Presence Of ST Elevation Research Articles

Prognostic value of elevated transaminase levels as predictors of adverse outcomes in patients with acute myocardial infarction

Aim. To assess the prevalence of elevated serum liver transaminases (LTs), including alanine aminotransferase (ALT) and aspartate aminotransferase (ALT), and their impact on in-hospital and long-term mortality in patients with acute myocardial infarction (AMI).Materials and methods. The prospective observational study included 416 consecutive AMI patients (median age 65 years, 40.9% female, 46.9% with ST elevation) without prior liver diseases, who underwent coronary angiography within 24 hours after hospitalization. AST and ALT levels were measured upon admission. LTs were considered as abnormal when their levels exceeded the local upper limit of normal. Clinical endpoints were all-cause in-hospital and 18-month mortality. Associations between clinical endpoints and various risk factors, including LT levels, were assessed by the multivariate logistic regression analysis.Results. Elevated LT levels were seen in 28.6% of AMI patients: an isolated increase in ALT was noted in 17.8% of patients, while an isolated increase in AST was registered in 25% of cases. In-hospital and 18-month mortality was 5.8 and 11.3%, respectively. Abnormal LT levels were associated with the presence of ST elevation (odds ratio (OR) 1.873, 95% confidence interval (CI) 1.218–2.881, p = 0.004), lower systolic and diastolic blood pressure (OR 0.993, 95% CI 0.986–1.0, p = 0.04 and 0.979, 95% CI 0.964–0.994, p = 0.007, respectively), higher Killip class (OR 1.510, 95% CI 1.142–1.999, p = 0.004), and higher creatinine level (OR 1.010, 95% CI 1.003–1.016, p = 0.004). In the multivariate analysis, elevated LT levels were independently associated with in-hospital and 18-month mortality (OR 3.607, 95% CI 1.199–10.848, p = 0.022 and 2.182, 95% CI 1.011–4.708, p = 0.047, respectively).Conclusion. Elevated LT levels were present in about a third of patients with AMI. They were associated with specific clinical, biological, and prognostic features, including in-hospital and long-term mortality in AMI patients.

ROLE OF ST–SEGMENT ELEVATION AT POST–ROSC ECG IN PATIENTS RESUSCITATED FROM OUT–OF–HOSPITAL CARDIAC ARREST

Abstract Background A 12–lead electrocardiogram (ECG), performed after return of spontaneous circulation (ROSC) in out–of–hospital cardiac arrest (OHCA), is essential for the identification of ST–segment elevation). The aim of the study is to investigate whether the presence of ST elevation may be a prognostic determinant in post–OHCA patients. Materials and Methods A total of 878 post–ROSC ECGs were collected from patients enrolled from 01/01/2015 to 12/31/2022 from the Lombardy Region Cardiac Arrest Registry (LombardiaCARe). Univariable and multivariable Cox regression models were applied to test the association between the presence of and morphology of supraST and mortality at 30 days after the event. Results Among the 878 post–ROSC ECGs, 406 (46.2%) had ST elevation [49 with tombstone morphology; 26 with lambda morphology; 45 with triangular morphology; and 8 with wave morphology]. Patients with ST elevation were more frequently males (73% vs 59%, p<0.001), younger [66 years old (57–75) vs 71 (61–80), p<0.01], and with a more frequently non–defibrillating rhythm of presentation (25%vs59%, p<0.01) and an event more frequently witnessed by 118 (30% vs 21%, p=0.008). Thirty–day survival was higher in patients with ST elevation (56% vs 41%, p<0.001). Correcting for variables associated with 30–day survival (age, sex, QRS amplitude, ECG acquisition time, first rhythm of presentation), the presence of ST elevation was not significantly associated with 30–day mortality [HR: 0.67 (95% CI: 0.27–1.64); p=0.05], while the number of segments was [1.1 (95%CI 0.85–0.15), p=0.004]. No morphology was independently associated with mortality when compared with standard morphology. Conclusions The presence of ST elevation on ECG post ROSC possesses, in addition to a known diagnostic role, a prognostic role in predicting 30–day survival especially if present in more than one segment.

