First-degree Block Research Articles

Combination of CHARGE AF score and index of 24-hour electrocardiogram to predict incident atrial fibrillation and cardiovascular events

Abstract Background Atrial fibrillation (AF) is associated with increased risks of stroke and heart failure. AF risk prediction can facilitate the efficient deployment of diagnosis or interventions to prevent AF. Purpose We sought to assess the combination prediction value of Holter electrocardiogram (Holter ECG) and the CHARGE-AF score (Cohorts for Aging and Research in Genomic Epidemiology-AF) for the new-onset of AF in a single center study. We also investigated the association between clinical findings and the new-onset of cerebral cardiovascular events. Methods From January 2008 and May 2014, 1246 patients with aged≥20 undergoing Holter ECG for palpitations, dizziness, or syncope were recruited. Among them, 350 patients were enrolled in this study after exclusion of 1) AF history at the time of inspection or before, 2) post cardiac device implantation, 3) follow-up duration <1 year, and 4) no 12-lead ECG records within 6 months around Holter ECG. Results During the 5.9-year follow-up, 40 patients (11.4%) developed AF incidence. Multivariate cox regression analysis revealed that CHARGE-AF score (hazard ratio [HR]: 1.59, 95% confidence interval (95% CI): 1.13–2.26, P<0.01), BMI (HR: 0.91, 95% CI: 0.83–0.99, P=0.03), frequent supraventricular extrasystoles (SVEs) ≥1000 beats/day (HR: 4.87, 95% CI: 2.59–9.13, P<0.001) and first-degree AV block (HR: 3.52, 95% CI: 1.63–7.61, P<0.01) were significant independent predictors for newly AF. The area under the ROC curve (AUC) of the combination of the CHARGE-AF score and frequent SVEs (≥1000) was greater than the CHARGE-AF score alone (0.73, 95% CI: 0.64–0.82 vs 0.66, 95% CI: 0.56–0.75, respectively). On the ROC curve, the CHARGE-AF score of 12.9 was optimum cut-off value for newly AF. Patients with both the CHARGE-AF score≥12.9 and SVEs≥1000 developed AF at 129.0/1000 person-years, compared with those with the CHARGE-AF score<12.9 and SVEs≥1000 (48.9), the CHARGE-AF score≥12.9 and SVEs<1000 (40.0) and the CHARGE-AF score<12.9 and SVEs<1000 (7.4), respectively. In multivariate cox regression analysis, age, past history of congestive heart failure and myocardial infarction, and antihypertensive medication were significant predictors of cerebral cardiovascular events (n=43), all of which signifying the components of the CHARGE-AF score. The AUC of the combination of the CHARGE-AF score and frequent SVEs (≥1000) was not different from the CHARGE-AF score alone (0.73, 95% CI: 0.64–0.81 vs 0.73, 95% CI: 0.64–0.82, respectively). Conclusion CHARGE-AF score has higher predictive power of both the new incident AF and cerebral cardiovascular events. The combination of CHARGE-AF score and SVEs≥1000 beats/day in Holter ECG can demonstrate the additional effect of prediction ability for the new incident AF, but not for cerebral cardiovascular events. Funding Acknowledgement Type of funding sources: None.

Lyme Carditis With Complete Heart Block Successfully Treated With Oral Doxycycline.

Lyme disease is a vector-borne infection that can affect multiple different organ systems. Lyme carditis represents one of these sequelae and is defined by acute onset of high-grade atrioventricular block in the presence of laboratory-confirmed infection. Current guidelines recommend patients with Lyme carditis be admitted for close cardiac monitoring and intravenous antibiotics therapy. Our case illustrates an active duty male who was initially diagnosed with Lyme disease after initially reporting symptoms including headache, fever, eye pain, and rash, with subsequent development of exercise intolerance 6 weeks later. An electrocardiogram (ECG) obtained at that time was misinterpreted as first-degree heart block, and he was initiated on oral doxycycline therapy and referred to cardiology. On follow-up to cardiology clinic, the prior ECG was reviewed and interpreted as complete heart block. A repeat ECG showed resolution of the heart block, and exercise stress testing showed chronotropic competence. This case illustrates the resolution of complete heart block in Lyme carditis with oral doxycycline, suggesting this antibiotic as a possible alternative treatment agent.

Clinical characteristics and risk of arrhythmic events in patients younger than 12 years diagnosed with Brugada syndrome.

