Ischemic EKG Research Articles

Utility of the AngelMed Guardian System in myocardial bridging: a case report

BackgroundMyocardial bridging (MB) is a known congenital anomaly in which a segment of the coronary artery transverses from the epicardium through the myocardium. MB may clinically manifest as recurrent angina, acute coronary syndrome, ventricular dysrhythmia, and even sudden cardiac death. On electrocardiogram (EKG), MB can present with findings consistent with significant ST-segment changes. The AngelMed Guardian System (the Guardian device) was developed in an effort to optimize the time from the onset of myocardial ischemia to intervention. The device analyzes myocardial electrical changes and alerts the patient to seek emergent medical evaluation if an acute ST-segment deviation is detected. We describe the first documented case of the Guardian device detecting acute ST-segment changes secondary to myocardial bridging.Case PresentationA 50-year-old male, with a history of percutaneous coronary intervention of the proximal left anterior descending (LAD) artery, presented to his cardiologist’s office with reports of recurrent, atypical chest pain. The Guardian device was implanted. One month after implantation, the patient experienced chest pain and was alerted by the Guardian device to seek emergent medical evaluation. Initial EKG and high-sensitivity troponins were negative for acute ischemia. Guardian device interrogation revealed significant ST depressions, encouraging further ischemic evaluation. The exercise myocardial perfusion imaging revealed an apical reversible defect. Left heart catheterization revealed a large segment of mid-LAD MB with the patient’s previous LAD stent noted to be widely patent along with no evidence of new obstructive coronary disease. Following the identification of the MB, medication regimen adjusted and the patient denied recurrence of chest pain or Guardian alerts.ConclusionsWe describe the first documented case of the Guardian device detecting acute ST-segment changes that were secondary to myocardial bridging. The Guardian device appropriately documented an ischemic event not appreciated with initial EKG or troponin testing. With the assistance of the Guardian device, we were able to rapidly identify MB as the cause for the ischemic EKG changes and subsequent abnormal stress test, optimize medical management, and prevent recurrent atypical chest pain along with office and hospital visits.

P106 AN INTRIGUING CASE OF INOCA IN THE CATH–LAB

Abstract A 63–year–old woman presented to our Center for a longstanding history of typically radiating oppressive chest pain, with both resting and exertional episodes,mostly occurring early in the morning and exacerbated by cold.Two years before for a treadmill test positive for electrocardiographic (EKG) criteria of exercise–induced ischemia, she underwent coronary angiography which was found negative for epicardial obstructive coronary artery disease.Given the suspicion of coronary microvascular disease,empirical antianginal therapy with Ranolazine was started at that time,with transient improvement of symptoms. She presented to our Center for a 6 month history of recurrence of symptoms. Her antianginal therapy with Ranolazine was up titrated to 750 mg BID and Verapamil (40 mg TID) was added to her usual therapy given the suspicion of coronary vasospasm as additional component in the pathogenesis of her symptoms,as suggested by the anamnestic recall.Moreover a 24–hour–Holter monitoring was performed with subsequent finding of several episodes of horizontal ST–segment depression(up to 3 mm),mainly on awakening,in the absence of significant arrhythmias.The patient underwent coronary angiography for the assessment of coronary physiology. On angiography, the absence of epicardial obstructive coronary artery disease was confirmed, with the finding of extensive coronary fistulas originating from the left coronary system and communicating with the left ventricular cavity.After induction of maximal hyperemia, the clinical suspicion of coronary microvascular disease was confirmed (CFR 1.9).In addition, reduced coronary flow reserve in the left anterior descending (LAD) territory compatible with both microvascular dysfunction and coronary steal was documented (RFR 0.91;baseline FFR:0.94,after systemic adenosine:0.79).Given the clinical suspicion, vasoreactivity test with intracoronary acetylcholine (2–20–100–200 mcg) was also performed,which was positive for epicardial spasm at mid–distal LAD and concomitant onset of chest pain and ischemic EKG changes(diffuse ST–segment depression) with prompt regression after intracoronary nitrate administration.Taken together,clinical and instrumental findings suggested the diagnosis of mixed angina by combination of three mechanisms:microvascular disease,epicardial spasm and coronary steal due to extensive coronary artery fistulas.The patient was discharged with Ranolazine and Diltiazem at maximum tolerated dose with clinical benefit.

