Ischemic Episodes Research Articles

Positive Stress Electrocardiography in Patients With Non-obstructive Coronary Disease.

Introduction The episodes of myocardial ischemia in patients with non-obstructive coronary disease are extremely variable in provoking factors and presentation. Purpose We investigated the significance of coronary blood flow velocity and epicardial diameter as correlates of a positive electrocardiographic exercise stress test (ExECG) in hospitalized patients with unstable angina and non-obstructive coronary artery disease. Methods The study was a single-center cohort retrospective. ExECG was performed and analyzed in a group of 79 patients with non-obstructive coronary disease (coronary stenoses < 50%). Thirty-one percent of the patients (n=25) were diagnosed with slow coronary flow phenomenon, SCFP; 40.5% (n=32) - patients with hypertensive disease, left ventricular hypertrophy (LVH), and slow epicardialflow; 27.8% (n=22) with hypertension, left ventricular hypertrophy and normal coronaryflow. The patients were hospitalized in University Hospital "Alexandrovska," Sofia in the period 2006-2008. Results The frequency of positive ExECG is increased as a trend was associated with smaller epicardial diameters and pronounced delay in epicardial coronaryflow.In the subgroup with SCFP, the risk for a positive ExECG test was determined by slower coronary flow (36.5±7.7 frames vs. 30.3±4.4 frames, p=0.044) and borderline significant by epicardial lumen diameters (3.3±0.8 mm vs. 4.1±1.0 mm, p=0.051) and greater myocardial mass (92.8±12.6 g/m2 vs. 82.9±8.6 g/m2, p=0.054). In cases of left ventricular hypertrophy, which included both patients with the normal and slow epicardialflow, there were no statistically significant correlates of an abnormal exercise stress ECG test. Conclusions In patients with non-obstructive coronary atherosclerosis and predominantly slow epicardial coronary flow, the provoking of ischemia at an electrocardiographic exercise stress test is associated with the lower epicardial flow velocity at rest and with the smaller epicardial diameter. In SCFP, the risk for an abnormal stress test is determined by slower coronary flow, smaller epicardial lumen diameter, and greater myocardial mass.The presence and size of the plaque burden are not associated with a greater risk of a positive ExECG in these patients.

CHARACTERISTICS OF HEART RHYTHM DISORDERS ACCORDING TO THE DATA OF HOLTER ECG MONITORING IN PATIENTS WITH HEART FAILURE AND ATRIAL FIBRILLATION

Chronic heart failure (CHF) is one of the most significant medical, economic and social problems of the 21st century and remains the main cause of morbidity and mortality worldwide.The purpose. To study the indicators of Holter ECG monitoring, the dynamics of ischemic changes, heart rate, indicators of heart rhythm variability and blood pressure in patients with heart failure and atrial fibrillation.Material and methods. 150 patients aged 45-65 were examined. All patients were divided into groups: Group I – patients with HF with sinus rhythm or atrial fibrillation (AF) (permanent or persistent form), (n=75). Group II – patients without HF with AF, (n=75). Group III – control group: 36 practically healthy people. All patients underwent a clinical examination, ECG, echocardiography (ECHOKG), Holter ECG monitoring (HM ECG) and daily BP monitoring (DMAT).Research results. The analysis of the ECG of the examined patients indicates the presence of heart rhythm disorders, which is an important risk factor and progression of CHF. The results of XM ECG indicate the presence of ventricular arrhythmias of various gradations along with AF. There was a probable difference in the direction of an increase in the number of ventricular extrasystoles (VAS), both single and, most importantly, extrasystoles of high gradations, in patients with CHF and AF compared with healthy subjects. In addition, the number of SHEs in patients with CHF and AF was likely lower than in patients with CHF with sinus rhythm. Indicators of maximum heart rate, ST segment depression and QT interval dispersion in patients with CHF and AF were significantly higher (p&lt;0.05) than similar parameters in patients without CHF with AF.Conclusions: Ventricular heart rhythm disturbances were detected in the examined patients, which is a predictor of an unfavorable prognosis in patients with chronic heart failure. There was a probable difference in the direction of increased levels of maximum heart rate, maximum depression, ST segment elevation, dispersion of the QT interval, QTc, an increase in the total duration of episodes of myocardial ischemia, in patients with chronic heart failure and atrial fibrillation in comparison with healthy subjects.

