Nonspecific ST-T Changes Research Articles

Electrocardiographic abnormalities in patients with sickle cell disease: A systematic review and meta-analysis.

Previous studies have documented that electrocardiography (ECG) can reveal a range of abnormalities, offering valuable insights into the cardiac evaluation of patients with sickle cell disease (SCD). The objective of this study is to assess the patterns of ECG abnormalities observed in these patients with SCD, and to determine their prevalence. We systematically reviewed the literature using online databases of PubMed, Scopus, Web of Science, Embase, and Google Scholar to identify original studies that reported findings of standard ECG assessments in patients with SCD. Statistical analyses were performed using the random effects model. Additional analyses including sensitivity analysis and subgroup analysis were also conducted. Analysis of data from 59 studies involving 897,920 individuals with SCD revealed that 75% of these patients had abnormal ECG findings (67%-81%), which were predominantly nonspecific ST-T changes, left ventricular hypertrophy, T-wave changes, prolonged corrected QT (QTc) interval, and ischemic changes. Besides, it was shown that these patients had significantly higher odds of having any ECG abnormalities (OR of 17.50, 4.68-65.49), right atrial enlargement (6.09, 1.48-25.09), left ventricular hypertrophy (3.45, 1.73-6.89), right ventricular hypertrophy (7.18, 2.28-22.57), biventricular hypertrophy (10.11, 1.99-51.38), prolonged QTc interval (5.54, 2.44-12.59), ST depression (3.34, 1.87-5.97), and T-wave changes (5.41, 1.43-20.56). Moreover, the mean of QTc interval was significantly higher among those with SCD (23.51milliseconds, 16.08-30.94). Our meta-analysis showed a higher prevalence of abnormal ECG findings among individuals with SCD. A significant proportion of these patients had various ECG abnormalities, suggesting a potential need for regular ECG assessments for patients with SCD.

Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data

Abstract Background Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated. Purpose By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool. Methods 11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports. Results Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1). Conclusion Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures. Funding Acknowledgement Type of funding sources: None.

Evaluation of the efficacy of signal-averaged electrocardiogram testing in the cardiac assessment of beta-thalassemia major patients

BackgroundMore than 70% of thalassemia’s major mortality is due to the cardiac complications of this syndrome, mostly consequent to myocardial Iron overload; therefore, evaluation of such complications is of utmost importance. T2*MRI is used to assess hepatic and myocardial Iron load in thalassemia patients, which is not always available. Signal-Averaged Electrocardiography is a rather easy method of evaluating major thalassemia patients regarding their risk for sudden cardiac death.Methods and materialsIn this cross-sectional study, 48 patients with thalassemia major underwent evaluation with electrocardiography, signal-averaged electrocardiography, echocardiography, T2*MRI, and ferritin level. The association of the existence of ventricular late potentials in SAECG and other cardiac variables was evaluated. Moreover, the association between myocardial and hepatic Iron load and cardiac characteristics was assessed.Results48 patients with a mean age of 30.31 ± 7.22 years old entered the study. 27 (56.3%) of the patients had ventricular late potentials, which were associated with myocardial dry Iron weight (P = 0.011). Nonspecific ST-T changes and premature atrial and ventricular contractions were seen more frequently in patients with late potentials (P = 0.002, 0.031, and 0.031, respectively). Patients with higher myocardial and hepatic Iron loads had longer QTc in their 12-lead surface electrocardiograms.ConclusionPatients with ventricular late potentials assessed by SAECG had a higher myocardial Iron load. Higher myocardial Iron load is associated with higher cardiac complications in patients with beta-thalassemia major; therefore, SAECG can be used as a screening test for cardiac complications in beta-thalassemia major patients.

Artificial intelligence-guided, single-lead EKG may be a game-changer for symptom-to-balloon time reduction in ST-elevated myocardial infarction