Abstract 15178: Impact of Anemia on Mortality Among Patients With Type 2 Myocardial Infarction

Introduction: Anemia, a common precipitant of Type 2 Myocardial Infarction (T2MI), is well studied in Acute Coronary Syndrome (ACS), but its impact on mortality in T2MI population is lacking. We evaluated the association of hemoglobin (Hgb) levels on all-cause mortality within 60 days in patients with T2MI. Methods: In this single-center retrospective study, we evaluated 812 patients with Hgb > 7g/dl and troponin >0.04 ng/L (>99 th percentile) presenting to a tertiary ED from 08/2016-08/2018. Exclusion criteria included patients with ischemic EKG changes, ACS treatment, cardiac catheterization showing intervenable lesions. Adjusted confounding variables are included in the figure. Iterative code was created to test each possible Hgb cut-off, from 7.1 to 15.2, to maximize the area under the curve while also looking for the smallest p-value and largest odds ratio. Five Hgb categories were then created, and mortality was calculated across groups. A multivariate-adjusted logistic regression model was used to predict mortality using Hgb category 13+ as the reference group. Results: Cut-off analysis showed Hgb of 9.9 as an inflection point of maximal mortality benefit (p<0.0001). Thus, our Hgb categories were 7-9.9, 10-10.9, 11-11.9, 12-12.9, and 13+. 60-day mortality rate for the above respective groups were 45.4% (n=216), 40.0% (n=135), 36.5% (n=104), 34.8% (n=115), and 26.9% (n=242) respectively. The overall 60-day mortality was 36.3% (295/812). In comparison with the reference group, multivariate analysis showing ORs for 60-day mortality for the above Hgb categories were 1.92 (95% CI: 1.28-2.96, p-0.003), 1.42 (0.87-2.32, p-0.16), 1.46 (0.86-2.49, p0.16), and 1.46 (0.88-2.42, p-0.15) respectively. Conclusions: Hospitalized patients with T2MI have an exceptionally high mortality rate that independently correlate with anemia severity. Those with Hgb < 9.9 had significantly higher mortality compared to Hgb > 9.9.

Evaluation of acute chest pain – is it possible to associate cardiovascular risk scores (TIMI, HEART, GRACE) and the presence of obstructive plaque on coronary computed tomography angiography?

Abstract Introduction Coronary artery disease (CAD) answers for almost 43.2% of cardiovascular deaths worldwide. In the United States, more than 8 million patients present to the emergency department each year with acute chest pain. Although, as few as 10% will be diagnosed with acute coronary syndrome. Cardiovascular risk scores are frequently used as tools to evaluate the chance of coronary disease, despite the fact that they were initially validated as prognostic schemes to categorize a patient's risk of death and ischemic events. The association of these scores and the presence of obstructive atherosclerotic plaques is scarce. Purpose To associate the presence of obstructive atherosclerotic plaque on coronary computed tomography angiography (CCTA) and cardiovascular risk scores, in the evaluation of patients who present with acute chest pain to the emergency department in a tertiary referral center in cardiovascular disease. Methods This is an observational and retrospective study that evaluated patients presenting to the emergency department with acute chest pain and were referred to CCTA. Exclusion criteria were ischemic EKG signs, positive troponin or history of coronary revascularization. CCTA images were reviewed by trained observers who performed a per-segment analysis to assess coronary artery stenosis, with complex cases classified by consensus. Atherosclerotic plaque was categorized as obstructive if luminal cross-sectional area stenosis was >50% in ≥1 major epicardial artery. Results Overall, 350 patients were recruited (52.6±11.9 years, 50% women) in whom 20.6% (72 patients) had significant atherosclerotic plaque. Male gender (OR: 1.87; 95% CI: 1.08–3.26), age >52 years (OR: 2.85; 95% CI: 1.6–5.07), diabetes (OR: 2.17; 95% CI: 1.12–4.2) and typical angina (OR: 2.17; 95% CI: 1.12–4.2) were the only clinical characteristics independently associated with the presence of obstructive plaque. More then 90% of patients with significant coronary stenosis were classified as low risk by GRACE and TIMI scores. HEART score was <4 in 23.6% of patients with obstructive plaque. Conclusion In patients who present to the emergency department in a tertiary referral hospital with acute chest pain, the initial evaluation based on clinical characteristics and cardiovascular risk scores was not sufficient to exclude safely the presence of coronary artery disease. Therefore, in such patients, CCTA could help to identify those with occult CAD and to target preventative treatments, thereby improving clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Smoky heart: cardiovascular manifestations of carbon monoxide poisoning