Acute stroke in familial Mediterranean fever: An analysis of 23 new cases and systematic review of the literature.

The nature of neurovascular involvement in cases of familial Mediterranean fever (FMF) has not been adequately clarified. Clinical features, infarct topography, vascular status, and stroke etiology were prospectively determined in 35 acute neurovascular events that occurred in 23 FMF patients. Clinicoradiological features were compared with an age- and gender-matched control group of 115 acute stroke patients. Characteristics of additional FMF and acute stroke cases (6 episodes in 6 patients) identified from a systematic literature review (PROSPERO registration no: CRD420212264820) were also analyzed. There were 27 acute ischemic stroke episodes in 19 patients, 7 transient ischemic attack episodes in 3 patients, and 1 patient with a single episode of parietal hematoma in our cohort. Twenty (74%) ischemic stroke episodes in 12 patients were cryptogenic. Ten of these 12 cases had a previous FMF diagnosis and were taking colchicine. There was no significant difference in the FMF group in terms of the presence of vascular risk factors and angiography-documented disease in comparison to controls. Cerebral distal artery involvement was significantly prevalent in FMF (78% vs 45%, P= .002). Especially, midbrain central deep perforating territory involvement was higher (30% vs 1%, P< .001). The long-term prognosis (median 8.5 years) under antiplatelet agents and colchicine is favorable. The acute stroke phenotype in FMF cases is herein described for the first time. Several clinicoradiological features such as thrombotic lacunar infarcts located in the central mesencephalon seem so typical that we recommend searching for FMF mutations in geographic regions where FMF is common.

The effectiveness of trimetazidine in the treatment of CHF patients with cardiopulmonary pathology

Introdiction. The article highlights the importance of optimizing the treatment of chronic heart failure (CHF) in patients with comorbid cardiopulmonary pathology, namely ischemic heart disease (CHD) in combination with chronic obstructive pulmonary disease (COPD). The results of our own research on the evaluation of the clinical efficacy of trimetazidine inclusion in the complex therapy of comorbid pathology are presented.Objective. To study the clinical efficacy of trimetazidine as part of the complex therapy of patients with ischemic heart failure in combination with COPD.Materials and methods. 60 patients with CHF II-III FC, left ventricular ejection fraction (LVEF) &lt;45% were studied against the background of postinfarction cardiosclerosis and COPD of 2–3 degrees of airflow restriction. The patients were divided into 2 groups: 1st (30 patients) took trimetazidine; 2nd (30 patients) received therapy without the addition of trimetazidine. The dynamics of: clinical condition with the use of SHOCK, FC CHF, test with 6-min. walking, quality of life (MLHFQ, SGRQ), indicators of 24-bifunctional monitoring, TTE, spirometry, platelet aggregation and blood viscosity.Results and conclusion. The use of trimetazidine as part of therapy led to an improvement in the clinical course of the disease, significantly increased exercise tolerance. The number and duration of ischemia episodes decreased by 34 and 39% (p &lt; 0.05). The number of angina attacks per week and the need for nitroglycerin decreased by 65% and 42% (p &lt; 0.05), respectively. There was an improvement in intracardiac and peripheral hemodynamics. Thus, LV LV increased by 21%, pulmonary artery pressure decreased by 18%, the indicators of LVD, platelet aggregation and blood rheology improved. There was a more positive dynamics of lipid peroxidation and antioxidant system indicators compared to the control group.

