Elevated Cardiac Enzymes Research Articles

Obstructive coronary artery disease in patient with acute thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) affects essentially all organ systems. Myocardial injury in TTP is often attributed to microthrombi formation. We present the first case report in the literature of an...

The relationship between the cardiac enzymes elevation and stroke

Background: Stroke is one of the causes of CK, CK-MB and troponin elevation except ischemic heart disease which creates a conflict for clinicians in emergency services.

Can a foreign body migrate against natural body barriers?

Pericardial foreign bodies (FBs) are a rare cause of chest pain in children. They can reach the pericardium through several routes including direct or iatrogenic implantation, transbronchial or transesophageal migration of inhaled or swallowed FBs. We reported a case of a 4-year-old girl presenting with persistent chest pain for 1 month. The child described the pain as ‘stitching’ in nature localized on the left side of the sternum. The child presented with increased pain intensity and a new onset of fever and cough. No history of chocking or swallowing of FB and no signs of trauma or child abuse were noted. Chest radiography revealed a needle in the left side of the chest. Computed tomography scan and echocardiography were used to precisely localize the needle and exclude intracardiac extension. ECG showed elevated ST segment and cardiac enzymes were normal. Removal of the needle was carried out surgically under fluoroscopic guidance. A small portion of the needle was found intrapericardially complicated by localized purulent pericarditis. The child had uneventful recovery and was discharged from the hospital on postoperative day 3. Keywords: foreign bodies, pain, pediatrics, pericardium, thoracic surgery

Takotsubo cardiomyopathy in amiodarone-induced hyperthyroidism.

SummaryTakotsubo cardiomyopathy (TC) is an atypical, severe but reversible form of acute heart insufficiency. It typically presents with left ventricular failure, transient apical and mid-segments hypokinesis, absence of significant coronary stenosis and new electrographic abnormalities and/or elevation in serum cardiac enzymes. Although TC (‘broken heart syndrome’) has classically been associated with emotional trauma, evidence suggests that other precipitants might exist, including iatrogenic and thyroid-mediated forms. Thyroid disease is a relatively common comorbidity in TC patients. We report a case of TC in a postmenopausal female with no history of emotional trauma or other potential precipitant factors who was diagnosed with amiodarone-induced hyperthyroidism during her hospital stay. Though some case reports of thyroid-related TC exist, we are not aware of any other reported case of TC precipitated by amiodarone-induced hyperthyroidism.Learning points:TC is a relatively new, rare, transient, severe, but reversible cardiovascular condition that is characterized by an acute left ventricular cardiac failure, which can clinically, analytically and electrocardiographically mimic an acute myocardial infarction.Many precipitant factors have been described in TC, being the most classical and emotional trauma. However, thyroid dysfunction is also a significant condition frequently found in patients with TC.A hypercatecholaminergic state leading to cardiomyocyte damage has been established as the main fact of TC physiopathology. Hyperthyroidism induces an upregulation of β-adrenergic receptors.Both hyperthyroidism and hypothyroidism have been related with TC development. Most reported cases of TC involving thyroid dysfunction correspond to hyperthyroidism due to Graves–Basedow disease, but there are also descriptions with severe hypothyroidism, radioiodine treatment or thyroid surgery.Amiodarone is a class III antiarrhythmic agent widely used, and it is a well-known cause of thyroid dysfunction, which can present either with hypothyroidism or hyperthyroidism, as approximately 40 percent of the amiodarone molecule is composed of iodine.In this case, a type II amiodarone-induced hyperthyroidism was the precipitant factor of a TC in a patient with a pre-existing atrial fibrillation. Given the high prevalence of atrial fibrillation and the wide use of amiodarone, the risk of this iatrogenic effect should be taken into account.

