Past Cardiac History Research Articles

Abstract 18703: No Time for Horseplay: A Case on a Traumatic Septal Defect

Background: A 74-year-old male with no past medical history presented to the clinic due to shortness of breath that had worsened over the past two weeks. He reports being “knocked over by a horse” about one month before and experienced chest pain immediately afterwards. A new holosystolic murmur was found prompting further evaluation. A walking test showed his oxygen saturation dropped from 98% to 81% on room air and was in respiratory distress. TTE revealed a large VSD of 1.5 cm with a left to right shunt, a dilated right ventricle measured at 4.9 cm, and severe pulmonary hypertension. Coronary angiography ruled out a prior myocardial infarction. RHC revealed an increase of oxygen saturation from the right atrium at 68.6% to 92% in the right ventricle. The patient was transferred to a facility where he underwent successful surgical VSD closure. He was discharged to rehab on post-operative day 8. He presented to the clinic one month later reporting resolution of his symptoms. Discussion: This patient with no past cardiac history presented with progressive dyspnea that was later identified to be caused by a trauma he experienced one month prior. The incidence of traumatic VSDs is quite low. Most VSDs are congenital in nature however few are reported to be trauma related. Trauma so intense that could cause a rupture in the septal muscle is quite intriguing. Prompt work up with imaging modalities such as TTE is the best next step for any trauma-related symptoms. Shared decision making with the patient and a multidisciplinary team will help to decide on a percutaneous or surgical repair of the defect. This case demonstrated a systematic approach to a unique presentation of a typically congenital condition.

The Framingham Study on Cardiovascular Disease Risk and Stress-Defenses: A Historical Review

The Framingham Heart Study (FHS) began in 1949 with the goal of defining the epidemiology of hypertensive or arteriosclerotic heart disease in the population of Framingham, Massachusetts, a primarily Caucasian suburb west of Boston with a population of approximately 28,000. The participants were without previous symptoms of heart disease and were followed for the occurrence of Cardiovascular Disease (CVD). The study documented a comprehensive medical history that included current symptoms, family history, past cardiac history, social history, and medications. The medical exam included diagnostic studies of chest X-ray, electrocardiogram (EKG), complete blood count (CBC), uric acid level, blood glucose, urinalysis, and venereal disease research laboratory test; Syphilis (VDRL). Serum lipids, recognized at the time to be associated with cardiovascular disease, were also measured. These included cholesterol, total phospholipids, and the Gofman’s Sf 10–20 fraction. Study participants underwent four examinations at 6-month intervals to document any clinical manifestation of CVD. The present understanding of the epidemiologic factors that influence cardiovascular disease risk (CVD-R) is based on the first report of study results at a 6-year median follow-up and numerous subsequent analyses of long-term follow-up data from the original Framingham cohort as well as their offspring. In this paper, we review the Framingham cohort study with regards to the risk factors of peripheral vascular disease.