Abstract Background Over decades, efforts to shave off life-saving minutes from ST-Elevated Myocardial Infarction (STEMI) care centred on reducing door-to-needle and door-to-balloon times. We firmly believe that symptom-to-balloon time should prove a better focus to this end. Challenges come with this goal as it heavily relies on a patient's perception and initiative to seek care, which we deem intelligent and wearable Artificial Intelligence (AI)-driven Single Lead EKG technologies as an attractive solution in modern-day cardiology. Purpose To provide an accurate, accessible, and cost-effective AI-driven Single Lead STEMI detection algorithm that can be embedded into wearable devices and employed in a self-administered fashion. Methods Database: EKG records from Mexico, Colombia, Argentina, and Brazil from April 2014 to December 2019. Dataset: A total of 11,567 12-lead EKG records of 10[s] length with a sampling frequency of 500 Hz, including the following balanced classes: angiographically confirmed and unconfirmed STEMI, branch blocks, non-specific ST-T abnormalities, normal and abnormal (200+ CPT codes, excluding those mentioned above). Cardiologists manually checked the label of each record to ensure precision. Pre-processing: We discard the first and last 250 samples as they may contain a standardisation pulse. The study applied a digital low pass filter of order 5 with a frequency cut-off of 35 Hz. The mean was subtracted from each Lead. Classification: The determined classes were “STEMI” (Including STEMI in different locations of the myocardium – anterior, inferior, and lateral); and “Not-STEMI” (Combination of randomly sample, branch blocks, non-specific ST-T changes, and abnormal records – 25% of each). Training and Testing: A 1-D Convolutional Neural Network was trained and tested with a dataset proportion of 90/10, respectively. A different model was trained and tested for each Lead, using the central 4,500 samples of the records. The last dense layer outputs a probability for each report of being STEMI or Not-STEMI. Lead V2 showed the best overall results. The model was further tested through the same methodology using the best Lead with a subset of the previous data, excluding the unconfirmed STEMI EKG records (Total 7,230 12-lead EKG records for Confirmed Only STEMI dataset). Performance metrics were reported for each experiment and compared. Results Combined STEMI data: Accuracy: 91.2%; Sensitivity: 89.6%; Specificity: 92.9%. Confirmed STEMI Only dataset: Accuracy: 92.4%; Sensitivity: 93.4%; Specificity: 91.4% (Figure 1). Conclusion By assiduously improving the quality of the model's input, we continue to assess our algorithm's performance and reliability for future clinical validation as a potential remote monitoring and early STEMI detection device. Funding Acknowledgement Type of funding sources: None.

Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data

Abstract Background Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated. Purpose By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool. Methods 11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports. Results Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1). Conclusion Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures. Funding Acknowledgement Type of funding sources: None.

Prevalence and Associated Factors of Electrocardiogram Abnormalities in Patients With Systemic Lupus Erythematosus: A Machine Learning Study.

Electrocardiogram (EKG) abnormalities are predictive of subsequent cardiovascular events. Cardiac involvement is common in systemic lupus erythematosus (SLE). We aimed to determine the prevalence of EKG abnormalities in SLE patients and to examine the factors associated with EKG abnormalities with machine learning approaches. Consecutive SLE patients' records were retrieved from the database of the hospital for the cross-sectional study. Abnormal EKGs with clinical significance were grouped by the presence of tachyarrhythmias, atrioventricular block, nonspecific ST segment changes, T wave abnormalities, ventricular hypertrophy, axis deviation, bundle branch block, and QT interval prolongation. Associated factors of the most common EKG abnormalities were assessed by comparing logistic regression and 4 other machine learning approaches. In the present study, 299 patients were enrolled, with 128 showing clinically significant abnormalities on EKG. T wave changes (52.3%), nonspecific ST segment-T wave (ST-T) changes (26.6%), and prolonged QT interval (8.6%) were the most prevalent abnormalities among patients with abnormal findings on EKG. Random forests models had the best performance in the discovery of associated factors. Age, disease duration, antinuclear antibody titer, disease activity (as measured by the Systemic Lupus Erythematosus Disease Activity Index 2000) were associated with nonspecific ST-T changes, prolonged QT interval, and T wave changes. Hypertension, positivity for anti-SSA antibodies, and secondary Sjögren's syndrome were influential factors for nonspecific ST-T changes, prolonged QT interval, and T wave changes, specifically. ST-T and T wave changes were the most common abnormalities seen on EKGs of SLE patients. Our finding suggests that age, longer disease duration, higher disease activity, hypertension, anti-SSA antibody positivity, and secondary Sjögren's syndrome are important and influential factors in these EKG abnormalities.