EVALUATION OF ASPIRIN USAGE SAFETY IN CORONARY BYPASS SURGERY

Recent guidelines it is permitted to continue aspirin before coronary bypass operation (CBG) (Class I, Level B). Nevertheless, absence of randomized multicenter studies makes it possible not to follow these in routine practice as the only. Practive of aspirin discontinuation before CBG is quite common due to anticipated risks of post-surgery complications. Aim . To evaluate the safety of CBG with continued aspirin. Material and methods. For the safety assessment of aspirin before CBG, we conducted prospective randomized study. Patients with stable coronary heart disease were included, who underwent CBG with continued aspirin (aspirin group), and another group included those who had aspirin discontinued (controls). Totally, 74 patients randomized. Treatment group included 37 patients, and 37 controls. Follow-up lasted for 5 minutes. As primary endpoint, the volume of operational blood loss was taken, during the next 24 hours post-surgery. As the second endpoint, the combination was taken as any cardiovascular adverse event: cardiac death, perioperational myocardial infarction, ischemic stroke. Results. There was noted, the comparability of intraoperational blood loss in comparison groups (p=0,166). Summary blood loss in 24 hours of postoperational blood loss showed statistical significance between groups (mean difference 100 mL, 95% CI 0-110 mL, p=0,027). This amount of blood loss is clinically non-significant. In aspirin group, there were 2 cases of perioperational myocardial infarction, by cardiac enzymes elevation, not statistically significant. Conclusion . Results of the study witness for the safety of CBG operations under continued aspirin as well as discontinued at least 5 days before surgery.

Tako-Tsubo cardiomyopathy after cardiopulmonary resuscitation during emergency Cesarean section in a 28 year old patient in the 31st week of pregnancy

Objective: Tako-Tsubo Cardiomyopathy is an extremely rare, reversible cardiomyopathy. The signs and symptoms can mimic myocardial infarction, including chest pressure, dyspnea, ECG abnormalities, and elevated cardiac enzymes. Although Tako-Tsubo primarily affects postmenopausal women ages 60 – 70, rare cases in younger patients have been described. A 28 year old patient in the 31st week of pregnancy presented with fetal bradycardia on admission. An emergency Cesarean section was performed. We describe a case of Tako-Tsubo Cardiomyopathy following intraoperative cardiopulmonary resuscitation (CPR).

15 Elevated troponins and normal coronary angiogram

Introduction Elevated Cardiac enzymes are associated with high morbidity and mortality. A significant subset of patients referred to the cardiac service has raised troponin levels and normal coronary angiography. This subset is distinctive from patients with type 2 myocardial infarction (MI). It includes patients with no active medical conditions who present with clinical and electrocardiographic features similar to that of acute coronary syndrome. In this report we describe a cohort of patients, in whom the diagnosis of type 1 myocardial infarction was very likely, but subsequently had normal angiogram. Purpose of study The aim of the study is to identify a diagnostic approach for patients who display features of MI with no evidence of obstructive coronary artery pathology. Methods The study included all patients with suspected with MI (STEMI or NSTEMI) with raised troponin, abnormal ECG and normal coronary angiography who attended the PCI centre at the University Hospital Limerick between September 2015 to January 2016. All patients received the standard diagnostic pathway of acute coronary syndrome. Data collected included baseline characteristics, ECG on presentation, laboratory profile, Grace score, cardiac imaging results, recurrence of symptoms and hospital readmission over 3–6 months period. All patients included in this study had normal coronary angiogram. Result A total of 26 patients included in this study, 13 (50%) patients were men and the mean age was 51 years old. 6.7 (26.9%) patients presented as STEMI while 19 (73.0%) patients had ST segment depression on presenting ECG. Mean troponin level on admission was 285.9 ng/dl with mean Grace score of 100.04. 69% of the patients had normal EF on Echocardiogram and 11 (42%) patients had cardiac MRI (CMR) and one patient under went optical coherence tomography (OCT) during coronary angiography. Confirmed diagnosis post-appropriate investigations included acute myocarditis (34.6%), acute myocardial ischemia on CMR (15.3%), Takotsubo syndrome (7.6%), pulmonary embolus (3.8%), Hypertrophic cardiomyopathy (11.5%) and severe aortic stenosis (3.8%). 4 (15.3%) patients had recurrent hospital admission with similar presentation while 84% had experienced no further symptoms or hospital admission. Conclusion Establishing a definitive diagnosis in patients with raised troponin and normal coronary angiogram is challenging, but using imaging modalities such as CMR and OCT provides a valuable insight to guide diagnosis and management. Acute myocarditis is the most common cause of raised troponin and normal angiogram in this cohort.