742 Myocarditis after SARS-CoV-2 vaccine: is that so simple?

SARS-CoV-2 vaccination is associated with potential side effects, particularly following second vaccine dose. Recent case series have reported a potential association between SARS-CoV-2 vaccination and acute myocarditis, predominantly in young males. We hereby describe a previously healthy 17-year-old man, with no past cardiac history, who presented to the emergency department with persistent chest pain and fever (up to 38 °C). The patient had received the first dose of Cominarty (BioNTech/Pfizer) vaccine 10 days before symptom onset and reported flu-like symptoms and conjunctivitis involving both eyes one week before administration of the first vaccine dose. On that occasion, no COVID test was performed and the patient was treated with anti-inflammatory drugs and antibiotic eye drops. On admission, laboratory tests were performed (Troponin-I Δ 19 500–23 270 ng/l. CRP 23 mg/dl, ESR 43 s, WBC 17 570 cell/mm3) as well as COVID-19 PCR, Serological tests and Autoimmune disorders panel all resulting negative. CT coronary angiogram did not reveal any spontaneous coronary artery dissection or anomalous origin of coronary arteries and Calcium Score was 0. Transthoracic echocardiography showed a depressed LVEF (36%) with concomitant posterior and inferior wall as well as posterior and anterior basal interventricular septum hypokinesia. Endomyocardial biopsy revealed multifocal lymphocytic myocarditis with sub-endomyocardial and interstitial fibrosis. CMR was also performed (1-week after presentation) demonstrating mildly depressed systolic function (LVEF 47%), with hypokinesia of the posterior and inferior wall, increased signal intensity on T2 maps (58 ms, n.v. <55 ms), prolonged native T1 values (1083 ms, n.v. <1030 ms) as well as subepicardial and intramyocardial LGE enhancement of infero-lateral segments reflecting intercellular fibrosis. Thereafter, the patient was discharged with medical therapy including ACE-inhibitor, colchicine, and ibuprofen. Given the close proximity between SARS-CoV-2 vaccine administration and the absence of other predisposing conditions, the aetiology of myocarditis was attributed to the vaccine. In addition, as the patient suffered from flu-like symptoms and conjunctivitis 1 week before the vaccine, a previous paucisymptomatic SARS-CoV-2 infection was suspected and anti-SARS-Coronavirus Nucleocapsid Protein antibody test revealed high antibody levels with low IgG avidity. Given that myocarditic symptoms evolved after complete Sars-Cov2 symptom resolution, our first hypothesis is that the infection is unlikely to be the cause of acute myocarditis in this patient. Indeed, current literature on COVID-related myocarditis reports close temporal association between respiratory symptoms and myocarditis onset. In support to our hypothesis, recent trials have reported that myocarditis more frequently occurs following administration of mRNA vaccines especially in male adolescents and young adults like our patient. However, cardiac side effects typically occur after full vaccination and symptoms appear within three days following the second dose, which does not fully apply to this case. Notwithstanding this, more recent studies have reported myocarditis even after first vaccination dose in patients with previous COVID-19 infection, analogously to the case described. This case suggests a complex interaction between immunological factors and covid infection/vaccination with potential significant implications on the cardiovascular system. From current literature, much uncertainty remains regarding time interval criteria for reliable post-vaccination myocarditis diagnosis, hence large-scale clinical trials are needed to address this issue.

C26. Case report: COVID-19 associated Takotsubo cardiomyopathy

BackgroundCOVID-19 infection can lead to several cardiovascular sequelae, including Takotsubo cardiomyopathy (TCM), which may portend worse clinical outcomes.Case DescriptionA 56-years-old woman with history of hypertension presented to the emergency room for dyspnea and gradual decrease of consciousness for seven days. She was positive for COVID-19 and transferred to intensive care unit to receive mechanical ventilation due to respiratory failure. Electrocardiogram showed pathological Q wave and ST elevation in inferior and anterior. Troponin I was mildly elevated (5.52 ng/ml). Inflammatory marker CRP and procalcitonin were increased (3.6 mg/dl and 0.235 ng/ml, respectively). Serum cortisol level was 525.8 ng/ml. Echocardiography showed reduced left ventricular ejection fraction (LVEF 41%), with severe hypokinetic of the apical segments and preserved basal myocardial function consistent with visual signs of apical ballooning in TCM. Her follow-up echocardiography showed normal contractility of the apical myocardial segments, with normalization of the left ventricular systolic function, further supporting the reversibility of acute stress cardiomyopathy.DiscussionMechanisms of TCM in viral infections include catecholamine-induced myocardial toxicity and inflammation related to sepsis. A presumptive diagnosis of TCM was made based on the characteristic echocardiogram findings of apical ballooning, normalization of left ventricular systolic function, unremarkable past cardiac history and spontaneous improvement in serum troponin-I levels in the setting of a severe systemic illness.ConclusionClinicians should be aware of the diversity of cardiovascular complications of COVID-19, including Takotsubo cardiomyopathy and should strategize appropriately for diagnosing and managing them.