Abstract Background Carbon monoxide (CO) poisoning is one of the most critical health concerns worldwide due to severe clinical effects with high morbidity and mortality. Tissue hypoxia and cellular damage from CO poisoning results in oxidative stress. Organs and tissues with high O2 demand including central nervous system (CNS) and cardiovascular (CV) system are the most susceptible to this oxidative stress. We investigate and describe the cardiovascular manifestations in 350 patients who were admitted for moderate to severe CO poisoning and treated with hyperbaric oxygen (HBO2) therapy. Purpose This study was conducted to identify the common cardiovascular manifestations of carbon monoxide poisoning. Methods We retrospectively collected data on 350 consecutive adult patients treated for CO poisoning between January 2011 to April 2018. Cardiac biomarkers, EKG and carboxyhemoglobin (COHb) levels were obtained from pre-hospital sources including EMS (emergency medical services) and from outside hospital records at the time of transfer. Glasgow Coma Scale (GCS) measurements were obtained at initial pre-hospital evaluation and upon arrival to the emergency room. Patient demographics, CV, CNS history and cardiac risk factors including hypertension, hyperlipidemia, diabetes, smoking history were obtained from electronic medical record. Myocardial injury was defined by cardiac troponin I level of ≥0.05 ng/mL. Results There were 350 patients admitted for CO poisoning from 2011 to 2018. 72% of the patients received HBO treatment due to severity of their symptoms. The mean age was 47.3 years with 60% men, 89% of the admissions were accidental exposure. Cardiac biomarkers were elevated in 40% of the patients and with 21% having sinus tachycardia. 6% had ischemic EKG changes with 23% having regional wall motion abnormalities on echocardiogram. In terms of intervention, 83% of the patients with elevated cardiac biomarkers received HBO treatment, 9% underwent coronary angiogram out of which 50% were candidate for either percutaneous intervention (PCI) or coronary artery bypass graft (CABG). In hospital mortality amongst this population was 2%. Conclusion Myocardial injury is common and widely seen with CO poisoning as seen by elevated cardiac biomarkers in 40% of the tested population. Initial work up for patients with CO poisoning should include evaluation with an EKG and serial biomarkers. If an abnormality is detected, patient should undergo an echocardiogram. Further evaluation with coronary angiography may be warranted in patients with new left ventricular dysfunction or wall motion abnormalities, especially in patients with risk factors. Funding Acknowledgement Type of funding sources: None.

B-PO04-158 TROPONIN ELEVATION DURING EPISODES OF SUPRAVENTRICULAR TACHYCARDIA

Patients presenting to the emergency room with episodes of supraventricular tachycardia (SVT) frequently have signs and symptoms of an acute coronary syndrome, including chest pain, ischemic EKG changes, and a mildly elevated serum troponin. Case reports and small studies have shown that in such cases the likelihood of obstructive coronary artery disease (CAD) is low but the true incidence is unknown. To quantify the risk of obstructive CAD in patients who are found to have an elevated serum troponin at the time of an episode of SVT. In a series of 696 successive patients referred for catheter ablation, we retrospectively studied the clinical outcomes of 180 patients who had their troponin-I (TnI) level measured immediately after an episode of SVT. There were 98 patients whose TnI level was normal (<0.03). Of these, 48 underwent stress testing and 12 underwent coronary angiography (CAG) but none had obstructive CAD. There were 53 patients whose TnI was in the indeterminate range (0.03 to <0.30). Of these, 29 underwent stress testing and 14 underwent CAG. Only 1 patient had obstructive CAD and underwent percutaneous coronary intervention (PCI). There were 23 patients whose TnI level was abnormal (≥0.30). Of these, 17 underwent stress testing and 13 underwent CAG. Three patients (13%) had obstructive CAD and underwent PCI. The serum TnI level can be used to risk stratify patients who present with episodes of SVT and symptoms of an acute coronary syndrome. Patients with an abnormally high TnI level (>0.3) have a ∼13% risk of obstructive CAD. Those with a normal TnI level had a very low incidence (<5%).