Preclinical identification of acute coronary syndrome without high sensitivity troponin assays using machine learning algorithms

Preclinical management of patients with acute chest pain and their identification as candidates for urgent coronary revascularization without the use of high sensitivity troponin essays remains a critical challenge in emergency medicine. We enrolled 2760 patients (average age 70 years, 58.6% male) with chest pain and suspected ACS, who were admitted to the Emergency Department of the University Hospital Tübingen, Germany, between August 2016 and October 2020. Using 26 features, eight Machine learning models (non-deep learning models) were trained with data from the preclinical rescue protocol and compared to the “TropOut” score (a modified version of the “preHEART” score which consists of history, ECG, age and cardiac risk but without troponin analysis) to predict major adverse cardiac event (MACE) and acute coronary artery occlusion (ACAO). In our study population MACE occurred in 823 (29.8%) patients and ACAO occurred in 480 patients (17.4%). Interestingly, we found that all machine learning models outperformed the “TropOut” score. The VC and the LR models showed the highest area under the receiver operating characteristic (AUROC) for predicting MACE (AUROC = 0.78) and the VC showed the highest AUROC for predicting ACAO (AUROC = 0.81). A SHapley Additive exPlanations (SHAP) analyses based on the XGB model showed that presence of ST-elevations in the electrocardiogram (ECG) were the most important features to predict both endpoints.

P320 AN UNUSUAL CASE SYNCOPE DUE TO SILENT CORONARY VASOSPASM

Abstract Background Variant angina is a condition due to a transient vasospasm of the epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. A non–negligible subset of patients can also experience silent myocardial ischemia, defined as objective documentation of myocardial ischemia in the absence of angina or equivalents. This condition is associated with increased cardiac mortality and incidence of acute cardiac events. Description of the case. A 65–years–old man was admitted to our Emergency Department for syncope. He reported palpitations before the event without chest pain. ECG showed biphasic T waves in V2–V6 (Fig 1A), troponin values were normal. Immediately after admission in our coronary care unit for monitoring, he developed dynamic ST segment elevation with signs of inferior and posterior transmural ischemia (Fig 1B) and non–sustained polymorphic ventricular tachycardias (Fig 2), being symptomatic only for palpitations. ECG abnormalities and symptoms quickly resolved after intra–venous nitrates administration. Coronary angiography was performed showing a critical non–occlusive (85%) fixed stenosis at the proximal right coronary artery (Fig 3 A). The lesion was treated by angioplasty and stenting (Fig 3 B) and the patients was discharged on dual anti–platelet therapy, statins and oral high–dose calcium–channel antagonist. Discussion This case underlines first the importance of searching for high–risk features in patients with syncope of non–obvious origin: our patient reported palpitations and ECG changes consistent with myocardial ischemia (even with normal troponin values and echocardiographic findings). A peculiarity of our case is that the patient did not complaint any chest pain despite the presence of ST elevation, a condition known as silent ischemia. The transient nature of ECG modification and ventricular arrhythmias, their dramatic response to nitrates and coronary angiography findings were suggestive of silent vasospasm. Coronary vasospasm induces transient myocardial ischemia and may cause ventricular arrhythmias which in turn can cause syncope due to transient cerebral hypoperfusion or, when sustained, even cardiac arrest and sudden death. We did not perform provocative test with acetylcholine or ergonovine due to the likely vasospastic origin of myocardial ischemia and to their potential risks, especially in the presence of non–sustained plymorphic ventricular tachycardias.