C26. Case report: COVID-19 associated Takotsubo cardiomyopathy

BackgroundCOVID-19 infection can lead to several cardiovascular sequelae, including Takotsubo cardiomyopathy (TCM), which may portend worse clinical outcomes.Case DescriptionA 56-years-old woman with history of hypertension presented to the emergency room for dyspnea and gradual decrease of consciousness for seven days. She was positive for COVID-19 and transferred to intensive care unit to receive mechanical ventilation due to respiratory failure. Electrocardiogram showed pathological Q wave and ST elevation in inferior and anterior. Troponin I was mildly elevated (5.52 ng/ml). Inflammatory marker CRP and procalcitonin were increased (3.6 mg/dl and 0.235 ng/ml, respectively). Serum cortisol level was 525.8 ng/ml. Echocardiography showed reduced left ventricular ejection fraction (LVEF 41%), with severe hypokinetic of the apical segments and preserved basal myocardial function consistent with visual signs of apical ballooning in TCM. Her follow-up echocardiography showed normal contractility of the apical myocardial segments, with normalization of the left ventricular systolic function, further supporting the reversibility of acute stress cardiomyopathy.DiscussionMechanisms of TCM in viral infections include catecholamine-induced myocardial toxicity and inflammation related to sepsis. A presumptive diagnosis of TCM was made based on the characteristic echocardiogram findings of apical ballooning, normalization of left ventricular systolic function, unremarkable past cardiac history and spontaneous improvement in serum troponin-I levels in the setting of a severe systemic illness.ConclusionClinicians should be aware of the diversity of cardiovascular complications of COVID-19, including Takotsubo cardiomyopathy and should strategize appropriately for diagnosing and managing them.

P1501 Huge lateral wall ventricular pseudoaneurysm complicating a silent myocardial infarction

Abstract Introduction Mechanical complications of acute myocardial infarction (AMI) are mainly ventricular septal rupture (VSR), free wall rupture, and ischemic mitral regurgitation. If the patient survives the acute phase, negative remodeling starts to occur leading to aneurysm or pseudoaneurysm formation. Case report A 44-year-old male patient, smoker with a past medical history of hypertension, diabetes mellitus and no past cardiac history except for recurrent pericardiocentesis of hemorrhagic pericardial effusion in another hospital since 3 months with no available data, presented to our medical facility complaining of dyspnea grade III with no orthopnea or paroxysmal nocturnal dyspnea that started 4 months ago and progressed gradually with no history of any acute events. He was hemodynamically stable with no audible murmurs and clear chest auscultation. Transthoracic echocardiography (TTE) showed reduced left ventricular (LV) systolic function (ejection fraction 40%) with accidentally discovered large lateral wall ventricular pseudoaneurysm containing a large mural thrombus (Panels A and B) and a small pericardial effusion with no evidence of constriction or tamponade. Cardiac Computed tomography (CT) confirmed the presence of large ventricular pseudoaneurysm with mural thrombus lining the wall of the aneurysm (Panels C and D). Invasive coronary angiography (CA) revealed a total occlusion of the left circumflex artery (LCx) and non significant lesions in the remaining coronaries. The patient refused to have surgery and he was discharged on anti-ischemic, anti-failure measures and anti-coagulation with close follow-up. Conclusion Bedside echocardiography is still the mainstay procedure for diagnosis of mechanical complications following AMI and other imaging modalities such as cardiac CT and cardiac magnetic resonance (CMR) are new diagnostic tools for confirming the diagnosis and planning for further interventions. Although rare, mechanical complications of AMI should always be considered in every ischemic patient. Abstract P1501 Figure. Echo and CT images

Screening Pediatric Patients in New-Onset Syncope (SPINS) Study.

Objectives. The primary objective is to determine the frequency of history findings associated with cardiac syncope. Second, to determine the frequency of abnormal electrocardiograms (EKG) in patients presenting with typical vasovagal syncope. Methods. Retrospective chart review from January 2006 to April 2017 of children aged 5 to 18 years presenting to the emergency department with a chief complaint of syncope. Target population was all patients with first episode of syncope and a documented EKG. Excluded patients were those with head trauma, drug intoxication, current pregnancy, seizure, and any endocrine problem. Patients with cardiac causes of syncope were identified by an abnormal EKG or echocardiogram. Specific history findings (past cardiac history, chest pain, palpitations, syncope with exercise, absence of prodrome with syncope) were compared with those with and without cardiac etiology of syncope. The possibility of missing a patient with cardiac cause of syncope based on specific history findings was identified. Results. Of the total 4115 visits of patients with chief complaints of syncope, 2293 patients (55.7%) met the inclusion criteria. Nine patients (0.39%) were identified with cardiac etiology of syncope. The remaining were determined to be of vasovagal origin. All patients with cardiac etiology of syncope were found to have one positive specific history findings. A total of 1972 patients were identified with absence of specific history findings; no patient had a cardiac etiology of syncope. Conclusions. This study identifies screening questions to identify cardiac syncope. Implementing these standard questions could potentially decrease resource utilization and time for evaluation as well as guide follow-up.