Transient J wave-like ST-segment elevation in intracerebral hemorrhage: a case report

BackgroundCertain cerebrovascular events can induce electrocardiography (ECG) abnormalities and cardiac dysfunction. The most frequent patterns reported are nonspecific ST-T change, inverted or broad T wave, prolongation of QT interval as well as ST-segment depression or elevation. Here we present a case of intracerebral hemorrhage (ICH) with transient J wave-like ST-segment elevation accompanied by myocardial lesion.Case presentationA 58-year-old woman was admitted to our hospital and diagnosed with right basal ganglia region cerebral hemorrhage. The ECG recorded on the second hospital day showed transient J wave-like ST-segment elevation accompanied by increased myocardial troponin I and myocardial enzyme.ConclusionsThe J wave-like ST-segment elevation may be not a specific ECG signs for primary ischemic heart diseases as it also could be found in ICH patients. We believe that the follow-up ECGs can be used in conjunction with repeated myocardial enzyme analysis and echocardiography to differentiate ICH-ralated J wave-like ST-segment elevation from acute myocardial infarction (AMI), thus avoiding unnecessary cardiac catheterization.

Post-RNA (mRNA) Vaccination Myocarditis: CMR Features.

RNA (mRNA) vaccines used to prevent COVID-19 infection may cause myocarditis. We describe a case of acute myocarditis in a 27-year-old male after receiving the second dose of a Pfizer immunization. Three days after receiving the second dose of vaccine, he had acute chest pain. Electrocardiographic examination revealed non-specific ST-T changes in the inferior leads. Troponin levels in his laboratory tests were 733 ng/L. No abnormalities were detected on his echocardiography or coronary angiography. The basal inferoseptal segment was hypokinetic. The LV EF was 50%, whereas the RV EF was 46%. Epicardial and mesocardial LGE were shown in the left ventricle’s basal and mid anterolateral, posterolateral, and inferoseptal segments. The native T1 was 1265 ± 54 ms, and the native T2 was 57 ± 10 ms. Myocardial strain indicated that the baseline values for LV GLS (−14.55), RV GLS (−15.8), and RVCS (−6.88) were considerably lower. The diagnosis of acute myocarditis was determined based on the clinical presentation and cardiac magnetic resonance (CMR) findings.

Study of cardiac function in adults with dengue

Background: Medical literature has reports of isolated cases of atrioventricular conduction disorders, supraventricular arrhythmias, and myocarditis in dengue fever (DF). There is a paucity of data available in the published literature on the cardiac manifestations of DF from India. The aim of the present study was to assess the cardiac manifestations of DF. Methods: The 140 patients aged ≥18 years with DF confirmed with a serology-dengue non-structural protein 1 antigen-positive were included for this prospective observational study. Three serial ECGs were taken on day one, day three and day seven or day of discharge. All the patients were evaluated using 2D echo on day one, day seven or day of discharge. The primary outcome measures were to find the incidence and type of echocardiographic abnormalities and electrocardiographic changes in dengue.Results: The incidence of cardiac abnormalities on ECG and 2D echo was 30 (21.4%), and 5 (7.0%) respectively. On ECG, 14 (10%) 9 (6.4%) 3 (2.1%) 3 (2.1%) and 1 (0.7%) patients had sinus bradycardia, sinus tachycardia, non-specific ST-T changes, right bundle branch block and atrio-ventricular block on ECG respectively. On 2D echo, 7 (5.0%), 5 (3.6%) and 1 (0.7%) patient had systolic dysfunction, ejection fraction (<45.0%) and diastolic dysfunction respectively.Conclusions: The incidence of cardiac abnormalities on ECG and 2D ECHO in dengue patients was considerable. ECG and 2 D echo should be undertaken in patients with DF.

C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes

Abstract Background Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina. Case Summary A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention. Discussion Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.

C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes

Abstract Background Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina. Case Summary A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention. Discussion Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.