Electrocardiogram changes in pediatric patients with myocarditis

BackgroundIt is traditionally taught that pediatric patients with myocarditis almost always have an abnormal electrocardiogram (ECG) at presentation. However, there has never been a study to objectively evaluate ECG changes in pediatric myocarditis patients compared to healthy controls or explore if specific ECG changes correlate with clinical outcomes. MethodsPediatric patients diagnosed with acute myocarditis were age and sex matched 1:2 with healthy controls in this retrospective case-control study spanning a seven-year period. ECGs from presentation through discharge were interpreted by electrophysiologists blinded to the patients' diagnoses. ResultsThirty-nine patients with myocarditis were identified. Twenty-eight (72%) had an abnormal ECG at presentation, 11 (28%) had a completely normal ECG. In this second group, six patients had an abnormal ECG at some point during their hospital course for a total of 34 (88%). Myocarditis patients who had an abnormal ECG at presentation spent more time in the hospital, 5 (2–19) versus 2 ((1–3) days (p < 0.01), and in the ICU, 1 (0–6) versus 0 (0–1) days (p < 0.01). Myocarditis patients were more likely to have ST elevation on their ECG compared to control patients (41% versus 17%, p < 0.01). Patients with ST elevation at presentation had a higher peak troponin level, 18.4 (5.8–31.0) versus 7.7 (0–19.1) ng/ml, (p < 0.01). ConclusionsOver a quarter of patients with myocarditis had a normal ECG at presentation to the emergency department. Patients with an abnormal ECG at presentation spent more time in the hospital. The presenting ECG, particularly the presence of ST elevation, may correlate with other clinical markers and help direct early management decisions.

C60 12–LEAD POST–ROSC ELECTROCARDIOGRAM DISCRIMINATES SURVIVAL TO HOSPITAL DISCHARGE. A SUB–ANALYSIS OF THE PEACE STUDY

Abstract Background Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients. Methods We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style. Results We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p &amp;lt; 0.001], ST elevation in more than one segment [HR 1.7(95% IC 1.2–2.5),p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95% IC 1.1–2.9), p = 0.03] and a right bundle branch block [HR 1.8 (95% IC 1.1–2.8), p = 0.01] were all associated with death before hospital discharge. In multivariable Cox regression, adjusted for the ROSC–to–ECG time, age older than 62 years [HR 1.6 (95% IC 1.1–2.3), p = 0.01], QRS wider than 120 msec [HR 1.7 (95%IC 1.2–2.5), p = 0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2–2.5), p = 0.004] were independently associated with death before hospital discharge. By considering these latter three risk factors, the rate of survival to hospital discharge was significantly influenced by their number [no risk factor: 80.8%; 1 factor: 71.2%; 2 factors: 61.9%; 3 factors: 34.4%; p &amp;lt; 0.001, p for trend &amp;lt;0.001]. With a Cox regression model, considering the absence of risk factor as a reference, we confirmed that having 2 or 3 risk factors was significantly associated with death before hospital discharge [HR 1.9 (95%IC 1–3.5), p = 0.037 e HR 5.1(95%IC 2.6–10.1), p &amp;lt; 0.001 respectively]. Conclusions Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

12-lead post-ROSC electrocardiogram discriminates survival to hospital discharge. A sub-analysis of the PEACE study