Temporal trends in stress Myocardial Perfusion Imaging (MPI) studies in patients with Coronary Artery Disease (CAD) and with no CAD among Saudi Arabian’s population

Introduction Previous studies showed that lower risk patients are being referred to stress testing. Few studies suggested that the frequency of abnormal myocardial perfusion imaging (MPI) studies have declined over the past two decades to even less than 10%. However, it is not clear if this is a universal observation. The aim of this analysis is to assess the temporal trends of the prevalence of abnormal and ischemic MPI studies among large consecutive cohort of Saudi Arabia’s population over a period of 11 years. Methodology From a high volume single center registry, we assessed all patients who undergone stress MPI studies between Octobers 2007 to June 2017 for changes in their demographics, baseline clinical information, past cardiac history, and cardiac risk factors. We also compared the trends of the frequency of abnormal and ischemic MPI. The sample was divided into 5 successive temporal subgroups for the purposes of analysis: 2007 to 2008; 2009 to 2010; 2011 to 2012; 2013 to 2014; and 2015 to 2017. Results A total of 13,786 MPI studies were analysed over the specified duration. There was a progressive decline in the prevalence of abnormal MPI in all patients, from 50.8% in 2007 to 32.3% in 2017, (P Conclusion There has been a temporal decline in the prevalence of abnormal and ischemic MPI studies over a period of 11 years. However, this decline is significantly lower than the previously reported from western cohorts.

Cardiac Vignette: Ruptured Coronary Sinus of Valsalva

A 35-year-old male with no significant past cardiac history presented to our institution with chest pain, dyspnoea and palpitations. On presentation, he was hypotensive and tachycardic. Examination revealed a Grade IV pansystolic murmur, loudest over the left parasternal region. Electrocardiogram revealed sinus tachycardia, right-axis deviation and right bundle branch block morphology. Blood tests showed a high sensitivity troponin leak of 900. Computed tomographic pulmonary angiography revealed right lower lobe segmental pulmonary embolus. Bedside transthoracic echocardiogram revealed a severely dilated right ventricle (RV) with severe impairment of systolic function. Left ventricular (LV) function was normal. Colour Doppler showed presence of a shunt between the LV and right atrium (RA) in the superior aspect of the septal leaflet. Transoesophageal echocardiography demonstrated a dilated RA and RV with a small peri-membranous ventricular septal defect located high in the interventricular septum with turbulent flow from the LV to the RV. An additional shunt was observed from the LV into the RA. Overall findings were consistent with a ruptured coronary sinus of Valsalva. The patient had a complicated clinical course with cardiogenic shock, acute liver injury and renal impairment. Decision was made for cardiothoracic intervention. Repair of sinus of Valsalva from the aortic non-coronary sinus to the right atrium with repair of the aortic valve and closure of secundum atrial septal defect. The patient had an uneventful intra-operative and postoperative course. Aneurysm of the coronary sinus of Valsalva is a rare congenital cardiac anomaly. Multimodality imaging is essential for accurate diagnosis and management.

TCTAP C-076 Percutaneous Coronary Intervention for Stumpless Ostial Left Anterior Descending Artery Chronic Total Occlusion with Poor Developed Collateral Connection

### Patient initials or identifier number DT ### Relevant clinical history and physical exam A 45-year-old man with exertional dysnea of 2 months duration refractory to maximal medical therapy. The past cardiac history was significant for PCI 13 years previously, including a bare metal stent

