but the difference was not significant (P = 0.35).Conclusions:Patent coronaries of UA/NSTEMI patients have a trend to higher TFCs compared to normal values. Presence of significant coronary lesions in these patients significantly increases TFC.

Pericarditis in takotsubo cardiomyopathy: a case report and review of the literature.

Case. A 64-year-old Caucasian woman was brought to the emergency department with severe dysphagia and left chest pain for last 4 days. Initial evaluation revealed elevated ST segment in precordial leads on EKG with elevated cardiac enzymes. Limited echocardiogram showed infra-apical wall hypokinesia. Cardiac angiography was done subsequently which showed nonflow limiting mild coronary artery disease. Takotsubo cardiomyopathy was diagnosed and she was treated medically. On the third day of admission, a repeat ECG showed diffuse convex ST-segment elevations in precordial leads, compatible with acute pericarditis pattern of EKG. Decision was made to start colchicine empirically for possible pericarditis. Follow-up EKG in 2 days showed decreased ST-segment elevations in precordial leads. The patient was discharged with colchicine and a follow-up echocardiogram in 4 weeks demonstrated a normal ejection fraction with no evidence of pericarditis. Conclusion. Acute pericarditis can be associated either as a consequence of or as a triggering factor for Takotsubo cardiomyopathy. It is vital for physicians to be aware of pericarditis as a potential complication of Takotsubo cardiomyopathy.

A Study of Coronary Heart Disease in Postmenopausal Women and Identification of Major Modifiable Determinant Risks for its Prevention

ABSTRACT This is a retrospective study of postmenopausal women admitted with myocardial infarction (MI) in five hospitals (Nepal Medical College, Bir Hospital, Institute of Medicine, Norvic International Hospital, Medicare Hospital) having coronary care unit (CCU) in Kathmandu, Nepal, in 1 year period, from 1st Jan 2001 to 31st Dec 2001. Out of 210 cases admitted in CCU,147 (70%) were suffering from acute MI. Two of the three following criteria were used for the diagnosis of MI: characteristic substernal pain of recent origin more than 30 minutes, elevated cardiac enzymes (creatinine kinase, lactate dehydrogenase, aspirate transaminase), ECG: evidence of infarction (pathological Q waves, ST elevation more than 1 mm in standard lead 1/Avl and/or ST elevation more than 2 mm in precordial leads V1-6 followed by T wave inversion. The major identifiable modifiable risks identified are hypertension in 111 (53.8%), smoking 73 (35.0%), diabetes mellitus in 47 (23.03%), hyperlipidemia in 17 (8.1%), previous coronary heart disease (CHD) in 32 (15.2%) and family history of CHD was present in 2% of the cases. Twenty-two patients (10%) died during treatment and six patients (3%) were readmitted with repeat Ml within 6 months of the 1st Ml and all recovered well. How to cite this article Pradhan P, Upadhya AV. A Study of Coronary Heart Disease in Postmenopausal Women and Identification of Major Modifiable Determinant Risks for its Prevention. J South Asian Feder Menopause Soc 2013;1(2): 56-62.

Protective effect of Trigonella foenum-graecum Linn. on monosodium glutamate-induced dyslipidemia and oxidative stress in rats

Objectives:The present study was designed to evaluate the effect of aqueous extract of Trigonella foenum-graecum(AqE-TFG) seeds on monosodium glutamate (MSG)-induced dyslipidemia and oxidative stress in Wistar rats.Materials and Methods:Neonatal Wistar rats were treated subcutaneously with MSG (4 g/kg b.w.) from day 2 to 14 after birth, on alternate days. After attaining six-weeks of age, MSG-treated rats were administered with AqE-TFG (0.5 and 1 g/kg b.w., orally) or orlistat (10 mg/kg b.w., orally) for 28 days, respectively. Serum chemistry and relevant enzymes in hepato-cardiac tissues were assessed on day 29.Results:AqE-TFG produced significant reduction in serum total cholesterol (TC), triglycerides (TGs), lactate dehydrogenase (LDH), aspartate amino transferase (AST), alanine amino transferase (ALT), hepatic and cardiac lipid peroxides (MDA) levels and elevation in serum high density lipoprotein cholesterol (HDL-C), hepatic and cardiac antioxidant enzymes [glutathione (GSH), and superoxide dismutase (SOD) and catalase (CAT)] levels.Conclusion:Results were comparable with orlistat, a standard anti-obesity drug, and provide clear evidence that the AqE-TFG treatment offered significant protection against MSG-induced dyslipidemia and oxidative stress, and may play an important role in amelioration of the free radical generated consequences like dyslipidemia and atherosclerosis.