Effect of early postoperative rehabilitation with aerobic exercise on functional status and cardiac remodeling in patients after heart valve surgery

Aim. To develop a program for early physical rehabilitation of inpatients after heart valve surgery and to evaluate its effectiveness and safety.Material and methods. The study included 80 patients with valvular heart disease (VHD) after elective on pump valve surgery. Patients in the control group (n=47) underwent standard cardiac rehabilitation after surgery; patients of the main group (n=33) additionally, starting from the 8th day after the intervention, had 14-day treadmill training with the program selection, taking into account the results of cycle ergometry spirometry (CES). A week after the operation and at the end of the training course (median, 24 days after the operation), cardiac remodeling and functional status was assessed according to echocardiography and CE, respectively.Results. For 7 days after surgery, patients of both groups were comparable. During physical training in the main group, there were no lifethreatening cardiac arrhythmias, episodes of ischemia, desaturation, as well as intracardiac hemodynamics deterioration. With a 14-day training, CES showed a significant increase in exercise tolerance (ET) in the main group from a median of 50 to 75 W (p=0,002), peak oxygen uptake (VO2peak) from 11,7 to 13,4 ml/kg/min (p=0,001). For 24 days after surgery in the control group, there was a trend towards improvement in ET and VO2peak, but without significant changes (p=0,09/p=0,08).Conclusion. Early inhospital rehabilitation, including physical training of moderate intensity with an individual treadmill speed and incline angle, starting from day 8 after surgery, showed effectiveness and safety in the form of an increase in ET and VO2peak, while not worsening hemodynamic parameters.

The significance of glycocalyx in surgery.

Surgical treatment is associated with an unwanted response of the organism to the so-called surgical trauma. This response is called surgical stress. Ischaemia-reperfusion injury is one of essential causes of tissue damage. It comprises functional and structural changes in tissue that occur after the restoration of circulation, after an episode of ischaemia. Necrosis of irreversibly changed cells and endothelial and mitochondrial-induced tissue swelling occur. Physiology, pathophysiology of endothelial glycocalyx: Endothelial glycocalyx is a 0.2 to 5 micrometres thin heteropolysaccharide layer that covers the endothelium on its intraluminal side. Backbone molecules of the glycocalyx include proteoglycans, glycoproteins, and glycosaminoglycans. Damage of the endothelial glycocalyx was described in trauma patients, in patients with septic shock, in ischemia and reperfusion injury, and during extensive surgical procedures. Approaches to prevent endothelial glycocalyx damage: Remote ischemic preconditioning was tested as a method of ischemia and reperfusion injury prevention during and after surgery. Nevertheless, the expected effect was not confirmed in performed meta-analyses. Endothelial glycocalyx damage can be prevented pharmacologically with a broad spectrum of substances, such as antithrombin III, doxycycline, hydrocortisone, etanercept, or nitric oxide donors. Hydrogen inhalation or albumin affects glycocalyx positively. Sulodexide provides a positive effect on the protection and reparation of endothelial glycocalyx. This proteoglycan with antithrombotic, fibrinolytic, hypofibrinogenemic, and lipolytic function is used for the treatment of venous diseases, ischaemic heart disease, and peripheral arterial disease. A positive effect of sulodexide on renal dysfunction was documented in a model of ischaemia and reperfusion injury. Equally, a positive effect of sulodexide was described on endothelium repair after its mechanical damage. Further research needs to be performed to evaluate the effect of endothelium-protectives on glycocalyx damage prevention and repair in ischaemia and reperfusion models involving large laboratory animals or in clinical trials in patients undergoing surgical revascularisation procedures.

Real Time In Vivo Evaluation of Mitochondrial Activity and Brain Functions during Ischemic Stroke

More than 50% of total energy consumed by the brain is utilized by active transport processes which are responsible for keeping the ionic homeostasis in the brain. Under an ischemic condition, energy availability is limited, and, as a result, inhibition of the ion pumps is unavoidable. The initial consequence of such inhibition is a gradual accumulation of K+ in the extracellular space leading to a second phase of the ischemic depolarization phenomenon. During ischemic depolarization, extracellular K+ will increase 15-20-fold, while extracellular Ca2+ is decreasing 10 fold. Another optional effect of mild ischemia is the development of Cortical Spreading Depression due to the leakage of K+ into the extracellular space. The Mongolian gerbil provides a very useful animal model to study the effects of ischemia on brain functions. The aims of the study were as follows: (1) To elucidate the mechanism behind the development of ischemic depolarization or cortical spreading depression under unilateral and bilateral carotid artery occlusion. (2) To correlate the kinetics of the recovery processes to the level of ischemia. We tested the correlation between energy depletion level (evaluated by intramitochondrial NADH redox state and Cerebral Blood Flow) and the development of ischemic depolarization or cortical spreading depression (evaluated by extracellular K+, H+, Ca2+, DC potential and 366 nm reflectance changes) under partial and complete ischemia using the multiparametric monitoring system. The results could be summarized as follows: (1) Under bilateral occlusion, in all gerbils the ischemic depolarization was recorded within 1-2 min. (2) Under unilateral occlusion, the level of ischemia obtained was significantly smaller and led to the ischemic depolarization in about 60% of the gerbils. (3) The K+ leakage during the ischemic depolarization had an 'all or none' nature in terms of maximal K÷ levels and time to reach it. (4) The main effect of various lengths of bilateral occlusion was on the recovery time of extracellular K+ level. (5) Cortical spreading depression develop in most cases during the recovery from the ischemic event when ischemic depolarization was not recorded under the ischemic episode.