Brugada syndrome (BrS) is an inheritable disease with an increased risk of sudden cardiac death. Although several score systems have been proposed, the management of children with BrS has been inconsistently described. The purpose of this study was to identify the characteristics, outcome, and risk factors associated with cardiovascular and arrhythmic events (AEs) in children younger than 12 years with BrS. In this single-center case series, all children with spontaneous or drug/fever-induced type 1 Brugada electrocardiographic (ECG) pattern and younger than 12 years at the time of diagnosis were enrolled. Forty-three patients younger than 12 years at the time of diagnosis were included. The median follow-up was 3.97 years (interquartile range 2-12 years). In terms of first-degree atrioventricular block, premature beats, nonmalignant AEs, malignant AEs, and episodes of syncope, no significant differences were observed either between patients with spontaneous and drug/fever-induced type 1 Brugada ECG pattern or between female and male patients (except a significant difference between female and male patients for first-degree atrioventricular block). A higher incidence of malignant AEs was observed in patients with syncope (3 of 8 [37.5%] vs 0 of 35 [0%]; P = .005) than in patients without syncope. SCN5A mutations were associated with a higher occurrence of malignant AEs (3 of 14 [21.4%] vs 0 of 25 [0%]; P = .04) compared with no SCN5A mutations. A spontaneous type 1 Brugada ECG pattern is not associated with a higher incidence of syncope, first-degree atrioventricular block, premature beats, nonmalignant AEs, and malignant AEs than the drug/fever-induced type 1 Brugada ECG pattern. Syncope events are correlated with an increased incidence of malignant AEs. Moreover, SCN5A mutations are associated with a higher occurrence of malignant AEs.

THICKEN, THICKEN, THICKEN, DROP: WENCKEBACH SECONDARY TO HYPERTROPHIC CARDIOMYOPATHY

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Wenckebach is an atrioventricular conduction disorder leading to progressively lengthened PR interval followed by dropped beats. Hypertrophic cardiomyopathy (HCM) is a genetic cardiac muscle disease characterized by left ventricular hypertrophy that can cause symptoms that are typically categorized into those from heart failure, chest pain, or arrhythmias. HCM is rarely associated with AV blocks with few case reports describing a connection. We will present a case of second degree AV block Mobitz Type I known as Wenckebach block secondary to HCM. CASE PRESENTATION: The patient is a 63-year-old woman with no significant past medical history reporting to the hospital for substernal chest pressure and lightheadedness. She was found to have symptomatic second degree AV block Mobitz Type I and was scheduled for dual chamber pacemaker. Prior to pacemaker implantation, echocardiogram was obtained that was concerning for left ventricular outflow tract obstruction and takotsubo cardiomyopathy. Left and right heart catheterization was performed that showed no significant coronary artery disease or takotsubo cardiomyopathy. Cardiac MRI was performed that showed features concerning for HCM. The patient underwent successful implantation of automatic implantable cardioverter defibrillator (AICD) with improvement in symptoms. Unfortunately, due to COVID-19 related limitations, further work up of HCM has been delayed including genetic testing. DISCUSSION: Wenckebach block is typically caused by myocardial ischemia, myocarditis, iatrogenic or cardiomyopathy of amyloidosis or sarcoidosis etiology. There is sparse literature discussing HCM causing first degree and complete heart block. Wenckebach block caused by HCM is very rare with only one other significant case found discussing the association. Once Wenckebach is discovered, a thorough work up for the underlying cause must be completed. In our case further work up via echocardiogram and cardiac MRI revealed HCM allowing for appropriate intervention with implantation of an AICD. CONCLUSIONS: Wenckebach block is rarely caused by HCM, but if obvious causes have been ruled out including myocardial ischemia, myocarditis, or iatrogenic then further work up is required. Cardiac imaging including echocardiogram and possibly cardiac MRI may be warranted to determine the underlying cause of the heart block, allowing for appropriate treatment. HCM is a rare cause of Wenckebach block, but must be considered on the differential diagnosis. REFERENCE #1: Wong TC. First-Degree Atrioventricular Block and Hypertrophic Cardiomyopathy: "I Have a Bad Feeling About This". J Am Heart Assoc. 2020 Mar 17;9(6):e015911. doi: 10.1161/JAHA.120.015911. Epub 2020 Mar 9. PMID: 32146897; PMCID: PMC7335525. REFERENCE #2: Dubey L, Guruprasad S, Bhattacharya R, Subramanyam G. Complete Heart Block in Hypertrophic Cardiomyopathy: A Rare Association. Kathmandu Univ Med J (KUMJ). 2015 Oct-Dec;13(52):372-4. doi: 10.3126/kumj.v13i4.16841. PMID: 27423292. REFERENCE #3: Konishi E, Kawasaki T, Shiraishi H, Yamano M, Kamitani T. Additional heart sounds during early diastole in a patient with hypertrophic cardiomyopathy and atrioventricular block. J Cardiol Cases. 2015 Apr 1;11(6):171-174. doi: 10.1016/j.jccase.2015.02.010. PMID: 30546559; PMCID: PMC6281973. DISCLOSURES: No relevant relationships by Anas Ahmed, source=Web Response No relevant relationships by Rebekah Lantz, source=Web Response No relevant relationships by Mark Saling, source=Web Response No relevant relationships by Steven Young, source=Web Response