165: Paediatric Chest Pain in the Emergency Department

Chest pain is a frequent chief complaint of paediatric patients presenting to the emergency department (ED). Despite the low risk of a cardiac cause in the paediatric population, chest pain is a worrisome presentation for patients and their families, and sometimes serious underlying pathology can occur. There is no evidence based diagnostic approach, and this results in significant practice variation often with extensive investigations, both in the ED and in follow-up. To establish poor predictive value and over-use of diagnostic testing in pediatric patients presenting with chest pain. After REB approval, a chart review was conducted of all patients presenting to an urban paediatric tertiary care ED with the chief complaint of chest pain over a three year period. Charts were analyzed for sex, age at presentation, associated symptoms, past cardiac history, investigations in the ED, discharge diagnosis, and outpatient echocardiogram and Holter monitor findings. Of the 473 visits, 50 were repeat visits. The mean age at visit was 12.1 years, and mean duration of pain was 53.4 minutes. 16.9% (n=80) of patients reported past cardiac-related medical history. 64.9% (n=307) of patients received chest x-ray, but only 2.9% (n=9) had an abnormal finding. Electrocardiogram was done in 75.7% (n=358) of the patients, and 23.7% (n=85) of the results were abnormal. Troponin was done in 9.5% (n=45) of the cases, with only one abnormal result unrelated to cardiac etiology. 96.0% of patients (n=454) were discharged, and 4% (n=19) were admitted to hospital. Most causes were idiopathic (n=282, 59.6%), followed by musculoskeletal causes (n=145, 30.7%). Within six months following discharge, 75 (15.9%) patients received echocardiogram, 45 (60%) of whom had no reported cardiac history or previous investigations, and 25 had normal ECG in the ED. The echocardiograms yielded only two cases of newly diagnosed mitral valve prolapse, and one case of small patent ductus arteriosus. 50 patients (10.6%) received Holter monitoring within six months following discharge, 20 of whom had no previous cardiac history, and had normal ECGs in the ED, and the arrhythmias found on Holter monitor correlated poorly with the presenting symptoms. This is the largest paediatric review of chest pain in Canada in published literature. Chest pain in the paediatric population are rarely due to cardiac causes, but most patients still receive unnecessary investigations in the ED, and in their follow-up visits. An evidence based diagnostic algorithm would be useful to improve resource utilization in children presenting with chest pain.

Ictal Asystole in Focal Epilepsy: To Pace or Not to Pace?

Ictal bradyarrhythmias are rare episodes occurring in patients with or without a past cardiac history. These episodes go unnoticed unless the patient is monitored on simultaneous video-electroencephalogram and 1-lead electrocardiogram. Recognizing ictal bradyarrhythmias is important, since episodes may predispose patients to sudden, unexplained death in epilepsy. We present 2 cases of ictal asystole in patients with right temporal lobe epilepsy. The first patient had seizures refractory to medical therapy and received a pacemaker. The seizures in the second patient responded well to antiepileptic medication, and a pacemaker was deferred. These cases highlight the differing cardiovascular treatment options for ictal asystole.

Congenital absence of left atrial appendage: A case report and literature review

Congenital absence of left atrial appendage (LAA) is an extremely rare entity. A 50-year-old man with no past cardiac history was admitted with symptomatic atrial fibrillation (AF). Before subjecting him to direct current (DC) cardioversion, the patient underwent a transesophageal echocardiography (TEE) examination, but neither LAA nor a cardiac thrombus could be detected. Absence of both was confirmed by cardiac computer tomography (CT) and a cardiac magnetic resonance imaging (MRI) scan. The patient reverted to sinus rhythm with an uneventful synchronized biphasic DC shock of 100joules.

Abstract P152: Differences in Symptom Presentation According to Type of Acute Myocardial Infarction

Background: Chest pain/discomfort is the hallmark symptom of Acute Myocardial Infarction (AMI). An important percentage of AMI patients may not present with chest pain/discomfort. We hypothesized that the presence or absence of chest pain/discomfort at the time of admission may be influenced by the AMI classification type: ST segment elevation MI (STEMI) or Non STEMI (NSTEMI). Methods: We analyzed data from 1,143,513 AMI patients (565,195 with STEMI; 578,318 with NSTEMI) in the National Registry of Myocardial Infarction (NRMI) during the 1994-2006 period. Multivariable models were developed to examine the predictors of AMI presentation without chest discomfort by AMI type, adjusting for age, gender, ethnicity, payer status, cardiac risk factors, past medical history and past cardiac history. Results: The proportion of AMI patients who presented with chest pain was significantly higher in patients with STEMI (72.9%) than NSTEMI (56.4%) (p &lt;0.001). Conversely, percentage of AMI patients who presented without chest pain was higher in NSTEMI (43.6%) and much lower in STEMI (27.1%) p &lt;0.001. Multivariable analysis indicates a strong association by AMI Type. TABLE. Differences in Presentation Without Chest Pain Among Patients Diagnosed By AMI Type: NRMI, 1994-2006 Unadjusted Odd Ratio + 95 CI Adjusted Odds Ratio + 95 CI STEMI NSTEMI STEMI NSTEMI Reference 2.07 [2.06, 2.09] Reference 1.93 [1.91, 1.95] Conclusions: Hospitalized AMI patients without chest pain/discomfort were almost 2x more likely to have NSTEMI than STEMI. These findings may have important clinical implications when evaluating patients with a suspected acute coronary syndrome.