Stress Cardiomyopathy Associated with Diffuse Alveolar Hemorrhage after Colonoscopy

Stress cardiomyopathy (SCM) is usually precipitated by a physiologically or psychologically stressful event. Although it occurs only rarely, hypoxia- and hypercapnia-induced sympathetic activation may also cause SCM. We present the case of a 37-year-old woman affected with SCM after a routine colonoscopy. During the procedure, she aspirated residual polyethylene glycol from her stomach. Hypotension, resting dyspnea, and hemoptysis were subsequently observed. Laboratory findings revealed elevated cardiac enzymes, and a transthoracic echocardiogram revealed left ventricular (LV) global hypokinesia. She was ultimately diagnosed with diffuse alveolar hemorrhage-associated SCM. After successful treatment with a ventilator and corticosteroids, her LV systolic function and dimensions normalized and she was discharged without complications.

Periprocedural hemoglobin changes and myocardial injury in patients undergoing percutaneous coronary intervention.

Background:Patients undergoing percutaneous coronary intervention are at serious risk of different complications such as periprocedural bleeding that can lead to myocardial injuries. Blood loss through puncture site hematoma formation and through catheter aspiration causes periprocedural hemoglobin drop.Objectives:Although percutaneous coronary intervention is an effective treatment of coronary artery disease, it seems necessary to investigate the impact of complications on outcomes including myocardial infarction and possible mortality. The purpose of this study was to evaluate the relationship between periprocedural hemoglobin levels and cardiac enzyme changes as a predictor of cardiac adverse outcomes in patients undergoing percutaneous coronary intervention.Patients and Methods:This study was conducted on 1012 consecutive patients with a diagnosis of coronary artery disease who underwent percutaneous coronary intervention. Hemoglobin levels were measured immediately before and post-procedurally and based on the baseline levels the patients were classified into anemic and non-anemic groups. The samples for TnI and CP-MB were collected before the procedure and at 8, 16, and 24 hours post-procedurally. The patients were stratified into three categories of myocardial injuries: patients with CK-MB ≥ 3×; those with TnI > 0.06 µu/l and individuals with both CK-MB ≥ 3× and TnI > 0.06 µu/l.Results:All categories divided by cardiac enzyme status either in positive or in negative groups were classified in non-anemic group. Although in all groups hemoglobin level decreased post-procedurally, in the second category (TnI ≥ 0.06) the positive patients had significantly lower hemoglobin amounts after the procedure (P = 0.008).Conclusion:Post-procedure hemoglobin dropping may be considered as a predictor of cardiac adverse outcome in patients undergoing PCI. We suggest that a good bleeding control during and after the procedure can reduce the risk of cardiac enzyme elevation post-procedurally.

Paroxysmal ventricular tachicardia and pure right insular stroke

Zini, Andrea; Fioravanti, Valentina; Ferraro, Diana; Casoni, Federica; Cavazzuti, Milena; Nichelli, Paolo Author Information

Massive pulmonary embolism with ST-elevation in the inferior leads and other interesting ECG findings

Introduction: Pulmonary embolism is associated with many ECG findings, most of which are non-specific and most can be explained by the sudden severe increase in the right ventricular afterload leading to dysfunction, hypoperfusion, dilation and in rare very severe cases to ischemic injury. Many case reports described patients presenting with massive pulmonary embolism and very rare atypical ECG findings especially ST-segment elevation in the anteroseptal leads (V1-V4). Case presentation: We present a case of a 73-year old African American male who suffered from a massive pulmonary embolism with interesting ECG findings mainly ST-segment elevation in the inferior leads mimicking Inferior wall myocardial infarction. To our knowledge, this is the first case of ST-elevation in the inferior leads in the setting of a massive PE. Conclusion: The most likely explanation to the case is that the associated cardiac injury is multifactorial. Severe right ventricular dilation with significant increase in wall tension and oxygen consumption, sudden coronary hypoperfusion caused by the sudden drop in the right and left ventricular output, hypoxia caused by the massive PE and finally possible coronary spasm caused by hypoxia and increased right heart pressure might all have contributed to inducing the acute right ventricular ischemia which showed as ST-segment elevation in the inferior leads and an elevation in cardiac enzymes.