COMPLEX REHABILITATION OF ISCHEMIC HEART DISEASE PATIENTS AFTER CORONARY BYPASS OPERATION WITH THE USE OF BIOLOGICALLY ACTIVE ADDITIVES

Aim: The purpose of the work was to study the possibility of using Dihydroquercetin in rehabilitation programs for patients with coronary artery disease after Coronary artery bypass grafting (CABG) surgery in order to increase the effectiveness of rehabilitation, which has notable scientific and practical significance. Materials and Methods: The methodological basis of the research is based on systemic, historical, terminological, and informational approaches. Results: The results of the study showed the high clinical effectiveness of Dihydroquercetin in the complex medical rehabilitation of patients with coronary artery disease who underwent the operation. The pill intake did not affect indicators of carbohydrate and lipid metabolism, which indicates its metabolic neutrality. None of the patients had any worsening of the condition, increased frequency of angina attacks, or episodes of painless ischemia. All patients indicated good tolerability of the drug, and improvement in general well-being (reduction or disappearance of shortness of breath, decrease in pain intensity, increase in activity, improvement in sleep). The implementation of the optimized rehabilitation program also contributed to the improvement of the psycho-emotional state of the patients. Conclusions: Сomplex medical rehabilitation of patients with coronary heart disease after Coronary artery bypass grafting surgery according to a program with the inclusion of Dihydroquercetin helps to improve the rheological properties of blood, strengthen the active vasomotor mechanisms of MC regulation, improve indicators of central and peripheral hemodynamics, blood oxygenation, increase in exercise tolerance, improve psycho-emotional the condition, which ultimately ensure an increase in the rehabilitation effect.

Parameters Of Myocardial Electrical Instability In Patients After Myocardial Infarction Comorbid With A Novel Coronavirus Infection (COVID-19)

Objective — This article aims to assess parameters of myocardial electrical instability and arrhythmic events in patients after myocardial infarction (MI), with and without ST-segment elevation, comorbid/noncomorbid with a novel coronavirus infection (COVID-19) using a long-term electrocardiographic (ECG) monitoring. Methods — The study included 64 subjects: 25 (39%) patients with MI comorbid with COVID-19 (MI+C group) and 39 (61%) patients with MI noncomorbid with a novel coronavirus infection (MI group). The mean age of patients was 54.3±6.8 years. A long-term ECG monitoring for 97.4 (95% CI 77.9-115.2) hours was performed with Astrocard®-Telemetry system (Meditek JSC, Russia), starting from the 4th day of MI. Rhythm and conduction disorders, along with ischemic episodes were recorded; an analysis of ventricular late potentials, heart rate turbulence, and QT dispersion was carried out. Results — There were no differences in the frequency of delayed afterdepolarizations in MI and MI+C groups: 15-28% and 18-33% of patients, respectively. An analysis of turbulence parameters did not reveal statistically significant differences between the groups. Such arrhythmic events as frequent supraventricular extrasystole and life-threatening arrhythmias (ventricular extrasystole of grade 4A and higher sensu B. Lown and M. Wolf) were recorded significantly more often in the MI+C group than in the MI group: 48% vs. 20.5% (p=0.021) and 24% vs. 5.1% (p=0.026), respectively. Conclusion — The novel coronavirus infection (COVID-19) exacerbates myocardial electrophysiological heterogeneity in the acute cardiovascular event and is associated with an increase in clinically significant arrhythmic events.