Abstract Funding Acknowledgements Type of funding sources: None. Background Once the return of spontaneous circulation (ROSC) after an out-of-hospital cardiac arrest (OHCA) is achieved the acquisition of a 12-lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients. Purpose The aim of the present study is to assess whether ECG features could be associated with survival to hospital discharge. Methods We analysed all the post-ROSC ECGs collected from January 2015 to December 2018 in three European centres. For every ECG, the main features were analysed and filed in the database together with the pre-hospital data collected for every patient according to the Utstein style. Every ECG was evaluated by two independent cardiologists and in case of doubt a third one was asked to solve the dispute. Results We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53-70 years); 121 from center 1 (32.7%), 38 from center 2 (10.3%) and 211 from center 3 (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95%CI 1.1-2.4), p=0.007], QRS wider than 120 msec [HR 1.87 (95%CI 1.3-2.7), p&amp;lt;0.001], the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2-2.5), p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95%CI 1.1-2.9), p=0.03] and the presence of a right bundle branch block [HR 1.8 (95%CI 1.1-2.8), p=0.01] were associated with death before hospital discharge. In multivariable Cox regression, after correction for the ROSC-to-ECG time, age older than 62 years [HR 1.6 (95%CI 1.1-2.3), p=0.01], QRS wider than 120 msec [HR 1.7 (95%CI 1.2-2.5), p=0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%CI 1.2-2.5), p=0.004] were confirmed to be independently associated with death before hospital discharge. By assigning one point to each one of these three variables, we have created a score ranging from 0 to 3. The rate of survival to hospital discharge was found to be significantly different in the four categories [score=0: 80.8%; score=1: 71.2%; score=2: 61.9%; score=3: 34.4%; p&amp;lt;0.001, p for trend &amp;lt;0.001]. Lastly, with a Cox regression model, assuming score 0 as a reference, we confirmed how scores 2 or 3 were significantly associated with death before hospital discharge [HR 1.9 (95%CI 1-3.5), p=0.037 e HR 5.1 (95%CI 2.6-10.1), p&amp;lt;0.001 respectively]. Conclusions Our study proves that after an out-of-hospital cardiac arrest, post-ROSC ECG features can be used for prognostic stratification in addition to the selection of patients who may benefit from urgent coronary angiography.

Development and validation of a model for predicting 18-month mortality in type 2 myocardial infarction

Despite the poor prognosis in patients with type 2 myocardial infarction (MI), no prospective data on risk stratification exists. The aim of this study was to develop and validate a model for prediction of 18-month mortality of among patients with type 2 MI (T2MI) and compare its performance with GRACE and TARRACO scores. The prospective observational study included 712 consecutive patients diagnosed with MI undergoing coronary angiography <24 h between January 2017 and December 2018. Diagnosis of T2MI was adjusted according to Third universal definition. A prognostic model was developed by using Bayesian approach and logistic regression analysis with identifying predictors for mortality. The model was validated by bootstrap validation. Comparison performance between scores using Delong test. T2MI was identified in 174 (24.4%) patients. The median age of patients was 69 years, 52% were female. The mortality rate was 20.1% at 18 months. Prior MI, presence of ST elevation, hemoglobin level at admission, Charlson comorbidity index and were independently associated with 18-month mortality. The model to predict 18-month mortality showed excellent discrimination (optimism corrected c-statistic = 0.822) and calibration (corrected slope = 0.893). GRACE and TARRACO scores had moderate discrimination [c-statistic = 0.748 (95% CI 0.652-0.843) and 0.741, 95% CI 0.669-0.805), respectively] and inferior compared with model (p = 0.043 and 0.037, respectively). The risk of mortality among T2MI patients could be accurately predicted by using common clinical characteristics and laboratory tests. Further studies are required with external validation of nomogram prior to clinical implementation.

Emergency Clinician Experiences Using a Standardized Communication Tool for Cardiac Arrest.

IntroductionSudden cardiac arrest remains a common and critical disease burden. As post-cardiac arrest care grows in complexity, communication between pre-hospital providers, emergency department personnel, and hospital consultants is increasingly important.MethodsThis study evaluated the use of a standard handoff tool between pre-hospital personnel and hospital staff, including emergency medical services (EMS), emergency department nurses, physicians, and cardiologists. Personnel were surveyed regarding attitudes surrounding the important aspects of cardiac arrest care, challenges faced, and preference of handoff mechanism.ResultsMost of the survey respondents (58, 76%) found that the initial rhythm was the most important factor in post-cardiac arrest care, followed by the presence of bystander cardiopulmonary resuscitation (CPR; 55, 72%) and the presence of ST-elevation on initial electrocardiogram (46, 61%). Both emergency physicians (7, 63%), as well as cardiologists (3, 100%), preferred to have this tool performed over radio prior to arrival in the emergency department.ConclusionThe importance given to various post-cardiac arrest factors varied amongst specialty and clinical background; however, all agreed on common features such as the initial rhythm, electrocardiogram (ECG) morphology, and the presence or absence of bystander CPR. Additionally, the timing and structure of how this information is delivered were further elucidated. This data will guide future handoff methods between specialties managing patients after cardiac arrest.