Prognostic value of creatine kinase‐myocardial band isoenzyme elevation following percutaneous coronary intervention: A meta‐analysis

To assess whether different degrees of creatine kinase-myocardial band isoenzyme (CK-MB) elevation after percutaneous coronary intervention (PCI) affect the subsequent risk of death. While there is consensus that extensive cardiac enzyme elevation increase mortality significantly, there is uncertainty about the exact clinical impact of smaller CK-MB elevations after PCI. The published literature was scanned by formal searches of electronic databases such as PubMed and MEDLINE from January 1999 to October 2011. Risk ratio (RR) was used as summary estimate. Ten studies have been included totaling 48,022 patients who underwent PCI (12,246 patients with CK-MB elevation and 35,776 patients without CK-MB elevation). Mean followup duration for each study ranged from 6 to 48 months. CK-MB elevation >1× the upper limit of normal (ULN) conferred a significant increase in the risk of mortality with an overall RR of 1.74 (95% confidence interval [CI], 1.42 to 2.13, P < 0.001). Compared with patients without CK-MB elevation, there was a dose-response relationship with RR for death being 1.48 (95% CI, 1.25-1.77, P < 0.001) with CK-MB elevation 1 to <3× ULN, 1.71 (95% CI, 1.23-2.37, P = 0.001) with CK-MB elevation 3 to 5× ULN, and 2.83 (95% CI, 1.98-4.04, P < 0.001) with CK-MB elevation ≥ 5× ULN. Even a small increase in CK-MB levels after PCI is associated with significantly higher risk of late mortality. Monitoring cardiac enzymes after PCI may help predict the long term clinical outcome.

Morpho-functional imaging of a rare case of tako-tsubo syndrome in a young pregnant woman

We report the case of a pregnant patient who developed the typical pattern of tako-tsubo syndrome after delivery (i.e., electrocardiographic changes, elevated cardiac enzymes, and no evidence of coronary stenosis). SPECT imaging showed myocardial perfusion defects and altered motility, which reversed 6 months later.

Postpartum spontaneous coronary artery dissection: A rare occurrence

Postpartum spontaneous coronary artery dissection is a rare but well described presentation of acute coronary syndrome. Acute phase mortality is 5-10%. The majority of dissections occur within two weeks postpartum. Risk factors include advanced age, multiparity, hormonal changes, activities that increase coronary shear stress and hemodynamic factors such as hypertension, cocaine use and weight lifting. Dissections typically involve proximal segment of coronary arteries. Angiographic studies confirm etiology of postpartum MI to be: dissection 35%, stenosis 30%, thrombus 15%, spasm ＜5%, and 10% with normal coronaries. Case Report: A 30-year-old female, 10 days postpartum presented with recurrent oppressive retro-sternal chest pain, radiating to left arm and back, with or thopnea and vomiting. She reported lifting weights the day prior to admission. Apart from elevated blood pressure, physical examination was otherwise unremarkable. Diagnosis of spontaneous coronary artery dissection was confirmed through laboratory and radiographic testing which showed elevated cardiac enzymes and both an abnormal echocardiogram and angiogram, respectively. Patient was managed medically due to difficult anatomy for percutaneous coronary intervention. Conclusion: SCAD is a rare life threatening condition that affects predominantly young, healthy women, particularly during pregnancy or postpartum period. The pathogenesis is still unclear. The mechanism, however, is increased shear stress in the coronaries by severe systolic hypertension, cocaine use, activities such as snow shoveling, weight lifting. Contributing factors in our young patient with dissection causing acute MI may have resulted from: lifting weights a day earlier, underlying CAD, parity and typical age/time frame for postpartum dissection.