Myocardial infarction in the absence of obstructive coronary artery disease - can the underlying causes be identified by cardiac magnetic resonance?

Abstract Funding Acknowledgements Type of funding sources: None. Background Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA) is a clinical entity that occurs in up to 15% of all acute coronary syndromes (ACS). It is a "working diagnosis", as it is constituted by several etiologies. Purpose To identify the utility of CMR in determining the etiological diagnosis of MINOCA events, with potential impact in the therapeutic management of these patients. Methods Patients with MINOCA who were admitted to the Cardiology department at a tertiary center, between 2015 and 2020, were included. MINOCA was defined as an ACS with non-obstructive (&amp;lt;50%) coronary artery disease and no other clinically specific cause, in accordance with definition adopted in the 2020 ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation. Patients who did not had a coronary exam (either CT or invasive angiogram) or a CMR were excluded. All CMR exams were performed in a 3 Tesla equipment using a comprehensive protocol (cine, T2-weighted, and late gadolinium sequences). Clinical, electrocardiographic, echocardiographic and CMR data were collected. Results In a population of 29 patients, the mean age was 55 ± 17 years-old at the time of the cardiac event, 51.7% were male. Concerning to cardiovascular risk factors, 58.6% of patients had dyslipidaemia, 51.7% had hypertension, 13.7% were diabetic, 41.4% were smokers or previous smokers and 31.0% had obesity. Atrial fibrillation was present in 3.4% of patients. As for the EKG patterns, 41.4% of the patients had ventricular repolarization changes, 13.8% had a transitory ST elevation pattern, 6.9% had a complete left bundle branch block and 37.9% had a normal EKG; most of the ischemic EKG alterations were on the anterior wall (66.7%). The median high sensitivity I troponin levels were 1877.5 (IQR 225.3 – 5985.8) ng/L. The majority of patients (58.6%) had echocardiographic wall motion abnormalities; of those, the most common (41.1%) were on the left anterior descendent artery territory. CMR (performed at a median of 5 days from presentation) was able to identify the cause for the troponin rise in 58.6% of the cases; late gadolinium enhancement and oedema were present in 41.4% and 62.1% of patients, respectively. The mean left ventricle ejection fraction (EF) was 57.7 ± 8.5% and the mean right ventricle EF was 61.5 ± 6.1%. An ischemic pattern was present in 29.4% of the total population. In 17.6% of the patients findings were consistent with Takotsubo syndrome and in 29.4% with myocarditis. Conclusion CMR established the etiological cause in 58.6% of the cases, with potential implications in medical therapy. These findings highlight the importance of CMR in MINOCA diagnosis and the potential improvement in patient care with multi-modality imaging.

An Unusual Case of Pannus Formation - A Late Postoperative Complication of a Prosthetic Valve Replacement Causing Severe Cardiomyopathy

There are several well-known long-term complications following prosthetic valve replacement. Pannus formation is one of the rare complications whose estimated incidence varies between 0.3% and 1.3% per patient-year [1]. The exact etiology of pannus formation is unknown but histopathologically, pannus formation is due to fibroelastic hyperplasia that variably occurs after valve implantation [2]. The rarity and acute coronary syndrome like clinical presentation makes pannus formation a clinically important diagnosis during initial presentation. Workup preferably includes Transthoracic Echocardiography (TEE) with or without CT angiography. Management includes urgent or emergent surgical excision of the pannus with or without re-replacement of the aortic valve [1]. We present a 66-year-old female who presented with typical angina symptoms along with diffuse ischemic EKG changes five years after aortic valve replacement surgery with Trifecta Bioprosthesis due to severe aortic stenosis with Non-ST Elevation Myocardial Infarction (NSTEMI). Coronary angiography done on admission showed left main ostial stenosis of 90-95 % in proximity to the aortic valve prosthesis. A Transthoracic Echocardiogram (TTE) revealed an ejection fraction of 30-35 % with global hypokinesia but did not suggest any valve dysfunction. CT angiogram was done the next day which revealed a noncalcified plaque (pannus) greater than 75% occlusion in the left main in proximity of the aortic valve. Despite expedited care and surgical evaluation, unfortunately the patient decompensated in the surgical operating room and did not survive.