Review of current ECG consumer electronics (pros and cons)

BackgroundSeveral wearable, medical-grade consumer ECG devices are now available and integrated into consumer electronics like multi sensor fitness watches and scales. Specific consumer ECGs can also come in the form of patches or thin sensor plates in credit card or other shapes. Watches with ECG capabilities are often multi vital sign sensor devices. The majority of these devices are usually connected to a mobile smartphone. However, there are pros and cons to their use. MethodsWe review here an exemplary selection of modern consumer ECG devices based on device type, recording method and the number of standard ECG channels derived. ResultsSingle-channel consumer ECG devices such as Smart Watches can be useful for detecting and monitoring atrial fibrillation and flutter and other arrhythmias, as well as ectopic complexes. However, they are currently limited with respect to recording duration and information content (a single-channel or limb‑lead ECG having less diagnostic information than a 12‑lead ECG). While some non watch-based consumer ECG devices can now record all 6 limb leads to yield increased information, no consumer ECG devices can currently reliably detect ST-segment deviations, potentially indicating myocardial infarction or ischemic episodes. Moreover, barriers to use still exist for at-risk elderly people. Finally, there currently is no universal data exchange format. ConclusionConsumer ECG devices, whether in fitness or fashionable design, allow for reliable detection of atrial fibrillation. Timely detection of atrial fibrillation and subsequent treatment might protect against stroke, especially in high-risk groups, yet prospective evidence is still lacking. Six-channel consumer ECG and longer data collection capabilities extend potential functionality, including for the monitoring of ST-segments and QT intervals. However, no currently available devices are sufficiently suitable for the detection of myocardial infarction or ischemia, which is why portable 12-channel technologies are desirable. For the reliable detection of a myocardial infarction, the determination of specific myocardial infarction blood markers and evaluation of patient medical history still is indispensable in addition to the 12 lead ECG.

A Rare Cause of Headache in A Middle-Aged Patient

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a genetic disease that commonly presents with migraine with aura, ischemic episodes, cognitive decline, and psychiatric manifestations. It is caused by mutations in the NOTCH3 gene with autosomal dominant inheritance. We report a 45-year-old male who presented with recurrent episodes of migraine over the last fifteen years and a history of migraine in his family members. A review of his imaging suggested CADASIL as a possible diagnosis. He underwent genetic testing which showed a positive NOTCH3 mutation. This report aims to highlight the importance of considering CADASIL as a cause of familial migraine. Keywords: CADASIL, Migraine, Stroke

Cardiac Ischemia Detection Using Parameters Extracted from the Intrinsic Mode Functions

Cardiac ischemia is the main cause of death in the world, thus the importance of prevention and early detection of these events. Traditionally, ischemia is detected by analyzing the alteration of the ST level in the electrocardiogram (ECG). In this study, we propose two new parameters extracted from the ECG to improve the cardiac ischemia detection. For this, the signal was decomposed using the Empirical Mode Decomposition, and the Intrinsic Mode Functions related to the frequency band of the ST level were selected. From these modes, two parameters were obtained: the Hjorth Activity and the frequency amplitude, using the Hilbert Transform. With these parameters, two analyses were done. First, the parameters obtained during normal periods were compared with those obtained during ischemic events. Second, a temporal series was obtained with both parameters, where the detection was done using an adaptative threshold. Results were obtained using all the patients with MLIII lead of the European ST-T Database. Parameters differed significantly across ischemic and non ischemic episodes, obtaining a sensitivity and positive predictive value of 88%, after removing noisy records. Also, a multi-lead detection was performed in patients with MLIII and V4 leads. The sensitivity and positive predictive value obtained were 92% and 80%, respectively.

When to set anticoagulant therapy in asymptomatic AF? looking for a cut-off duration.