Cardio-COVID clinic – a one-center experience

BackgroundPersistent symptoms affect a relatively large portion of coronavirus disease (COVID) survivors. Hence, specific clinics had been established in order to better characterize and manage this emerging entity of Post-COVID, among them our Cardio-COVID Clinic, which is dedicated to the cardiovascular (CV) aspects of the phenomenon.AimTo present the experience of our Cardio-COVID Clinic.MethodsIncluded in this report are 76 adult patients seen at the clinic between June 2020 and March 2021, who have recovered from a polymerase chain reaction (PCR)-confirmed COVID, and who were suspected by their referring physicians to experience ongoing cardiac sequelae. All participants underwent a structured assessment by a single cardiologist, which consisted of history taking, physical examination (PE), electrocardiogram (ECG), trans-thoracic echocardiogram (TTE), and further tests as deemed appropriate, including any combination of Holter, ischemic provocation test, cardiopulmonary exercise test (CPET), cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT).ResultsInitial visits occurred within a median of 131 days after diagnosis. Most participants (83%) were referred from our general Long-COVID Clinic. About half were males, and the mean age was 53 years. 18% of participants had prior CV conditions, and the majority (72%) had at least one CV risk factor, mostly dyslipidemia. Nearly all participants experienced a symptomatic acute illness, which was graded according to the National Institutes of Health (NIH) criteria as severe in 23% of the study cohort. As for Post-COVID, late symptoms were present in 97% of patients, the most common being dyspnea (57%). While PE was unremarkable in all but 3 patients who exhibited murmurs, ECG findings were revealed in 45% – mostly non-specific ST-T changes (31%) and conduction abnormalities (14%) – and TTE aberrations were discovered in 28% – including pericardial effusion (24%), reduced left ventricular ejection fraction (LVEF) (5%), grade 2 diastolic dysfunction (3%), moderate and up valvular dysfunction (1%), and systolic pulmonary hypertension (1%); right ventricular function was universally normal. Upon conclusion of the work-up, CV diagnoses were made in 8 (11%) patients – including myocarditis (4), myopericarditis (1), inappropriate sinus tachycardia (1), chronotropic incompetence (1), and an aberrant coronary (1). Of note, CPET and CMR had the highest diagnostic yield, in light of 57% positive results on each – followed by CCT, Holter, and provocation test. Interesting as well, among those with abnormal CMR findings, 40% had normal ECG's and TTE's. Also, none of the CV restraints on CPET translated to provocation test anomalies.ConclusionCV symptoms of Post-COVID are highly prevalent, but signify actual CV disease only in a minority of patients. Further research is needed that will help identify predictors for CV morbidity and define optimal clinical pathways.Funding AcknowledgementType of funding sources: None.

Abstract P137: Nonspecific ST-T Change In Electrocardiogram Was Associated With A Reduced Constructive Myocardial Work In Hypertensive Patients With Preserved Ejection Fraction

Background: Nonspecific ST-T change in electrocardiogram can be observed in hypertensive heart disease with preserved left ventricular ejection fraction (LVEF); however, the relationship between nonspecific ST-T change and global myocardial work in echocardiography was unclear. Methods: We evaluated global longitudinal strain (GLS), GWI (global work index), GCW (global constructive work), GWW (global wasted work), GWE (global work efficiency), using offline analyzing system (View Pal, GE) in 196 hypertensive patients with preserved LVEF (>50%). Nonspecific ST-T change and major ST-T change (depression of ST in V5 lead >1mV) was also evaluated in electrocardiogram. Results: Mean age was 79.3±8.2 years (men 37.8%). Compared with patients with no ST-T change, those with nonspecific and major ST-change had a smaller absolute value of GLS (-20±3, -18±4, -14±5%, P<0.001) and had smaller constructive work load [GWI (2140±488, 1915±472, 1523±776 mmHg%, P<0.001), GCW (2410±514, 2165±471, 1694±784 mmHg%, P<0.01)]. Additionally, those with nonspecific and major ST-T change had an increased wasted myocardial work [GWW (87±61, 109±58, 138±71 mmHg%, P<0.001)], and this resulted in reduction of myocardial work efficiency [GWE (95±4,93±3,87±12%,P<0.001)]. Even after adjustment for age, sex, diabetes, dyslipidemia, EF, LV mass index, relative wall thickness, parameters of diastolic function (E/A, E/e’, left atrial volume index, tricuspid valve regurgitant flow velocity), and electrocardiogram LVH of Cornell product and Sokolow-Lyon voltage, the patients with nonspecific ST-T change had a significantly smaller LV global constructive work. [GWI (2243±41 vs. 1998±96 mmHg%, P=0.025), GCW (2501±45 vs. 2210±105 mmHg%, P=0.015)]. Conclusion: In hypertensive patients with preserved LVEF, nonspecific ST-T change in electrocardiogram was associated with a reduced constructive work in LV.

Cardiac Involvement in Recovered Patients From COVID-19: A Preliminary 6-Month Follow-Up Study.