Successful treatment using corticosteroids in early phase of eosinophilic myocarditis with eosinophilic granulomatosis with polyangiitis

We report the case of a 50-year-old man with eosinophilic myocarditis and bronchial asthma treated successfully with prednisolone. He was initially diagnosed with eosinophilia, and complained of acute chest pain with electrocardiographic changes and elevation of cardiac enzymes. Coronary angiography showed no atherosclerotic changes; therefore, we performed endomyocardial biopsy and started oral prednisolone therapy immediately. His general condition improved with the disappearance of eosinophilia upon treatment. He was finally diagnosed with eosinophilic granulomatosis with polyangiitis complicated by eosinophilic myocarditis. This case report highlights that eosinophilic myocarditis may occur in association with systemic disease, and early steroid therapy is essential.<Learning objective: We report the case of a 50-year-old man diagnosed with eosinophilic granulomatosis with polyangiitis complicated by eosinophilic myocarditis. This was a rare case of eosinophilic granulomatosis with polyangiitis with eosinophilic infiltration that was observed pathologically in multiple organs, including the myocardium. This case report highlights that eosinophilic myocarditis may occur in association with systemic disease, and early steroid therapy is essential.>

To Be or Not to Be … Acute Coronary Syndrome

Abstract Introduction: The association between ST segment abnormalities, elevated cardiac enzymes, and chest pain is usually a marker of acute coronary injury. However, certain other pathologies can sometimes mimic acute coronary syndromes. Case report: A 40-year-old Caucasian male, former smoker, with no other cardiovascular risk factors, presented to the Emergency Department for typical ischemic, prolonged chest pain. The ECG demonstrated inverted T waves in leads I, II, aVL, and V3 to V6. The patient presented high cardiac necrosis markers (troponin I 2.65 ng/ml). Based on these findings, the case was interpreted as non-ST segment elevation myocardial infarction, but coronary angiography excluded the presence of significant coronary lesions. The ventriculography showed an efficient left ventricle, with mild hypokinesia of the two apical thirds of the anterior left ventricular wall. Cardiac magnetic resonance imaging demonstrated areas of hypersignal on the T2-weighted imaging sequence in the left ventricular myocardium, suggestive for acute myocarditis. The patient was started on antiplatelet, beta-blocker, and angiotensin converting enzyme inhibitor, with favorable evolution. Conclusion: This case underlines the polymorphic appearance of acute myocarditis, which can often mimic an acute coronary event.

Takotsubo cardiomyopathy in a patient with dengue fever

Takotsubo cardiomyopathy is referred to a transient, stressinduced cardiomyopathy, or a transient left ventricular apical ballooning syndrome. Its postulated pathogenesis includes excess secretion of catecholamine, coronary artery spasm, or focal myocarditis. It may occur after surgery or acute medical condition such as acute emotional stress or septicemia. Association with acute dengue virus infection was rarely reported in the literature. A 72-year-old woman with hypertension and diabetes mellitus suffered from general malaise and poor appetite in recent days. She experienced cold sweating and then had an attack of syncope in the morning of admission on August 5, 2015. She denied having fever, chest tightness, productive cough, or tarry stool passage. Her electrocardiogram showed sinus bradycardia, inverted T wave changes (V3eV6), and prolonged QT interval (QTcZ 597 milliseconds; Figure 1A). Elevated cardiac enzymes including total creatine kinase, 312e341 IU/L (normal, 29e168 IU/L); creatine kinase MB form, 13.0e18.4 ng/mL (normal, <5.1 ng/mL); and hs-troponin I, 7848.8e8499.3 pg/mL (normal, <26.2 pg/mL) were noted. Non-ST-elevated acute myocardial infarction (NSTEMI) was impressed. Initially, dual antiplatelet agents (aspirin and ticagrelor) were given. However, laboratory data of blood obtained before the antiplatelet therapy revealed the following:

Flax lignan concentrate attenuate hypertension and abnormal left ventricular contractility via modulation of endogenous biomarkers in two-kidney-one-clip (2K1C) hypertensive rats

The present investigation was designed to study the effect of flax lignan concentrate obtained from Linum usitatissimum L., Linaceae, in two-kidney, one clip (2K1C) hypertension model in Wistar rats. 2K1C Goldblatt model rats were divided randomly into six groups: sham, 2K1C control, captopril (30mg/kg), flax lignan concentrate (200, 400 and 800mg/kg). Flax lignan concentrate and captopril were administered daily for eight consecutive weeks. Sham-operated, and 2K1C control rats received the vehicle. Treatment with flax lignan concentrate (400 and 800mg/kg) significantly and dose-dependently restored the hemodynamic parameters systolic blood pressure, diastolic blood pressure, mean arterial blood pressure and left ventricular functions. The flax lignan concentrate significantly restored the elevated hepatic, renal and cardiac marker enzymes in the serum. It also restored the organs weights (kidney and heart), serum electrolyte level and histological abnormalities. Furthermore, flax lignan concentrate significantly elevated the level of biochemical markers that is enzymatic antioxidants superoxide dismutase, glutathione and decreased malondialdehyde in the heart and kidney tissues. Meanwhile, we found that plasma nitric oxide and plasma nitric oxide synthase contents were significantly increased in the flax lignan concentrate-treated group, and plasma endothelin-1 and renal angiotensin-II levels were significantly lower than 2K1C hypertensive group. In conclusion, the antihypertensive and antioxidant effect of flax lignan concentrate were dose-dependent and at the highest dose (i.e. 800mg/kg) similar to those of captopril (30mg/kg). It is suggested that flax lignan concentrate reduced blood pressure by reduction of renal angiotensin-II level, inhibition of plasma endothelin-1 production, induction of the nitric oxide, nitric oxide synthase and in vivo antioxidant defense system.

CLOZAPINE-INDUCED MYOCARDITIS IN RATS: ROLE OF L-CARNITINE IN PROTECTION

Clozapine (CLZ) is an atypical antipsychotic and often used in refractory schizophrenia. The present study was carried out to investigate clozapine-induced myocarditis in albio rats and evaluate if L-Carnitine can reduce myocarditis through cardio-protective effect. The rats were divided into four groups as follows; group 1: negative control; group 2: received. 25 mg/kg/day/4 weeks of CLZ intraperitoneal (I.P), group 3: received 500 mg/kg/day/4 weeks of L-Carnitine I.P and, group 4: received 25 mg/kg/day/4 weeks of CLZ I.P plus 500 mg/kg/day L-Carnitine I.P. The rats were sacrificed on the 29th day of the experiment. Measuring serum levels of lactate dehydrogenase (LDH) enzyme, creatine phosphokinase (CPK-MB), tissue malondialdehyde (MDA), and glutathione peroxidase (GSHPx) was done. Histopathological examination of heart was performed by light and electron microscopy. The current study revealed significant statistical elevation of serum cardiac enzymes; LDH and CPK-MB in CLZ-treated group in comparison to control and significant reduction of cardiac enzymes in rats co-treated with CLZ & LCarnitine in comparison to CLZ-treated group. Significant statistical increase was observed in tissue MDA with significant reduction in tissue GSHPx in CLZ-treated group as compared to control group. Meanwhile, significant reduction in tissue MDA with significant increase in tissue GSHPx in rats co-treated with CLZ & L-Carnitine in comparison to CLZ-treated group. Histopathological changes in CLZ-treated group were showed by light microscopy and by electron microscopy. In group co-treated with CLZ & L-Carnitine, the histopathological changes were disappeared. Conclusion is that CLZ induced evident myocarditis which was partially relieved by L-Carnitine. So, L-Carnitine had cardio-protective effects in CLZ-induced myocarditis in rats