The incidence of atrial fibrillation (AF) is progressively increasing, in line with the aging of the population and with the increase in chronic diseases. The care burden of the disease and above all to its consequences (i.e. ischaemic stroke and heart failure) significantly impacts the various health systems with forecasts of exponential increase in the near future. Clinical forms of AF, i.e. those diagnosed with electrocardiogram, have a clear correlation with systemic embolic events and also with a reduction in survival. Thromboembolic prophylaxis in these patients, with anticoagulant drugs, has in fact been shown to greatly reduce the incidence of ischaemic stroke and improve survival. In recent decades, the widespread use of therapeutic intra-cardiac devices, which allow constant and continuous monitoring of myocardial electrical activity, is bringing to light a large number of atrial high rate episodes (AHREs), which are not associated with clinical manifestation. The incidence of these findings grows linearly with the duration of the observation. More independent studies have shown that AHREs are associated with a risk of stroke that is higher (about double) than controls but significantly lower than in patients with manifest AF. However, taking into consideration patients with ischaemic stroke and wearers of implantable devices, no temporal correlation emerged between the incidence of the ischaemic episode and arrhythmia. The presence of AHRE is associated with an approximately six-fold increase in the incidence of clinical AF but only a minority of these patients meet the criteria for prescribing anticoagulation. Pending the publication of the studies still in progress, the European Society of Cardiology guidelines for the treatment of AF recommend considering the initiation of anticoagulant therapy in patients with long-lasting AHRE (> 24 h) associated with a high embolic risk. In patients with episodes of shorter duration (1-24 h), especially if with high burden, anticoagulant therapy can be considered in case of very high embolic risk (e.g. secondary prevention, CHADVASc ≥ 3).

Abstract 213: Remote Ischemic Conditioning To Enhance Resuscitation After Cardiac Arrest

Introduction: Restoration of blood flow after out-of-hospital cardiac arrest (OHCA) induces inflammation that causes cellular injury and death. Remote ischemic conditioning (RIC) consists of brief episodes of ischemia then reperfusion to a limb. Trials in animal models in cardiac arrest and in humans with acute infarction show RIC reduces RI. Objective: We sought to demonstrate the feasibility and safety of RIC in patients resuscitated from OHCA and transported to hospital. Methods: Single site 2-arm, single blind randomized feasibility trial comparing a treatment group receiving RIC versus usual care following OHCA. For patients allocated to the intervention group, RIC was performed via 3 cycles of 5-minutes inflation then 5-minutes deflation of a blood pressure cuff applied to an upper extremity. Included were adults resuscitated from OHCA with non-traumatic etiology of arrest, spontaneous circulation present upon emergency department arrival, no response to verbal commands and ongoing or planned induced hypothermia. Excluded were those with: ST-elevation on first 12-lead ECG obtained after return of spontaneous circulation, do not attempt resuscitation (DNAR) status, drowning or hypothermia as cause of arrest, dialysis fistula in either upper extremity or pre-existing amputation of upper extremity, pregnancy or incarcerated status. The primary outcome was attrition, i.e., the proportion of patients enrolled and not on allocated therapy for the study duration. Results: N=30 patients were enrolled (n=14 control, n=16 intervention). Mean age was 52.5 ± 16.2 years. Twenty-seven percent had female gender and 27% had a shockable first recorded rhythm. There was 0% attrition amongst enrolled patients. Other outcomes are summarized (Table). Conclusions: Application of RIC after OHCA is feasible and safe. An adequately powered trial is required to assess whether RIC is effective at decreasing morbidity and mortality after CA. TABLE: OUTCOMES

Abstract 15025: Bone Marrow Cells Transdifferentiate Into Heterogenous Populations of Endothelial Cells in the Heart