EXTRA-CARDIAC SHUNT: AN UNUSUAL CAUSE OF STROKE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Embolic phenomenon, while not contributing as much as a cause as atherosclerotic disease for ischemic stroke, remains an important cause for ischemic stroke. While atrial fibrillation represents the majority of the patients in this subset, there are other less conspicuous causes. Here, we present a case of an ischemic stroke, found to be due to an isolated extra-cardiac shunt without a patent foramen ovale. CASE PRESENTATION: A 56-year-old right-handed female with no significant past medical history presented with left-sided weakness concerning for acute stroke. On admission, her National Institute of Health Stroke Scale (NIHSS) was 20. MRI showed an occlusion of the right middle cerebral artery at M1 and right carotid terminus. Dual anti-platelet therapy (DAPT) and statin were started. Revascularization was achieved with thrombectomy. Deep vein thrombosis was ruled out and trans-thoracic echocardiogram was unremarkable. Telemetry revealed persistent first-degree AV block. Suspecting a cardioembolic etiology, a loop recorder was placed and DAPT was changed to apixaban. Trans-esophageal echocardiogram ruled out valvular abnormalities or clots, but identified an extra-cardiac shunt, suspected to be from pulmonary arteriovenous malformation (PAVM). Despite the findings, the patient declined further workup in the hospital and was discharged with medical management. DISCUSSION: PAVM, often associated with Osler-Weber-Rendu disease (OWRD) or migraines is a rare cause for stroke.[1] The absence of a capillary bed allows small thrombi or bacteria to reach the systemic circulation. The resulting manifestations can be severe, including cerebrovascular accidents and brain or intra-medullary abscesses.[2] In a study involving over 700 patients with stroke, only 4 with isolated PAVM were identified, suggesting this is a very rare presentation.[3] In our patient, however, there was no history of migraines or clinical features of OWRD other than PAVM (1 out of 4 per Curacao diagnostic criteria). Therefore, we believe the stroke was likely secondary to an isolated PAVM. Studies reported varied approaches on management of isolated PAVM, with majority opted for embolization. There was also varied recommendations on anti-platelet therapy or anti-coagulation. Our patient was managed with anti-coagulation therapy. CONCLUSIONS: Cryptogenic strokes in low-risk patients warrant evaluating for less common causes, such as AVM, as the implications could be devastating. Although there are treatments that lower the risk of recurrent strokes, little is known on the best practice for patients with isolated PAVM. REFERENCE #1: Peery WH. Clinical Spectrum of Hereditary Hemorrhagic Telangiectasi (Osler-Weber-Rendu Disease). Am J Med. 1987;82:9. REFERENCE #2: Kawano H, Hirano T, Ikeno K, Fuwa I, Uchino M. Brain Abscess Caused by Pulmonary Arteriovenous Fistulas without Rendu-Osler-Weber Disease. Intern Med. 2009;48(6):485-487. REFERENCE #3: Kimura K, Minematsu K, Nakajima M. Isolated pulmonary arteriovenous fistula without Rendu-Osler-Weber disease as a cause of cryptogenic stroke. J Neurol Neurosurg Psychiatry. 2004;75(2):311-313. DISCLOSURES: No relevant relationships by Vernon Chan, source=Web Response No relevant relationships by Dana Daoud, source=Web Response No relevant relationships by Jayaram Thimmapuram, source=Web Response

Incidence prevalence and management of different types of arrhythmia in patients with ischemic heart disease in Taif city