Picture Quiz Answer: A young man with palpitations

A 17 year old male was referred to the Accident and Emergency department (A&amp;E) by his GP after he had experienced an episode of palpitations associated with dyspnoea whilst attempting exercise. He did not have any past cardiac history.

Clinical assessment of a patient with stable heart failure

Heart failure is a complex condition with numerous symptoms and signs, both specific and nonspecific. Consequently, obtaining a comprehensive patient history is of great importance. Thorough assessment of past medical and cardiac history, comorbid conditions, signs and symptoms are essential forthe planning and implementation of effective care. This article describes a practical approach to conducting such an assessment and uses a case study as an example of this. Social and psychological factors may not impact greatly at the beginning of the disease trajectory, but are relevant for patients who wish to consider future coping strategies. Health education enhances patient understanding and concordance with the management plan and is paramount to patient empowerment and effective care. A management plan for the patient discussed in the case study is suggested.

Young patients with chest pain: 1-year outcomes

Objective Prior studies found that young adult chest pain patients without known cardiac disease with either no cardiac risk factors or a normal electrocardiogram (ECG) are at low risk (<1%) for acute coronary syndromes (ACS) and 30-day cardiovascular events. Longer-term event rates in this subset of patients are unknown. We hypothesized that patients younger than 40 years without past cardiac history and a normal ECG are at less than 1% risk for 1-year adverse cardiovascular events. Methods We conducted a prospective cohort study in an urban university emergency department evaluating patients younger than 40 years who received an ECG for evaluation of potential ACS. Cocaine users, cancer patients, and patients with a history of myocardial infarction or revascularization were excluded. Structured data collection at presentation included demographics, chest pain description, history, laboratory results, and ECG data. Hospital course was followed. Follow-up was obtained by telephone, record review, and social security death index search. Our main outcome was 1-year adverse cardiovascular events (death; acute myocardial infarction [AMI]; or revascularization—percutaneous coronary intervention [PCI] or coronary artery bypass graft). Descriptive statistics and 95% confidence intervals were used. Results Of 3846 chest pain patients, 609 met criteria. Of those, 35.5% were admitted. Patients had a mean age of 34.8 years (SD, 3.8 years). They were most often female (57.6%) and black (69.5%). There were 7 patients (1.1%; 95% CI, 0.5%-2.4%) with adverse cardiovascular events over the year. Of the subset of 560 patients with a normal/nonspecific ECG, there were 2 deaths (0.4%), 3 AMI (0.5%), and 2 PCIs (0.4%) by 1 year for a composite adverse cardiovascular event rate of 6 (1.1%; 95% CI, 0.4%-2.3%). Of the subset of 269 patients with no cardiac risk factors and a normal/nonspecific ECG, there were no deaths, 1 AMI, and 1 PCI for a composite adverse cardiovascular event rate at 1 year of 0.3% (0.01%-2.1%). The addition of an initial cardiac marker to this group resulted in a cohort that was event-free at 1 year (95% CI, 0%-1.4%). Conclusions Patients younger than 40 years without a cardiac history who present to the ED with symptoms consistent with ACS but have either no risk factors or a normal or nonspecific ECG have a very low rate of adverse events during the subsequent year.