Background: Accumulating evidence has revealed that coronavirus disease 2019 (COVID-19) patients may be complicated with myocardial injury during hospitalization. However, data regarding persistent cardiac involvement in patients who recovered from COVID-19 are limited. Our goal is to further explore the sustained impact of COVID-19 during follow-up, focusing on the cardiac involvement in the recovered patients.Methods: In this prospective observational follow-up study, we enrolled a total of 40 COVID-19 patients (20 with and 20 without cardiac injury during hospitalization) who were discharged from Zhongnan Hospital of Wuhan University for more than 6 months, and 27 patients (13 with and 14 without cardiac injury during hospitalization) were finally included in the analysis. Clinical information including self-reported symptoms, medications, laboratory findings, Short Form 36-item scores, 6-min walk test, clinical events, electrocardiogram assessment, echocardiography measurement, and cardiac magnetic resonance imaging was collected and analyzed.Results: Among 27 patients finally included, none of patients reported any obvious cardiopulmonary symptoms at the 6-month follow-up. There were no statistically significant differences in terms of the quality of life and exercise capacity between the patients with and without cardiac injury. No significant abnormalities were detected in electrocardiogram manifestations in both groups, except for nonspecific ST-T changes, premature beats, sinus tachycardia/bradycardia, PR interval prolongation, and bundle-branch block. All patients showed normal cardiac structure and function, without any statistical differences between patients with and without cardiac injury by echocardiography. Compared with patients without cardiac injury, patients with cardiac injury exhibited a significantly higher positive proportion in late gadolinium enhancement sequences [7/13 (53.8%) vs. 1/14 (7.1%), p = 0.013], accompanied by the elevation of circulating ST2 level [median (interquartile range) = 16.6 (12.1, 22.5) vs. 12.5 (9.5, 16.7); p = 0.044]. Patients with cardiac injury presented higher levels of aspartate aminotransferase, creatinine, high-sensitivity troponin I, lactate dehydrogenase, and N-terminal pro–B-type natriuretic peptide than those without cardiac injury, although these indexes were within the normal range for all recovered patients at the 6-month follow-up. Among patients with cardiac injury, patients with positive late gadolinium enhancement presented higher cardiac biomarker (high-sensitivity troponin I) and inflammatory factor (high-sensitivity C-reactive protein) on admission than the late gadolinium enhancement–negative subgroup.Conclusions: Our preliminary 6-month follow-up study with a limited number of patients revealed persistent cardiac involvement in 29.6% (8/27) of recovered patients from COVID-19 after discharge. Patients with cardiac injury during hospitalization were more prone to develop cardiac fibrosis during their recovery. Among patients with cardiac injury, those with relatively higher cardiac biomarkers and inflammatory factors on admission appeared more likely to have cardiac involvement in the convalescence phase.

Hypertrophic cardiomyopathy: Totally a ST-elevation myocardial infarction mimic

Hypertrophic cardiomyopathy (HCM) commonly presents with nonspecific ST-T changes in an electrocardiogram (EKG), and a paucity of literature description exists about index presentation of HCM totally as ST-elevation myocardial infarction (STEMI) in a very young age. The presence of convex ST elevation in surface EKG in HCM patients indicates disease progression, becomes evident in the fifth or sixth decade of life, and warrants further risk stratification for the need of automated intracardiac defibrillator therapy. We present a rare presentation of nonobstructive HCM totally mimicking acute anterior wall STEMI in a very young male in his third decade of life, which has not been described in the literature so far. Because of the presence of typical convex shaped ST elevation with biphasic terminal T wave inversion across anterior precordial leads with ongoing typical angina, the patient was subjected to right transradial coronary angiogram which revealed the presence of normal nonatherosclerotic coronaries.

Enriching artificial intelligence ST-elevation myocardial infarction (STEMI) detection algorithms with differential diagnoses