Background: Despite considerable progress in management over the recent years, coronary artery disease (CAD) remains the leading cause of death. Objectives: to assess the different types of arrhythmias in patients with ischemic heart diseases in Taif city. Methods: A retrospective study was done on 529 patients from Taif, Saudi Arabia aged 30 to >75 years, of both genders and who had CAD, through the review of medical records of cardiac patients in AL Hada armed forces hospital. A checklist was used that included demographic features and risk factors for ischemic heart disease, symptoms of heart failure, medications that patients who had CAD used and types of arrhythmias. Results: All patients had a type of arrhythmia during their hospital stay. The main types of arrhythmias were AF (26.8 %), conduction disturbance (38.2%) and first-degree heart block (9.1 %). Patients who had STEMI with symptoms of heart failure and arrhythmias had a significantly higher percentage for the need of DC shock compared to other patients. Patients with UA who developed low EF were shown to be significant as regards arrhythmias rather than normal EF. The number of affected vessels had no effect on the development of arrhythmias during the acute stage. The development of arrhythmia that required DC shock was more common in STEMI patients especially those who developed heart failure symptoms. Conclusion: The need of assessment of heart failure symptoms and EF in patients with UA is essential to determine the need for implantable device insertion. Also, early administration of b-blocker decreases the risk of development of arrhythmia during an acute ischemic event. Key words: arrhythmias, patients, ischemic, heart, disease, Taif

A Case of Stress-Related Heart Block in Cardiac Sarcoidosis

There are often remarkably long delays in the diagnosis of cardiac sarcoidosis. We present a case of a 61-year-old man with exertional dyspnea and light-headedness. A resting ECG showed a 1st-degree AV block. A complete heart block was unmasked by an exercise stress test. The coronary angiogram was normal as were the cardiac troponins and Lyme antibody titer. He received a pacemaker on an emergent basis. Cardiac PET scan confirmed sarcoidosis. Computed tomography of the chest was significant for hilar and mediastinal adenopathy. He was treated with methotrexate with good symptom relief. This case demonstrates the importance of prompt clinical suspicion and immediate stress testing to unmask higher degree heart blocks in patients with cardiac sarcoidosis, which would have been missed otherwise. Treatment with a pacemaker, an ICD, and an immunosuppressant is recommended in such patients.

Hydroxychloroquine/chloroquine in patients with COVID-19 in Wuhan, China: a retrospective cohort study

BackgroundSince the COVID-19 pandemic, several therapeutic agents have been used in COVID-19 management. However, the results were controversial. Here, we aimed to evaluate the efficacy and safety of hydroxychloroquine (HCQ)/chloroquine (CQ) in COVID-19.MethodsWe retrospectively reviewed the medical charts of patients with COVID-19 admitted to an inpatient ward in Wuhan from 2020/Feb/08 to 2020/Mar/05. Patients with HCQ/CQ and age, gender, disease severity matched ones without HCQ/CQ were selected at a 1:2 ratio. The clinical, laboratory and imaging findings were compared between these two groups. The multivariate linear regression analysis was performed to identify the factors that might influence patients’ virus shedding periods (VSPs).ResultsA total of 14 patients with HCQ/CQ and 21 matched ones were analyzed. The HCQ/CQ treatment lasted for an average of 10.36 ± 3.12 days. The mean VSPs were longer in the HCQ/CQ treatment group (26.57 ± 10.35 days vs. 19.10 ± 7.80 days, P = 0.020). There were 3 patients deceased during inpatient period, two patients were with HCQ/CQ treatment (P = 0.551). In the multivariate linear regression analysis, disease durations at admission (t = 3.643, P = 0.001) and HCQ/CQ treatment (t = 2.637, P = 0.013) were independent parameters for patients’ VSPs. One patient with CQ had recurrent first-degree atrioventricular block (AVB) and obvious QTc elongation, another one complained about dizziness and blurred vision which disappeared after CQ discontinuation. One patient with HCQ had transient AVB.ConclusionsIn summary, we identify that the HCQ/CQ administration is not related to less mortality cases at later phase of COVID-19. More studies are needed to explore whether HCQ/CQ treatment would lead to SARS-Cov-2 RNA clearance delay or not.

Left atrial reverse remodeling improves sinus restoration following mitral valve replacement: A case report.

IntroductionMitral stenosis is one of the most common abnormalities in rheumatic heart disease (RHD). These patients often experience atrial fibrillation, due to left atrial dilatation, causing a high risk of thromboembolic events; rhythm or heart rate control are thus important treatment strategies. In patients undergoing surgery, sinus rhythm restoration is not fully understood, and not all surgical patients return to sinus rhythm. We report an adult woman with mitral regurgitation who experienced sinus restoration after mitral valve replacement (MVR) surgery.Case presentationA 44-year-old woman presented with chief complaints of orthopnea and shortness of breath during activity for 2 months. Electrocardiography (ECG) revealed atrial fibrillation with normal ventricular response, and echocardiography showed severe mitral stenosis with Wilkins score of 10 (3-2-3-2), moderate mitral and aortic regurgitation due to RHD, moderate tricuspid regurgitation with probable pulmonary hypertension, normal left ventricular systolic function, ejection fraction of 60.5% (biplane). MVR surgery was performed using a mechanical mitral valve. Postoperative ECG found sinus rhythm and first-degree AV block. Postoperative echocardiography found a decreased left Atrial volume index of 70.8 mL/m2, indicating further remodeling of the patient's heart.ConclusionSinus restoration sometimes occurs in patients after MVR. The correction procedure causes minimal anatomical changes, particularly the loss of non-conductive and pathological tissue, followed by hemodynamic changes that eventually lead to the left atrial reverse remodeling mechanism.