Introduction: A substantial number of studies in animal as well as human have shown contribution of bone marrow (BM) derived cells to postnatal angiogenesis in physiological and pathological conditions. Despite this information, questions remain regarding whether bone marrow-derived cells can become endothelial cells and engraft in blood vessels. Methods: To address this question, we generated chimeric rats containing BM from transgenic rat with the ubiquitin promoter driving GFP (GFP + BM) that was transplanted into a wild-type irradiated recipient. Chimeric rats were subjected to repetitive ischemia (RI, LAD occlusion) over a period of 17 days using a model in which the LAD is subjected to episodic ischemia to induce angiogenesis and collateral growth. Results: Measurements of myocardial blood flow (MBF) in the collateral-dependent region revealed a 3-fold increase in the ratio of collateral-dependent to normal zone MBF after 17 days. This increase in flow is due to collateral growth and angiogenesis in the ischemic region. Fluorescence microscopy in conjunction with immunostaining for rat endothelial cell antigen-1 showed the BM derived endothelial cells integrated into coronary blood vessels. We performed single cell RNAseq after sorting GFP + /propidium iodide - cells from hearts (enzymatic digestion) and bone marrow of control and RI rats. After quality filtering we had a total of 24103 cells. Clustering the cells identified 28 clusters. we annotated endothelial cell clusters based on the expression of endothelial cell markers. We had comparable proportion of endothelial cell populations in control and RI groups. Using canonical markers of different endothelial cell subtypes, we characterized arterial, venous, capillary, and lymphatic subpopulations within endothelial cell cluster. The endothelial cell population in the RI group had more angiogenic profile with higher expression of angiogenesis markers and vessel development pathways in gene ontology analysis. Conclusions: Taken together, our data suggest that BM cells can differentiate into endothelial cells in hearts, representing a heterogenous population of endothelial cells and contributing to vascular growth.

Microvascular Dysfunction in Hypertrophic Cardiomyopathy.

Myocardial ischemia is an established pathophysiological feature of hypertrophic cardiomyopathy (HCM) that impacts various clinical features, including heart failure (HF) and sudden cardiac death (SCD). The major determinant of myocardial ischemia in HCM is coronary microvascular dysfunction (CMD) in the absence of epicardial coronary artery abnormalities. Despite the impossibility to directly visualize microcirculation in vivo, a multimodality approach can allow a detailed assessment of microvascular dysfunction and ischemia. Accordingly, the non-invasive assessment of CMD using transthoracic Doppler echocardiography, positron emission tomography, and cardiac magnetic resonance should now be considered mandatory in any HCM patient. Noteworthy, a complete diagnostic work-up for myocardial ischemia plays a major role in the approach of the patients with HCM and their risk stratification. Chronic and recurrent episodes of ischemia can contribute to fibrosis, culminating in LV remodeling and HF. Ischemia can potentially constitute an arrhythmic substrate and might prove to have an added value in risk stratification for SCD. Accordingly, strategies for the early diagnosis of CMD should now be considered an important challenge for the scientific community.

LBODP070 A Rare Neuroendocrine Tumor-Insulinoma

Abstract Introduction Insulinoma is a rare neuroendocrine tumor, which presents sporadically or as a complex of multiple endocrine neoplasia type 1 syndrome (MEN-1). Most Insulinoma cases present with fasting hypoglycemia and some with both fasting and postprandial hypoglycemia. Case Report A 48-year-old male with no significant past medical or surgical history presented for an evaluation of hypoglycemia. He was recently seen in the Emergency Room after having a transient ischemic attack-like episode. The patient reported that he was at a family gathering where he was found confused and his blood glucose was checked by a family member with diabetes, which was noted to be 39 mg/ dl. He reported having other such episodes of lesser severity, occurring once or twice a month for many years. His symptoms would typically wake him from sleep, especially during early mornings with diaphoresis. He would take a snack to resolve his symptoms. Except for being overweight, no other abnormal findings were detected on physical examination. Fasting blood work revealed glucose of 42 with elevated insulin, C-peptide, proinsulin levels, and negative beta-hydroxybutyrate and insulin antibodies. An MRI abdomen with contrast demonstrated a 1.2 cm pancreatic lesion in the uncinate process, suspicious for a neuroendocrine tumor. Endoscopic Ultrasound staged the mass in the uncinate process of the pancreas as T1 N0 M0. FNAC showed a few atypical monomorphic cells suggestive of neuroendocrine origin. Immunohistochemical stains on the sample were positive for CD45 while CAM5.2, synaptophysin, and Ki65 were negative. The patient ultimately underwent exploratory laparotomy and resection of the neuroendocrine tumor with partial pancreatectomy. Discussion The symptoms of hypoglycemia are classified into sympathoadrenal (palpitation, diaphoresis, tremulousness) or neuroglycopenic (confusion, blurry vision, change in behavior, seizures, and amnesia of hypoglycemic episode). The neuroglycopenic symptoms of hypoglycemia mimic transient ischemic attack (TIA). The diagnosis of insulinoma needs biochemical proof of endogenous hyperinsulinemia and localization of the tumor. Surgery is the treatment of choice in resectable tumors. Conclusion This case highlights insulinoma as a rare cause of hypoglycemia and shows the importance of detailed history taking and appropriate investigations in its diagnosis.