P1492Is early repolarization pattern only an ion channel disease?

Abstract Background Early repolarization pattern (ERP) has been generally described as a benign electrocardiographic (ECG) sign despite it is associated with the development of malign ventricular arrhythmias. Although the pathophysiological mechanism of malign ventricular arrhythmias in ERP has been explained only electrophysiologically, whether the presence of structural changes in myocardium has not been known yet. Purpose We hypothesized that ERP is not only an ion channel disease. The structural changes in myocardium begin in individuals with ERP sign on 12 lead surface ECG even if a young person. The aim of the present study was to determine myocardial dysfunction due to early decaying in myocardial structure in individuals with ERP sign by the use of 2D- speckle tracking echocardiography (STE). Method We prospectively included 99 individuals who admitted to our clinic between 01.04.2018 and 01.09.2018. 48 individuals had ERP. 12 lead surface ECG was taken from all individuals at admission, all individual's ECG were further analysed for presence of ERP and ERP was divided into three groups which were defined as presence of ST elevation, J wave and QRS slurring. 2D-STE (Philips Epiq 7C Ultrasound System for Cardiology (Andover, USA)) was performed in all individuals. All strain echocardiographic recordings were further analysed off- line by the use of associated software. Results ERP had significantly lower left ventricular (LV) global longitudinal strain (GLS), circumferential peak systolic strain rate (CPSSr) in basal segments of LV and left ventricular ejection fraction compared to controls. In addition, LV diastolic function especially in LV basal segments were significantly impaired in individuals with ERP when assessed by circumferential peak diastolic strain rate (CPDSr) compared to controls. GCS, LV- longitudinal peak systolic Sr (LPSSr) and LV- longitudinal peak diastolic Sr (LPDSr) in all of the apical chambers were similar between two groups (Table 1). There was not a relationship between type of ERP and all of these parameters including GLS, GCS, LPSSr, CPSSr, LPDSr, CPDSr. Finally, ST elevation pattern had higher GCS value while QRS slurring pattern had higher GLS value (Figure 1). Figure 1 and Table 1 Conclusion Our study firstly demonstrated ERP can be combined of structural and electrical heart disease. LV-GLS can be more closely associated with ERP than LV-GCS. In addition, the either of impaired of circumferential systolic and diastolic function in LV basal segments can be detected in individuals with ERP.

Utility of aVR electrocardiogram lead for identifying the culprit lesion in patient with acute coronary syndrome

Background: The lead aVR is neglected electrocardiography (ECG) lead while interpreting various cardiac diseases including coronary artery disease (CAD). The aVR lead is a potentially useful tool in ECG in diagnosing and managing patients with CAD. Aim and Objectives: The aim is to study the usefulness of ECG in localizing the culprit vessel by coronary angiogram (CAG) in patients with the acute coronary syndrome (ACS) and to find the relation of ECG findings, with regional wall motion abnormality (RWMA) and CAG profile. \Materials and Methods: This was a cross-sectional observational study done on patients admitted with the diagnosis of ACS. A total of 54 patients were included in this study satisfying the inclusion criteria presented with ACS. Results: A total of 54 patients (males: 55.7% and females: 46.3%) were enrolled fulfilling inclusion criteria of the study (male: 59.72 [±10.59], female: 55.24 [±11.93]). A total 59.36% of patients had resulting RWMA. About 33.33% of patients had single-vessel disease, 24.07% had double-vessel disease , and 18.52% had triple-vessel disease (TVD) with P = 0.081. A total 79.62% of patients ECG could able to diagnose CAD. About 100% of patients with proximal left anterior descending (LAD) lesion 85.71% with LMCA, 40% with TVD had ST elevation in aVR lead. About 66.67% of patients with the right coronary artery (RCA) and 50% with left circumflex infarction (LCx) lesion had ST depression in aVR lead. About 59.36% had RWMA on echocardiogram. Conclusions: The presence of ST elevation in aVR indicates a culprit lesion in the proximal segment of LAD or LMCA. The absence ST elevation in aVR excludes the left main coronary artery as the underlying cause in the context of anterior wall ST-elevation myocardial infarction (STEMI). ST elevation in aVR is valuable for distinguishing proximal from distal lesions in the LAD in anterior wall STEMI. ST-segment depression in lead aVR is valuable for differentiating RCA from those with LCx in the inferior STEMI. Echocardiography findings aid triage for the management of the patient with ACS.