B-PO05-033 PACEMAKER IMPLANTATION AFTER SELECTIVE ALCOHOL SEPTAL ABLATION

Complete heart block (CHB) with permanent pacemaker (PPM) placement is a known risk of alcohol septal ablation (ASA) for hypertrophic cardiomyopathy. Historically, the incidence has been around 10% in all-comer populations. However, rates of 25% are reported in centers that selectively target older, higher risk patients (pts). Understanding predictors of CHB in this evolving cohort is important. Report baseline characteristics, associated factors (AF) of PPM placement, longer-term pacing need following ASA in a high-volume HCM center. 94 consecutive pts underwent ASA from 2/2017 to 12/2020. 25 were excluded due to prior septal reduction or device. Criteria for PPM included persistent post-ASA CHB >24 hours, recurrent pacing due to 2nd degree HB/ transient CHB >24 hours. 69 pts (mean age 65.7 ± 11 years, females 53.6%) were included. 19 (27.5%) required PPM prior to discharge, 6 (31.5%) of whom were prohibitive surgical risk for myectomy (20.3% PPM rate in pts not at prohibitive surgical risk). All had reduction in peak provoked gradient (pre-procedure mean 149.8 mm Hg vs. post-procedure mean 10.5 mmHg, p<0.01) and improved NYHA class. Comparison of baseline clinical, ECG, and procedural characteristics (e.g., peak troponin and gradient reduction) yielded no AF of PPM implantation, with exception of intraprocedural CHB (OR 12.4, 95% CI 3.4 - 45.3, p<0.0001). Post procedure PR prolongation >50 ms (OR 6.1, 95% CI 1.5 - 24.5, p = 0.01), first-degree AV block with RBBB and LAFB (OR 6.1, 95% CI 1.5 - 24.5, p = 0.01) and change in QRS axis >700 (OR 5.3, 95% CI 1.4 - 18.9, p= 0.01) was also associated with PPM. At 1 month, 16 pts (84.2%) required >1% RV pacing (mean 59.2%) suggesting appropriateness of PPM implantation. At 3 months 10 pts (52.6%) required pacing (mean 52.4%) indicating some late recovery. No procedural factors were associated with PPM following ASA with exception of intraprocedural CHB. Daily ECGs identified dynamic abnormalities associated with PPM. Short term follow up suggests PPM criteria are appropriate, with longer term follow up showing some recovery. As higher risk cohorts are targeted for ASA, PPM risk factors of long term pacing will be vital.

Rare Coding Variants Associated With Electrocardiographic Intervals Identify Monogenic Arrhythmia Susceptibility Genes: A Multi-Ancestry Analysis.

Alterations in electrocardiographic (ECG) intervals are well-known markers for arrhythmia and sudden cardiac death (SCD) risk. While the genetics of arrhythmia syndromes have been studied, relations between electrocardiographic intervals and rare genetic variation at a population level are poorly understood. Using a discovery sample of 29 000 individuals with whole-genome sequencing from Trans-Omics in Precision Medicine and replication in nearly 100 000 with whole-exome sequencing from the UK Biobank and MyCode, we examined associations between low-frequency and rare coding variants with 5 routinely measured electrocardiographic traits (RR, P-wave, PR, and QRS intervals and corrected QT interval). We found that rare variants associated with population-based electrocardiographic intervals identify established monogenic SCD genes (KCNQ1, KCNH2, and SCN5A), a controversial monogenic SCD gene (KCNE1), and novel genes (PAM and MFGE8) involved in cardiac conduction. Loss-of-function and pathogenic SCN5A variants, carried by 0.1% of individuals, were associated with a nearly 6-fold increased odds of the first-degree atrioventricular block (P=8.4×10-5). Similar variants in KCNQ1 and KCNH2 (0.2% of individuals) were associated with a 23-fold increased odds of marked corrected QT interval prolongation (P=4×10-25), a marker of SCD risk. Incomplete penetrance of such deleterious variation was common as over 70% of carriers had normal electrocardiographic intervals. Our findings indicate that large-scale high-depth sequence data and electrocardiographic analysis identifies monogenic arrhythmia susceptibility genes and rare variants with large effects. Known pathogenic variation in conventional arrhythmia and SCD genes exhibited incomplete penetrance and accounted for only a small fraction of marked electrocardiographic interval prolongation.