PC030. Clinical Outcomes of Open and Endovascular Abdominal Aortic Aneurysm Repair Over a 15-Year Period in the Veteran Population

Disease acuity and perioperative morbidity amongst Veterans is considered to be greater than in the general U.S. population. The reduced morbidity and mortality associated with endovascular aneurysm repair (EVAR) hold promise of improving safety of management of abdominal aortic aneurysms (AAA) in this population. We examine the outcomes of open repair and EVAR, over a 15-year period, in a Veteran population at our regional VA Medical Center. With IRB approval, a retrospective review was conducted of all patients who underwent open infrarenal open AAA repair and EVAR at a single VA hospital between 2000 and 2015. Emergency AAA repairs were excluded. Open and EVAR groups were compared. Variables reviewed include demographics, medical history, surgical details, complications (perioperative and late), and mortality. The primary end points were 30-day, 6-month, 1-year, and 2-year mortality. Survival was estimated using actuarial life-table method. During the 15-year study period, 212 patients (mean age, 71.44 years) underwent 91 open (70.37 years) and 121 endovascular (72.56 years) AAA repairs (Table). Perioperative (30-day) complications, including pneumonia, creatinine elevation, and surgical site infection, were significantly increased in the open group. Need for dialysis, graft infection, pulmonary embolism, cardiac enzyme elevation were not different between groups. Mortality was greater in the open group (3) than the EVAR group (0), but this was not statistically significant. Late morbidity was not significantly different between groups ,with exception of endoleaks and aortic enlargement after EVAR. The EVAR group had 27 (22.73%) endoleaks (7 type I and 24 type II), 20 (18.2%), and 15 (12.3%) required interventions. Our study is consistent with the national trend toward EVAR as the preferred approach for AAA repair. Overall perioperative mortality for AAA repairs (0% EVAR, 2% open) was below the national average. Mortality at 2 years was similar for the open and EVAR groups. Our study supports EVAR as a safe elective operation with low mortality and few complications in a group of patients who are characterized by greater disease acuity and elevated complication rates. With lower perioperative mortality and shorter recovery time, EVAR has become the preferred method of AAA management in the Veteran population.TableOpen repair and endovascular aneurysm repair (EVAR) in 212 patientsPerioperative complications (30-day mortality)Open repairEVARP valuen = 91 (42.9%), No. (%)n = 121 (57%), No. (%)Creatinine elevation6 (6.6)0 (0.0).003Dialysis2 (2.2)1 (0.8).38Creatine kinase elevation3 (3.2)0 (0.0).39Surgical site infection6 (6.6)2 (1.6).036Graft infection1 (1.1)1 (0.8).812Pneumonia10 (10.9)0 (0.0).001Late morbidity (>30 days) Claudication4 (4.4)10 (8.3).305 Incisional hernia5 (5.4)1 (8.2).016 Graft infection0 (0.0)0 (0.0) Erectile dysfunction4 (4.4)5 (4.1).807 AAA enlargement2 (2.1)20 (16.5).002 Migration0 (0.0)1 (0.8).008 Rupture0 (0.0)0 (0.0)Mortality 30 days2 (2.2)0 (0.0).099 6 months5 (5.4)2 (16.5).116 1 year8 (8.7)4 (3.3).081 2 years11 (12.1)6 (4.9).030 5 years24 (26.1)17 (14.0).013 10 years38 (41.8)19 (15.8)<.001Endoleak (>30 days)27 (22.73) Type I7 Type II24AAA, Abdominal aortic aneurysm. Open table in a new tab

Shopping can ruin your day…

Takotsubo cardiomyopathy is an acute, temporary heart failure characterised by apical ballooning, with a presentation of acute cardiac chest pain, elevated cardiac enzymes, and normal coronary angiogram. Anthony Young discusses the case of a patient for whom a daily activity as simple as shopping ruined her day and impacted her heart.