Correlations between hematological indicators and other known markers in acute coronary syndromes

Introduction: Recently, many hematologic markers have identified as prognostic and diagnostic indicators in different acute coronary syndrome (ACS) patients. In particular, neutrophil / lymphocyte ratio (NLR) and platelet / lymphocyte ratio (PLR) are recognized as markers in the diagnosis and prognosis of ACS. In this study, our aim was to investigate the correlation between the diagnostic yield of PLR and NLR values and other markers such as troponin in all ACS patients. Material and methods: 319 patients admitted to our hospital with ACS and 283 control patients were included in the study. Leukocyte, neutrophil, platelet, lymphocyte counts, PLR, NLR and high sensitive troponin I (HsTnI) measurements were taken. Results: Leukocyte, neutrophil and platelet counts were significantly higher in the ACS group than the controls (p <0.001). Lymphocyte count was significantly lower in the ACS group than the controls (p <0.001). NLR and PLR were found to be significantly higher in the ACS group than the controls (4.0 ± 3.3 vs 2.1 ± 1.4 and 126.3 ± 68.9 vs 106.9 ± 49.4, p <0.001, respectively). NLR was showed significant correlation with HsTnI, PLR, angina time, presence of ST elevation and T wave negativity (p <0.05), and PLR revealed significant correlation with NLR, HsTnI, ST elevation and T wave negativity (p <0.05). Conclusion: Hematologic markers were found to be significantly higher in the ACS group than the controls. The difference also continued in subgroup analyzes. NLR and PLR correlated with many other ACS indicators.

Percutaneous coronary intervention reduces mortality in myocardial infarction patients with comorbidities: Implications for elderly patients with diabetes or kidney disease

BackgroundPercutaneous coronary intervention (PCI) reduces mortality in most myocardial infarction (MI) patients but the effect on elderly patients with comorbidities is unclear. Our aim was to analyse the effect of PCI on in-hospital mortality of MI patients, by age, sex, ST elevation on presentation, diabetes mellitus (DM) and chronic kidney disease (CKD). MethodsCohort study of 79,791 MI patients admitted at European hospitals during 2000–2014. The effect of PCI on in-hospital mortality was analysed by age group (18–74, ≥75years), sex, presence of ST elevation, DM and CKD, using propensity score matching. The number needed to treat (NNT) to prevent a fatal event was calculated. Sensitivity analyses were conducted. ResultsPCI was associated with lower in-hospital mortality in ST and non-ST elevation MI (STEMI and NSTEMI) patients. The effect was stronger in men [Odds ratio (95% confidence interval) 0.30 (0.25–0.35)] than in women [0.46 (0.39–0.54)] aged ≥75years, and in NSTEMI [0.22 (0.17–0.28)] than in STEMI patients [0.40 (0.31–0.5)] aged <75years. PCI reduced in-hospital mortality risk in patients with and without DM or CKD (54–72% and 52–73% reduction in DM and CKD patients, respectively). NNT was lower in patients with than without CKD [≥75years: STEMI=6(5–8) vs 9(8–10); NSTEMI=10(8–13) vs 16(14–20)]. Sensitivity analyses such as exclusion of hospital stays <2days yielded similar results. ConclusionsPCI decreased in-hospital mortality in MI patients regardless of age, sex, and presence of ST elevation, DM and CKD. This supports the recommendation for PCI in elderly patients with DM or CKD.