Cardiac effects of rapid intravenous loading of lacosamide in patients with epilepsy

BackgroundLacosamide (LCM) is a new antiseizure medication, and intravenous (IV) loading of LCM is recently used against status epilepticus. IV loading of LCM is usually well-tolerated; however, there are concerns about LCM-induced serious adverse cardiac events. This study was aimed at investigating whether rapid IV loading of LCM is associated with adverse cardiac or hemodynamic events in cases of epilepsy emergencies in real-world settings. MethodsWe reviewed medical records of consecutive adult epilepsy patients who received a single loading dose (400 mg) of IV LCM between January 2019 and December 2020 and included patients who exhibited status epilepticus or acute repetitive seizures. Electrocardiography findings, blood pressure, and heart rate before and after the IV infusion of LCM were collected. ResultsOf the 85 patients included, 32.9 % (28/85 patients) had experienced at least one cardiac adverse event. The most common adverse events were new-onset first-degree atrioventricular block (19 patients) and hypotension (seven patients). Atrial fibrillation and bradycardia developed in two patients and atrial flutter in one. There were significant increases in the mean PR interval (from 169.3 msec to 184.5 msec, P < 0.01) and decreases in the mean heart rate (from 91.7 to 86.9, P = 0.01) after IV loading of LCM. Older age was significantly associated with a higher magnitude of the PR interval difference between before and after IV loading of LCM. ConclusionsIn cases of epilepsy emergencies, adverse cardiac events commonly developed after IV loading of LCM, although most adverse events were mild in severity or not clinically significant. Elderly patients or patients with underlying cardiac diseases were prone to exhibiting a more prolonged PR interval after IV loading of LCM. Thus, the loading dose of IV LCM should be infused under careful ECG monitoring in these patients.

Prognostic Implication of First-degree Atrioventricular Block in Patients with Hypertrophic Cardiomyopathy

Prognostic Implication of First-degree Atrioventricular Block in Patients with Hypertrophic Cardiomyopathy

The Auxiliary Diagnostic Value of a Novel Wearable Electrocardiogram-Recording System for Arrhythmia Detection: Diagnostic Trial.

Background: AMAZFIT®, a novel wearable electrocardiogram (ECG)-recording system is used for the measurement, acquisition, and storage of single-lead cardiac waveforms for adults. The aim of the study was to evaluate the accuracy of AMAZFIT® for diagnosing arrhythmia in older patients.Methods: From May to December 2019, we recruited 291 elderly individuals with an average age of 78±10 years old, and 41.9% women. All cardiac waveforms were obtained from the AMAZFIT® which included limb and chest leads. Two trained technicians reviewed all ECG data to determine cardiac rhythm using standard diagnostic criteria. We evaluated the accuracy of AMAZFIT® for identifying arrhythmia by comparing the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios with those of a standard 12-lead ECG.Results: Of the 291 participants, 197 older adults had arrhythmias, including AF (n = 119), first-degree AVB (n = 28), PACs (n = 25), and PVCs (n = 28). Three of these participants had arrhythmias of AF and PVCs. Chest lead data from 100% and limb lead data from 4.7% of the participants were analyzed. An evaluation of AMAZFIT® for atrial fibrillation (AF) reported a sensitivity, specificity, PPV, NPV PLR, and negative likelihood ratio (NLR) of 93.28, 95.35, 93.28, 95.35, 20.06, and 0.07%, respectively. AMAZFIT® also demonstrated excellent sensitivity for premature atrial contractions (PACs) (84.00%) and premature ventricular contractions (PVCs) (89.29%). However, the device demonstrated a low sensitivity for first-degree atrioventricular block (32.14%).Conclusions: The AMAZFIT® showed significantly higher sensitivity and specificity for AF, PACs, and PVCs. This portable ECG-recording device based on an algorithm has a potential auxiliary diagnostic value for identifying arrhythmia compared with a standard 12-lead ECG device.

Expert consensus document on automated diagnosis of the electrocardiogram: The task force on automated diagnosis of the electrocardiogram in Japan. Part 1: Nomenclature for diagnosis and abnormal findings.

As these terms should accurately represent the abnormal findings and conditions as much as possible, we propose to unify these terms into terminologies that are not confusing and easy to understand for everyone.