Anaesthesia for interventional neuroradiology

### Key points The scope of interventional neuroradiology has expanded rapidly. Conditions which were previously untreatable or only amenable to open surgical techniques are now being considered for interventional radiological management (Table 1). View this table: Table 1 Classification of interventional neuroradiological procedures Subarachnoid haemorrhage (SAH) accounts for about 5% of all strokes and may be due to congenital or acquired conditions, the most common being intracranial aneurysms. Cerebral aneurysms are present in up to 6% of the population.1 SAH requires a multi-disciplinary approach to management, at a dedicated neurosciences centre. Patients may present with sudden-onset occipital headache (‘thunder clap’). Associated features include nausea and vomiting, neck stiffness, photophobia, focal neurology, deteriorating level of consciousness, seizures, and cardiac arrest.2 Complications after an SAH include re-bleeding (5–10% in the first 72 h), obstructive hydrocephalus (incidence of 20–30% within 3 days of ictus), and vasospasm (angiographically demonstrated arterial narrowing 3–14 days after SAH). Delayed cerebral ischaemia and vasospasm may be asymptomatic and are associated with a worse outcome after SAH. The mortality rate at 7 days post-SAH is up to 40%. Other multisystem features include ECG changes (e.g. shortened PR interval, prolonged QTc interval, ST segment changes, and changes to T wave morphology), elevated cardiac enzymes, cardiogenic and neurogenic pulmonary oedema, and sodium disturbances. Patients with suspected diagnosis of SAH should have an urgent non-contrast computerized tomography (CT) scan (sensitivity of …

Focal Myopericarditis as a Rare but Important Differential Diagnosis of Myocardial Infarction; a Case Series.

Distinguishing ST-elevation myocardial infarction (STEMI) differential diagnoses is more challenging. Myopericarditis is one of these differentials that results from viral involvement of myocardium and pericardium of the heart. Myopericarditis in focal form can mimic acute STEMI in its electrocardiogram (ECG) features and elevated cardiac enzymes. Myocarditis patients may face thrombolytic related complications such as intracranial bleeding, myocardial rupture, and hemorrhagic cardiac tamponade. Furthermore, re-administration of streptokinase (a common thrombolytic agent in our country) is banned for at least six months of previous administration; however, it can save patients' lives in emergency conditions such as massive pulmonary embolism. It seems that, when dealing with a young patient presenting to emergency department with acute chest pain and ST segment elevation on ECG, we should consider focal myocarditis as an important but rare differential diagnosis of STEMI. In this report, we describe three cases of focal myocarditis, primarily misdiagnosed as STEMI.

Acute tuberculous myopericarditis mimicking acute myocardial infarction: A case report and literature review.

A number of cases of acute myopericarditis mimicking acute myocardial infarction (AMI) have previously been reported in the literature. However, to the best of our knowledge, such a case resulting from Mycobacterium tuberculosis infection has not previously been described. The present study reports the case of a 21-year-old male patient presenting with acute chest pain, in whom focal ST-segment elevation and elevated cardiac enzymes mimicked a diagnosis of AMI. However, acute tuberculous myopericarditis was diagnosed on the basis of a variety of imaging examinations, laboratory tests, as well as the changes observed in electrocardiograms (ECGs) and in the cardiac enzyme levels. The case highlights the importance of a detailed collection of medical history, comprehensive explanations of serial ECGs, thoracic computed tomography, echocardiogram and coronary angiography in the diagnosis and differentiation of acute tuberculous myopericarditis mimicking AMI.

Manual Thrombus Aspiration and the Improved Survival of Patients With Unstable Angina Pectoris Treated With Percutaneous Coronary Intervention (30 Months Follow-Up).