Tension Hemopneumothorax in the Setting of Mechanical CPR during Prehospital Cardiac Arrest

Introduction There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient’s condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.

Higher incidence of vasodilator-induced left ventricular cavity dilation by PET when compared to treadmill exercise-ECHO in hypertrophic cardiomyopathy

BackgroundVasodilator-induced transient left ventricular cavity dilation (LVCD) by positron emission tomography (PET) is associated with microvascular dysfunction in hypertrophic cardiomyopathy (HCM). Here we assessed whether HCM patients who develop LVCD by PET during vasodilator stress also develop LV cavity dilation by echocardiography (ECHO-LVCD) following exercise stress. MethodsA retrospective analysis of cardiac function and myocardial blood flow (MBF) was conducted in 108 HCM patients who underwent perfusion-PET and exercise-ECHO as part of their clinical evaluation. We performed a head-to-head comparison of LV volumes and ejection fraction (LVEF) at rest and stress (during vasodilator stress, post-exercise), in 108 HCM patients. A ratio > 1.13 of stress to rest LV volumes was used to define PET-LVCD, and a ratio > 1.17 of stress to rest LVESV was used to define ECHO-LVCD. Patients were divided into 2 groups based on the presence/absence of PET-LVCD. MBF and myocardial flow reserve were quantified by PET, and global longitudinal strain (GLS) was assessed by ECHO at rest/stress in the two groups. ResultsPET-LVCD was observed in 51% (n = 55) of HCM patients, but only one patient had evidence of ECHO-LVCD (ratio = 1.36)—this patient also had evidence of PET-LVCD (ratio = 1.20). The PET-LVCD group had lower PET-LVEF during vasodilator stress, but ECHO-LVEF increased in both groups post-exercise. The PET-LVCD group demonstrated higher LV mass, worse GLS at rest/stress, and lower myocardial flow reserve. Incidence of ischemic ST-T changes was higher in the PET-LVCD group during vasodilator stress (42 vs 17%), but similar (30%) in the two groups during exercise. ConclusionPET-LVCD reflects greater degree of myopathy and microvascular dysfunction in HCM. Differences in the cardiac effects of exercise and vasodilators and timing of stress-image acquisition could underlie discordance in ischemic EKG changes and LVCD by ECHO and PET, in HCM.

All’s Not Well(ens) that Ends Well: Case Study of Significant Thebesian Veins Mimicking Wellens Syndrome

Thebeisan veins are microfistulous connections between a coronary arterial branch directly to a ventricular or atrial chamber. Extensive thebesian veins that empty into the left ventricle can cause typical chest pain symptoms, troponin elevation, and ischemic EKG changes from coronary steal leading to acute coronary syndrome in extreme cases. Literature review exposed a consistent pattern of EKG findings among patients with extensive thebesian veins involving all three major coronary arteries. We present a case study as an example of this rare anatomic finding of extensive thebesian veins draining into the left ventricle causing acute coronary syndrome in a symptomatic patient with elevated troponin and ischemic changes on EKG. This same EKG pattern that is present in our patient was discovered to be consistent among available case studies reviewed that had included an EKG tracing in their report. A newly proposed association between the ischemic changes on EKG due to extensive thebeisan veins and those of a severe proximal left anterior descending coronary artery stenotic lesion was discovered. The newly discovered consistency in the EKG pattern with acute coronary syndrome caused by extensive thebesian veins is the same pattern as that seen in Wellens Syndrome.