Echogenic Fetal Heart Without Conduction Defect in Maternal Autoimmune Disease: A Lesser Known Association

AbstractPositive anti-Ro/SSA and anti-La/SSB antibodies in pregnant mothers are strongly associated with fetal congenital heart block (CHB). Increased echogenicity of fetal endo-myocardium is one of the lesser known manifestations of maternal autoimmune disease. In this retrospective analysis of data from the last ten years (2010–2019) at our fetal medicine unit, we identified nine fetuses presenting in the second trimester with isolated increased echogenicity of the endo-myocardium without CHB. In three cases, mothers had a pre-existing autoimmune disease. The others were diagnosed with positive autoimmune antibodies following evaluation for the echogenic fetal heart. One fetus developed a first-degree heart block at 33 weeks and another had a second-degree heart block three weeks after presentation. There was no fetal mortality. All were live-born. One fetus with tachycardia and ventricular dysfunction died within a few days of birth. Both babies with heart block are stable and on medical follow-up, while others remain asymptomatic with a normal rhythm. There seems a spectrum of fetal disease caused by maternal auto-antibodies affecting the endo-myocardium but sparing the conduction system. In fetuses with echogenic hearts, evaluation of maternal autoimmune status should be part of the protocol for optimal fetal and maternal care.

Repolarization abnormalities at admission predict 30-day outcome in COVID-19

Funding AcknowledgementsType of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): BV is supported by a research grant of the Frans Van de Werf Fund for Clinical Cardiovascular Research.IntroductionCOVID-19 can be related with a poor clinical outcome. ECG abnormalities in COVID-19 have been widely described, but literature on the predictive value of a 12-lead ECG at hospital admission and normalization of these abnormalities after infection is limited.PurposeTo describe the predictive value of ECG abnormalities on admission and after recovery of COVID-19.MethodsAfter informed consent patients older than 18 years admitted with COVID-19 between March and July 2020 were included in a prospective registry. Diagnosis was confirmed by PCR-assay or based on suggestive clinical and radiological presentation. Demographic and clinical data were collected by review of the electronic medical record. All ECGs from admission until last follow-up were assessed lead by kead for repolarization abnormalities. The index ECG was defined as first ECG available after admission, a post-COVID ECG was obtained after hospital discharge in the absence of acute pathology. Minor abnormalities included iso-electric T-waves and ST-depression ≤2 mm. Major abnormalities were ST-depression >2 mm, ST-elevation, biphasic T-waves and T-wave inversion. Myocardial regions were defined as anterior (V1-V4), lateral (I, aVL, V5, V6) and inferior (II, III, aVF). Patients with a ventricular pacemaker were excluded.ResultsA total of 283 patients were included, median age 65 years and 64.7% were male. The 30-day mortality rate was 20.5%. In 96.8% of patients an ECG was available within 48 hours after admission.Repolarization abnormalities were observed in 48.8% of patients. In 27.2% this was limited to minor abnormalities. Abnormal repolarization was related to age, cardiovascular medical history, renal function, high-sensitive troponin-T and NT-proBNP levels. There were no significant differences in clinical presentation, ICU admission, need for ventilation or ECMO.On Kaplan-Meier analysis (figure) the presence (p < 0.001) and the extent of repolarization abnormalities (p < 0.001) were associated with 30-day mortality. Forward Cox regression modelling identiefied age (per year, HR 1.07, 95% CI 1.05-1.09), history of heart failure (HR 2.12, 95% CI 1.08-4.52), neurological disorders (HR 2.47, 95% CI 1.36-4.51), active oncological disease (HR 2.13, 95% CI 1.01-4.50) and the extent of repolarization abnormalities (per region, HR 1.37, 95% CI 1.05-1.79) as independent predictors.A post-COVID ECG was available in 172 patients (60.8%), the median time between index and post-COVID ECG was 63.3 days. There was 1 new first-degree AV-block and 1 new RBBB. Repolarization abnormalities were present in 32 patients (11.3%); however, only 3 patients (1.7%) had new abnormalities, 2 of whom died during further follow-up.ConclusionsThe extent of repolarization abnormalities on an ECG at admission for COVID-19 is an independent predictor of 30-day mortality. New ECG abnormalities after COVID-19 infection are uncommon but may be associated with adverse outcome. Figure.