Abstract Background STEMI outcomes, although improved with systems of care, are hamstrung by delayed presentation and prevaricates of a 12-lead ECG. We report an artificial intelligence (AI) guided, single lead EKG algorithm for a self-administered tool to reliably detect STEMI and trigger ambulance dispatch. Purpose To provide a reliable and improved AI-guided Single Lead EKG methodology. Methods From our cardiologist-annotated repository, we assigned a dataset of 11,118 classified ECG. Ontology organized 5 groups apportioned for an interclass balance among commoner STEMI differential diagnoses. This anonymous, pre-classified data included 5,549 STEMI, 1,391 normal, 1,393 Bundle Branch Block, 1,393 non-specific ST-T changes and 1,392 miscellaneous. Each ECG was fragmented into individual 1-lead strips. Algorithm: 1-D Convolutional Neural Networks. Gender and age were included before the last dense layer. Training and Testing: Preset 90% dataset (10,008 ECG) train, 10% test (1,110 ECG). Statistical Analysis and ROC curves: Digitized dataset, 500 samples/second, 10s duration, total 5,000 samples per lead. Statistical mean for each lead was calculated and subtracted from the original lead. Statistical values and ROC curves were assessed. Results Most Accurate: Lead V2 – 91%; Most Sensitive: Lead I – 92% Most Specific: Lead III – 96%. Best AUC: Lead V2 – 91%. Conclusions Incorporating subtypes of STEMI differential diagnosis enriches the single lead AI algorithm. Validating the derived algorithm with our entire database of 18 million ECG will further strengthen the results. Funding Acknowledgement Type of funding source: None

To reperfuse or not to reperfuse: a case report of Wellens\u2019 syndrome with suspected COVID-19 infection

BackgroundWellens’ syndrome is known to be associated with left anterior descending artery occlusion that could lead to an extensive anterior wall myocardial infarction. Thus, emergency cardiac catheterization is needed. However, during coronavirus disease 2019 (COVID-19) pandemic, it is recommended for hemodynamically stable acute coronary syndrome patients with COVID-19 infection to be treated conservatively in an isolated hospital ward.Case presentationWe report an 85-year-old patient with chief complaints of typical, squeezing chest pain in the past 4 h. The patient had a high fever, dyspnea, sore throat, and fatigue for 3 days. He had previously come into contact with COVID-19 positive relatives. The patient was hemodynamically stable and pulmonary auscultation revealed coarse rales in the entire lung. Electrocardiography (ECG) evaluation during the pain episode showed non-specific ST-T changes in lead V2-V5. After sublingual nitrate was administered, ECG evaluation during the pain-free period revealed a biphasic T wave inversion in lead V2 and V3. Laboratory workup showed elevated cardiac marker and leucopenia with neutrophilia and lymphopenia. Rapid immunochromatographic test and initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription-polymerase chain reaction (RT-PCR) evaluation from nasopharyngeal swab showed negative results. However, radiographic evaluations suggest the diagnosis of COVID-19 infection. While waiting for the second RT-PCR evaluation, the patient was diagnosed with Wellens’ syndrome with suspected COVID-19 infection. The patient was treated conservatively according to national guidelines and scheduled for elective cardiac catheterization. On the third day, the patient felt better and insisted on being discharged home. Ten days after discharged, the patient died of myocardial infarction.ConclusionEmergency cardiac catheterization should be done for patient with Wellens’ syndrome, regardless of the COVID-19 infection status.

Nonalcoholic fatty liver disease, a potential risk factor of non-specific ST-T segment changes: data from a cross-sectional study.

BackgroundNon-specific ST-T segment changes are prevalent and are proven risk factors for early onset of cardiovascular diseases. They can increase all-cause mortality by 100∼200% and are candidate for early signs of cardiovascular changes. Nonalcoholic fatty liver disease (NAFLD) is prevalent worldwide and is one facet of a multisystem disease that confers substantial increases morbidity and mortality of nonalcoholic fatty liver-related cardiovascular diseases. It is unclear whether NAFLD is associated with non-specific ST-T changes warning early signs of cardiovascular changes. Therefore, we investigated this association.MethodsA cross-sectional study was designed that included a sample consisting of 32,922 participants who underwent health examinations. Participants with missing information, excessive alcohol intake, viral hepatitis, chronic liver disease or established cardiovascular diseases were excluded. Electrocardiograms were used for analysis of non-specific ST-T segment changes. NAFLD was diagnosed by ultrasonographic detection of hepatic steatosis without other liver diseases. A multivariable logistic regression model was served to calculate the OR and 95% CI for non-specific ST-T segment changes.ResultsThe prevalence of non-specific ST-T segment changes was 6.5% in participants with NAFLD, however, the prevalence of NAFLD was 42.9% in participants with non-specific ST-T segment changes. NAFLD was independently associated with non-specific ST-T segment changes (OR: 1.925, 95% CI: 1.727-2.143, P < 0.001). After adjusting for age, sex, heart rate, hypertension, body mass index, fasting glucose, total cholesterol, triglycerides, HDL-C, NAFLD remained an independent risk factor of non-specific ST-T segment changes (OR: 1.289, 95% CI: 1.122-1.480).ConclusionNon-specific ST-T segment changes were independently associated with the presence of NAFLD after adjusting for potential confounders.