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

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

03: Utility of EKG for preoperative evaluation in benign hysterectomy

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

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

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

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

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

Omentin-1 and Nonfatal Ischemic Heart Disease in Postmenopausal Women: A Population-Based Study

There is growing evidence that supports the existence of a link between lower levels of circulating omentin-1 and the pathogenesis of coronary atherosclerosis. However, no population-based study has been performed to elucidate the cardioprotective role of this beneficial adipocytokine. A total of 378 healthy, postmenopausal women were randomly selected from 13 clusters in the port city of Bushehr, Iran. The prevalence of nonfatal ischemic heart disease (IHD) was assessed using the Minnesota code with a 12-lead resting electrocardiogram (EKG). EKG with evidence of IHD (IHD-EKG) was defined as myocardial infarction (codes 1.1 and 1.2) and ischemia (codes 1.3, 4.1 to 4.4, 5.1 to 5.3, and 7.1) occurring together. Serum omentin-1 and adiponectin levels were measured using enzyme-linked immunosorbent assay methods. The prevalence of IHD-EKG among the studied population was 41.8% (159 women). Serum levels of omentin-1 were significantly lower in women with ischemic EKG than in normal subjects (geometric mean ×/multiplicative standard deviation, 10.31 ×/2.35 ng/mL versus 12.44 ×/2.12 ng/mL, respectively; P = .038). Multiple logistic regression analysis indicated that higher serum levels of omentin-1 were significantly associated with a lower prevalence of ischemic EKG after adjusting for potential confounders, including classical cardiovascular risk factors and circulating adiponectin levels (odds ratio, 0.48; confidence interval, 0.24 to 0.95; P = .038). A higher level of circulating omentin-1 is independently associated with a lower prevalence of nonfatal IHD in postmenopausal women. The cardioprotective role of this novel adipocytokine needs to be further elucidated in large-scale longitudinal studies. BMI = body mass index EKG = electrocardiogram ELISA = enzyme-linked immunosorbent assay HDL = high-density lipoprotein IHD = ischemic heart disease LDL = low-density lipoprotein.

TCT-310 Impact of Ischemic EKG Changes during the Acetylcholine Provocation Test on 12-month Clinical Outcomes in Patients with Vasospastic Angina

Clinical significance and angiographic characteristics of patients (pts) with ischemic EKG changes during the Ach provocation test are not clarified yet as compared with pts without EKG change. A total 3034 consecutive pts underwent coronary angiography with Ach provocation tests were enrolled. EKG

Impact of Ischemic EKG Changes During the Acetylcholine Provocation Test on 12-month Clinical Outcomes in Patients with Vasospastic Angina

Impact of Ischemic EKG Changes During the Acetylcholine Provocation Test on 12-month Clinical Outcomes in Patients with Vasospastic Angina

The Impact of High Sensitivity C-Reactive Protein Level on Coronary Artery Spasm as Assessed by Intracoronary Acetylcholine Provocation Test

PurposeHigh sensitive C-reactive protein (hs CRP) is well known as a strong risk factor of cardiovascular disease (CVD). The aim of this study is to evaluate the impact of elevated hs CRP on coronary artery spasm (CAS) as assessed by intracoronary acetylcholine (ACh) provocation test.Materials and MethodsA total of 1729 consecutive patients without significant CVD who underwent coronary angiography and intracoronary ACh test between November 2004 and August 2010 were analyzed. The patients were divided into five groups according to quintiles of hs CRP levels.ResultsAt baseline, the prevalence of elderly, hypertension, diabetes mellitus, current smoking, and lipid levels were higher in patients with higher hs CRP. During ACh test, the incidences of significant CAS, ischemic electrocardiography (EKG) change, multivessel, and diffuse CAS were higher in patients with higher hs CRP. Multivariate analysis showed that the old age (OR=1.01, CI; 1.0-1.02, p=0.0226), myocardial bridge (OR=3.34, CI; 2.16-5.17, p<0.001), and highest quintile hs CRP (OR=1.54, CI; 1.12-2.18, p=0.008) were independent predictors of ACh induced CAS. However, there was no difference in clinical outcomes up to 12 months.ConclusionIn conclusion, higher hs CRP was associated with higher incidence of CAS, worse angiographic characteristics and ischemic EKG change, but was not associated with clinical outcomes.

Type B aortic dissection in a patient with unknown left ventricular non-compaction cardiomyopathy: Cardiovascular magnetic resonance diagnosis

A 61-year-old man was referred at our hospital for a cardiac evaluation after an episode of oppressive chest pain at rest. He was discharged with a MRI diagnosis of non-compaction cardiomyopathy presented with typical angina, left ventricle dysfunction and ischemic EKG findings without atherosclerotic narrowing and also with a type B aortic dissection, documented also by computed tomography.