AL type cardiac amyloidosis: a devastating fatal disease

ABSTRACT Introduction Cardiac amyloidosis is a rare entity with a grave prognosis. Due to the low index of suspicion secondary to non-specific symptoms, it is often diagnosed at an advanced stage with multi-organ involvement. Methods We report a case of systemic AL amyloidosis with predominant cardiac and renal involvement associated with multiple myeloma. Case Summary A 60-year-old male presented with progressive anasarca, orthopnea and weight gain over 8 months. On clinical examination, 3+ pitting edema was found in bilateral extremities and scrotum. Serum N-type proBNP and troponin T were elevated, and EKG showed diffuse low voltage QRS, right axis deviation, and 1st degree AV block. Echocardiography revealed granular myocardium, biventricular hypertrophy, bi-atrial dilation and apical sparing pattern on global longitudinal strain which was suggestive of cardiac amyloidosis. Light chain assessment showed elevated kappa and lambda chains with kappa to lambda ratio of 16.2. Endomyocardial biopsy revealed AL type cardiac amyloidosis, and bone marrow biopsy confirmed the diagnosis of multiple myeloma. He received six cycles of bortezomib, cyclophosphamide, and dexamethasone but continued to deteriorate. He experienced an episode of cardiac arrest following which he had a return of spontaneous circulation but due to poor prognosis, the family opted for pursuing comfort measures only. Conclusions Cardiac involvement in AL type amyloidosis imparts significant morbidity and mortality. The management of cardiac amyloidosis entails a multidisciplinary approach with an emphasis on cardiology and oncology. Despite the novel diagnostic modalities and treatment regimens, the outcome for AL-type cardiac amyloidosis remains poor.

Maska brzuszna ostrego zespołu wieńcowego czy ... ? Celowość włączenia badania przesiewowego aorty brzusznej do rutynowego protokołu badania echokardiograficznego

An 86-year-old woman with a history of hypertension, paroxysmal atrial fibrillation, chronic kidney disease, type 2 diabetes and hypothyroidism, was admitted due to weakness and atypical chest pain accompanied by dyspnoea, abdominal pain, vomiting and lack of appetite. Also, a month ago the patient underwent left lower limb erysipelas and reported a 10 kg decrease in body weight over the past year. On admission, the patient was hemodynamically stable. Electrocardiography revealed sinus rhythm, first-degree atrioventricular block, and persistent ST-segment depression in the anterolateral loads. Biochemical tests revealed elevated high-sensitivity troponin level and high N-terminal pro-B-type natriuretic peptide concentration. Echocardiography showed normal left ventricle systolic function, ejection fraction of 50%, without evidence of significant valvular heart disease. Taking into consideration all of the above, the diagnosis of the acute coronary syndrome was proposed. Due to the standards applied in our echocardiography protocol (screening of abdominal aorta dimension in people over 65-years-old), a significant widening of the abdominal aorta was found. In computed tomography angiogram, abdominal 57 mm aortic aneurysm with a haemorrhagic thrombus and right iliac aneurysm with a large thrombus with deep ulceration were confirmed. The whole clinical picture suggests that the patien’s complaints resulted from the presence of large abdominal aortic and common iliac artery aneurysms, accompanied by pressure on the adjacent abdominal organs and with a high risk of sudden rupture. The described case confirms the validity of supplementing routine echocardiographic protocol with a screening assessment of the abdominal aorta, following European Society of Cardiology guidelines. Accurate diagnosis, in this case, protected the patient from acute coronary syndrome invasive treatment, which could result in intensive anticoagulant and antiplatelet therapy implementation and lead to life-threatening complications.

Cardiac manifestations in Finnish gelsolin amyloidosis patients

Introduction Finnish gelsolin amyloidosis (AGel amyloidosis) is an inherited systemic amyloidosis with well-known ophthalmological, neurological and cutaneous symptoms. Additionally, cardiomyopathies, conduction disorders and need of cardiac pacemakers occur in some patients. This study focuses on electrocardiographic (ECG) findings in AGel amyloidosis and their relation to cardiac magnetic resonance (CMR) changes. We also assessed whether ECG abnormalities were associated with pacemaker implantation and mortality. Materials and methods In this cohort study, 51 genetically verified AGel amyloidosis patients (mean age 66 years) without cardiac pacemakers underwent 12-lead ECG and CMR imaging with contrast agent in 2017. Patients were followed-up for 3 years. Results Conduction disturbances were found in 22 patients (43%). Nine (18%) presented with first-degree atrioventricular block, six (12%) with left anterior hemiblock, seven (14%) with left or right bundle branch block and two (4%) with non-specific intraventricular conduction delay. Low QRS voltage was present in two (4%) patients. Late gadolinium enhancement (LGE) concentrating on the interventricular septum and inferior parts of the heart was present in 19 (86%) patients with conduction abnormalities. During the follow-up, only one patient received a pacemaker, and one patient died. Discussion Conduction disorders and septal LGE are common in AGel amyloidosis, whereas other ECG and CMR findings typically observed in most common cardiac amyloidosis types were rare. Septal pathology seen in CMR may interfere with the cardiac conduction system in AGel amyloidosis, explaining conduction disorders, although pacemaker therapy is rarely required.