Cardiac arrest in a case of undiagnosed dilated cardiomyopathy patient presenting for emergency cesarean section

Cardiac diseases in the pregnancy pose a multitude of challenges to the obstetricians as well as anesthesiologists. Cardiac pregnant patients presenting for emergency cesarean section do not give time for cardiac optimization and stabilization if they come to the hospital for the first time without any antenatal check-up. The situation can get worse if there is no history related to the decompensated cardiac tissue with asymptomatic gestation and also if the relatives hide all the facts from the doctor about any past cardiac history. We report a case of term pregnancy for emergency cesarean section with asymptomatic dilated cardiomyopathy, which developed severe ventricular arrhythmias and cardiac arrest during the surgical procedure. She was resuscitated successfully on the operation table and was shifted to Intensive Care Unit for further management. The diagnosis of dilated cardiomyopathy was made only after carrying out echocardiography in the postoperative period. The history of previous cardiac complaints was not revealed purposefully by the relatives to avoid the expenses which they would have incurred on investigations and treatment of cardiac ailment.

Cardiovascular events (CVEs) associated with tyrosine kinase inhibitor (TKI) therapy in patients with metastatic renal cell carcinoma (mRCC) at a regional cancer center

e16040 Background: Recent studies suggest the incidence of CVEs associated with TKIs has been underestimated. Phase III trials have reported low incidences of heart failure, cardiac ischemia and hypertension. A recent observational study reported that one third of patients taking sunitinib or sorafenib experienced a cardiovascular event often without symptoms. We assessed the incidence of CVEs in mRCC patients who received TKIs at our centre. Methods: Eligible mRCC patients were identified from a mRCC database between January 2006 and November 2008. Data was retrospectively extracted including age, sex, diagnosis, histology, past cardiac history, cardiac risk factors, number and type of TKI regimens, and CVEs. A CVE was defined as unexplained death, acute coronary syndrome (ACS), heart failure, or arrhythmia requiring intervention. We also identified any new or exacerbated cases of hypertension after the start of TKI therapy, as a CVE. Results: Eighty-five eligible patients were identified. Average age was 61 years (range, 23–78), 72% were male and 80% were clear cell in origin. A total of 31 CVEs occurred in 28 patients (33%). These events occurred at a median of 5 weeks of TKI therapy (range, 1 - 64 weeks). There were 8 cases of ACS, 2 of heart failure, 2 of arrhythmia, and 3 unknown causes of death. Only 2 of these particular CVEs were associated with new or increased hypertension. There were 16 cases of hypertension alone. Those who had CVEs had a higher mean number of cardiac risk factors. They were also more likely to have an echocardiogram during treatment, and less likely to receive sorafenib following sunitinib. Conclusions: Our study suggests a lower rate of CVEs than recent studies, but the true rate may be underestimated, as routine cardiac studies were not performed in all patients. Rational surveillance strategies for patients receiving TKI therapies should be developed. Prospective trials should address predictive and prognostic factors for CVEs. [Table: see text] [Table: see text]

Lack of an association between medicare supplemental insurance and delay in seeking emergency care for patients with myocardial infarction

Study objective: Previous studies have shown that Medicare patients without supplemental insurance are less likely to receive preventive services, such as mammography. The effect of supplemental insurance on the appropriate use of emergency services is unknown. We sought to determine whether the absence of supplemental Medicare coverage is associated with increased delay in seeking care for acute myocardial infarction. Methods: In this retrospective cohort study, we compared the time from symptom onset to hospital arrival (the time-delay interval) in Medicare patients with and without supplemental insurance coverage who presented with an acute myocardial infarction to 1 of 19 hospitals in King County, WA, from 1989 to 1993. There were 1,373 patients with Medicare-only coverage and 2,050 patients with Medicare plus supplemental insurance coverage. Results: The age-, sex-, and race-adjusted median time delay was 135 minutes for the Medicare-only group and 130 minutes for the Medicare plus supplemental insurance group (P =.34; 95% confidence interval for median time-delay difference in minutes −5 to 10). There was no significant association between the presence of Medicare supplemental insurance coverage and time delay in Cox regression models, which also adjusted for event year, income, education, past cardiac history, and clinical symptoms. Conclusion: For this cohort of Medicare patients, the absence of supplemental insurance coverage did not lead to significantly increased delays in seeking care for myocardial infarction. Lack of supplemental insurance for Medicare patients might not have as great an effect on the use of emergency services as it has on other health care services. [Ann Emerg Med. 2002;40:381-387.]