Treatment Delays and Chance of Reperfusion Therapy in Patients with Acute Stroke: A Danish Nationwide Study

Introduction: We aimed to determine the treatment delay for ischemic stroke patients in Denmark. Methods: A nationwide register-based study on acute ischemic stroke patients admitted through emergency medical services. Treatment delay comprised patient, prehospital, and in-hospital delay. Analyses were stratified according to length of prehospital delay (<3 vs. ≥3 h). Results: A total of 5,356 ischemic stroke episodes were included. The median onset-to-door time was 187 min, and 2,405 (43%) arrived at the stroke unit within 3 h. Overall, the median patient delay was 115 min. For early arrival (n = 2,280), patient delay was 27 min compared to 437 min for late arrivals (n = 2,448). Median prehospital delay varied by 9 min between early- and late-arriving patients. Approximately 48% of the early-arriving patients compared to 9% of the late-arriving patients received i.v. thrombolysis. For thrombectomy, the numbers were 10% and 3%, respectively. This corresponded to an unadjusted relative risk (RR) of 0.18 (95% CI: 0.16–0.21) and adjusted (age, sex, cohabitation status, and stroke severity) RR of 0.20 (95% CI: 0.18–0.23) for i.v. thrombolysis when comparing patients arriving later than 3 h with patients arriving earlier. For thrombectomy, the unadjusted and adjusted RRs were 0.30 (95% CI: 0.23–0.39) and 0.40 (95% CI: 0.31–0.52), respectively. Conclusions: Patient delay remains the most important barrier for use of reperfusion therapy among acute ischemic stroke patients calling 1-1-2, whereas system delay seems independent of patient delay.

UNUSUAL BEGINNINGS: A CASE OF ABERRANT CORONARY ARTERY ANATOMY

UNUSUAL BEGINNINGS: A CASE OF ABERRANT CORONARY ARTERY ANATOMY

Effect of Antiplatelet Activity of Aspirin on Chronic Kidney Disease

Background and aim: Individual differences in the pharmacological responsiveness to aspirin are considerable. A higher likelihood of ischemic episodes is linked to aspirin's inadequate antiplatelet actions. It has been hypothesized that chronic kidney disease (CKD) influences the pharmacologic reaction to antiplatelet drugs. The elevated chance of fatality and cardiovascular problems in CKD sufferers has already been found to be largely explained by high on-treatment platelets response (HTPR) to clopidogrel. This research aimed to examine at how aspirin affects blood clotting in CKD sufferers. Method: We performed cross-sectional research on 120 people in Medical center of Lahore taking aspirin regularly. The thromboxane production generated by AAI was used to gauge the pharmacologic reaction to aspirin. Result: Individuals with poor kidney functioning were more likely to experience HTPR to aspirin (48% vs. 23%; odds ratio, 3.17; 95% confidence interval [CI], 1.35-7.42; P = 0.007). When compared to individuals with healthy or mildly diminished kidney performance, those with mild or serious CKD had lower pharmacokinetic responsiveness to aspirin (91; interquartile ranged [IQR], 281 ng mL-1; differential in medians, 56; CI, 6-110 ng mL-1; P = 0.012). Remaining thromboxane production and glomerular filtration rate were both associated by bivariate Pearson correlation analysis (R = 0.312; R2 = 0.093; P = 0.001). Individuals with CKD were usually old age and being women. Women and aged were not significant predictors of the connection, according to multivariate linear regression analyses (R = 0.313; R2 = 0.081; P = 0.002 and P = 0.006) respectively. Conclusion: Aspirin pharmacological reaction is associated with kidney function. Individuals who have CKD are more likely to have aspirin's antiplatelet action compromised. To evaluate the therapeutic significance of this data and look into the best antithrombotic strategy for CKD individuals, additional research is required. Keywords: Chronic kidney disease, platelets, treatment, aspirin, cardiovascular