MON-364 Severe Postoperative Encephalopathy in a Patient with Oncogenic Osteomalacia and Neurofibromatosis Type 1

Background: Acute hypophosphatemia superimposed on chronic phosphate depletion results in decline in intracellular ATP and 2,3-diphosphoglycerate levels, affecting virtually all organ systems. It can lead to metabolic encephalopathy, impaired myocardial and diaphragmatic contractility, skeletal and smooth muscle dysfunction, increase in erythrocyte rigidity leading to hemolysis, and increased risk for postoperative morbidity and mortality. Risk of symptomatic hypophosphatemia may be greater in patients with urinary phosphate wasting syndromes hospitalized for intercurrent illness. Tumor-induced (oncogenic) osteomalacia (TIO) is a rare paraneoplastic disorder associated with mesenchymal tumors caused by tumor production of fibroblast-derived growth factor-23 (FGF-23). FGF-23 impairs transport of phosphorus in renal tubules, inhibits renal 25(OH)-1-α-hydroxylase activity, causing decreased levels of calcitriol, leading to hyperphosphaturia, hypophosphatemia and osteomalacia. We present a case of a patient with underlying TIO who presented with acute hypophosphatemia following hip surgery. Case: 50-year-old woman with Neurofibromatosis type-1(NF-1) complicated by TIO, presented after a fall resulting in left femur fracture requiring surgery. During her initial management in an outside hospital for 4 days and following transfer her home calcitriol and phosphorus replacement regimen was not administered leading to treatment interruption of 7 days. On postoperative day 1 she became hypotensive, tachycardic with non-specific ST-T changes and encephalopathic requiring ICU care. At the time of endocrinology consultation, she was non-verbal, not following simple commands, had severe hypophosphatemia, transaminitis, hyperbilirubinemia, elevated LDH, anemia and elevated troponin. She required aggressive phosphate and calcitriol replacement reaching 4 doses of 20mEq IV Na- Phos daily, Na-KPhos Q6H and Calcitriol IV 0.5mcg Q8H over the course of 72 hours. After 4 days in the ICU, once phosphorous levels normalized, she had dramatic improvement in mental status and gradual resolution of laboratory abnormalities. Discussion: To our knowledge, this is the first report of a patient with TIO associated with NF-1 presenting with severe symptomatic hypophosphatemia causing metabolic encephalopathy and multiple organ dysfunction following surgery. It underscores the fact that abrupt interruption of calcitriol and phosphorus supplementation in such cases can cause acute hypophosphatemia carrying high morbidity. High phosphate replacement requirements are indicative of severity of phosphate depletion. This case illustrates importance of recognition of presence of urinary phosphate wasting syndrome in hospitalized patients in order to minimize risk of preventable complications and morbidity.

Impact of electrocardiographic morphology on clinical outcomes in patients with non-ST elevation myocardial infarction receiving coronary angiography and intervention: a retrospective study.

BackgroundThe impact of electrocardiography (ECG) morphology on clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving percutaneous coronary intervention (PCI) is unknown. This study investigated whether different ST morphologies had different clinical outcomes in patients with NSTEMI receiving PCI.MethodsThis retrospective study analyzed record-linked data of 362 patients who had received PCI for NSTEMI between January 2008 and December 2010. ECG revealed ST depression in 67 patients, inverted T wave in 91 patients, and no significant ST-T changes in 204 patients. The primary endpoint was long-term all-cause mortality. The secondary endpoint was long-term cardiac death and non-fatal major adverse cardiac events.ResultsCompared to those patients whose ECG showed an inverted T wave and non-specific ST-T changes, patients whose ECG showed ST depression had more diabetes mellitus, advanced chronic kidney disease (CKD) and left main artery disease, as well as more in-hospital mortality, cardiac death and pulmonary edema during hospitalization. Patients with ST depression had a significantly higher rate of long-term total mortality and cardiac death. Finally, multiple stepwise Cox regression analysis showed that an advanced Killip score, age, advanced CKD, prior percutaneous transluminal coronary angioplasty and ST depression were independent predictors of the primary endpoint.ConclusionsAmong NSTEMI patients undergoing coronary angiography, those with ST depression had more in-hospital mortality and cardiac death. Long-term follow-up of patients with ST depression consistently reveals poor outcomes.