The clinical effect of intracoronary thrombus aspiration during percutaneous coronary intervention in patients with unstable angina pectoris is unknown. In this study, we aimed to assess how thrombus aspiration during percutaneous coronary intervention affects in-hospital and 30-month mortality and complications in patients with unstable angina pectoris.We undertook an observational cohort study of 645 consecutive unstable angina pectoris patients who had performed percutaneous coronary intervention from February 2011 to March 2013. Before intervention, 159 patients who had culprit lesion with thrombus were randomly assigned to group 1 (thrombus aspiration group) and group 2 (stand-alone percutaneous coronary intervention group). All patients were followed-up 30 months until August 2015.Thrombus aspiration was performed in 64 patients (46%) whose cardiac markers (ie, creatinine kinase [CK-MB] mass and troponin T) were significantly lower after percutaneous coronary intervention than in those of group 2 (CK-MB mass: 3.80 ± 1.11 vs 4.23 ± 0.89, P = 0.012; troponin T: 0.012 ± 0.014 vs 0.018 ± 0.008, P = 0.002). Left ventricular ejection fraction at 6, 12, and 24 months postintervention was significantly higher in the group 1. During a mean follow-up period of 28.87 ± 6.28 months, mortality rates were 6.3% in the group 1 versus 12.9% in the group 2. Thrombus aspiration was also associated with significantly less long-term mortality in unstable angina pectoris patients (adjusted HR: 4.61, 95% CI: 1.16–18.21, P = 0.029).Thrombus aspiration in the context of unstable angina pectoris is associated with a limited elevation in cardiac enzymes during intervention that minimises microembolization and significantly improves both of epicardial flow and myocardial perfusion, as shown by angiographic TIMI flow grade and frame count. Thrombus aspiration during percutaneous coronary intervention in unstable angina pectoris patients has better survival over a 30-month follow-up period.

Predictors of Elevated Cardiac Enzyme Levels in Hospitalized Patients with Atrial Fibrillation and No Known Coronary Artery Disease.

We retrospectively studied the predictive capabilities of elevated cardiac enzyme levels in terms of the prognosis of patients who were hospitalized with atrial fibrillation and who had no known coronary artery disease. Among 321 patients with atrial fibrillation, 60 without known coronary artery disease had their cardiac enzyme concentrations measured during hospitalization and underwent stress testing or cardiac catheterization within 12 months before or after hospitalization. We then compared the clinical and electrocardiographic characteristics of the 20 patients who had elevated cardiac enzyme levels and the 40 patients who had normal levels. Age, sex, and comorbidities did not differ between the groups. In the patients with elevated cardiac enzyme levels, the mean concentrations of troponin T and creatine kinase-MB isoenzymes were 0.08 ± 0.08 ng/mL and 6.49 ± 4.94 ng/mL, respectively. In univariate analyses, only peak heart rate during atrial tachyarrhythmia was predictive of elevated enzyme levels (P <0.0001). Mean heart rate was higher in the elevated-level patients (146 ± 22 vs 117 ± 29 beats/min; P=0.0007). Upon multivariate analysis, heart rate was the only independent predictor of elevated levels. Coronary artery disease was found in only 2 patients who had elevated levels and in one patient who had normal levels (P=0.26). Increased myocardial demand is probably why the presenting heart rate was predictive of elevated cardiac enzyme levels. Most patients with elevated enzyme levels did not have coronary artery disease, and none died of cardiac causes during the 6-month follow-up period. To validate our findings, larger studies are warranted.

Child with fulminant dengue myocarditis survived by ECMO support

Like many other infections, Dengue is known to cause myocarditis. Dengue myocarditis can be mild or fulminant. Fulminant myocarditis can rapidly lead to end organ damage and even death. We present here an adolescent girl suffering from Dengue infection who developed fulminant myocarditis. Myocarditis was diagnosed by presence of low left ventricular ejection fraction, shock and elevated cardiac enzymes. When she developed refractory shock (unresponsive to preload optimization, inotropes, positive pressure ventilation, colloids, myocardial protective strategies, Intravenous immunoglobulins etc.), she required emergency Veno-arterial ECMO (Extra Corporeal Membrane Oxygenation) support. On 6th day, as her condition improved, she was weaned from the ECMO. Echocardiography on follow up shows normal study and she is leading a normal life today. Hence, for patients with refractory shock caused by Dengue myocarditis, timely referral to higher centre with Extra-corporal life support facility should be considered.