The Relationship of ST Segment Changes in Lead aVR with Outcomes after Myocardial Infarction; a Cross Sectional Study.

Among the 12 leads studied in electrocardiography (ECG), lead aVR can be considered as the most forgotten part of it since no attention is paid to it as the mirror image of other leads. Therefore, the present study has been designed with the aim of evaluating the prevalence of ST segment changes in lead aVR and its relationship with the outcome of these patients. In this retrospective cross sectional study medical profiles of patients who had presented to emergency department with the final diagnosis of myocardial infarction (MI) in a 4-year period were evaluated regarding changes of ST segment in lead aVR and its relationship with in-hospital mortality, the number of vessels involved, infarct location and cardiac ejection fraction. 288 patients with the mean age of 59.00 ± 13.14 (18 - 91) were evaluated (79.2% male). 168 (58.3%) patients had the mentioned changes (79.2% male). There was no significant relationship between presence of ST changes in lead aVR with infarct location (p = 0.976), number of vessels involved (p = 0.269) and ejection fraction on admission (p = 0.801). However, ST elevation ≥ 1 mv in lead aVR had a significant relationship with mortality (Odds = 7.72, 95% CI: 3.07 - 19.42, p < 0.001). Sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios of ST elevation ≥ 1 for prediction of in-hospital mortality were 41.66 (95% CI: 22.79 - 63.05), 91.53 (95% CI: 87.29 - 94.50), 31.25 (95% CI: 16.74 - 50.13), 94.44 (95% CI: 90.65 - 96.81), 0.45 (95% CI: 0.25 - 0.79), and 0.05 (95% CI: 0.03 - 0.09), respectively. Based on the results of the present study, the prevalence of ST segment changes in lead aVR was estimated to be 58.3%. There was no significant relationship between these changes and the number of vessels involved in angiography, infarct location and cardiac ejection fraction. However, presence of ST elevation ≥ 1 in lead aVR was associated with 8 times increase in in-hospital mortality risk.

Takotsubo Cardiomyopathy and Intra-Cardiac Thrombus Complicating Cerebellar Haemorrhage

An 86-year-old female with background of hypertension and mild Alzheimer's was found with dysarthria, nausea and vomiting. She was haemodynamically stable without chest pain or dyspnoea. Computed tomography of her brain revealed right cerebellar haemorrhage. ECG showed anterolateral ST elevation; not initially addressed perhaps due to lack of cardiac symptoms and more pressing haemorrhage. Three days later she developed heart failure. Elevated troponin and transthoracic echocardiogram (TTE) were consistent with Takotsubo cardiomyopathy (TTC) but also revealed left ventricular apical intra-cardiac thrombus (ICT). Intracranial events are well reported triggers of TTC, most commonly subarachnoid haemorrhages. Intracerebral haemorrhages (ICH) are less common, though interestingly of nine reported ICH triggered-TTC, four were cerebellar haemorrhages, suggesting an increased risk with this location. ICT occurs in 2.5-8% of TTC patients, with cardio-embolic events occurring in 12.2% of these, similar to rates following myocardial infarction (MI). Risk factors for ICT following TTC include apical variant, presence of ST elevation on ECG, and elevated CRP–all seen in this patient. Evidence for management of ICT in TTC is scant. Indirect data from MI-related ICT suggest benefit in oral anticoagulation for preventing ICT and reducing rates of embolisation. Of course, with recent ICH and risk of future ICH due to presumed amyloid angiopathy, anticoagulation was contraindicated here. This is an unfortunate situation with limited recourse other than to monitor left ventricular recovery and thrombus resolution. In absence of bleeding, more research into early anticoagulation for prevention of ICT in TTC in high-risk patients is warranted.

Clinical Significance of the Forsaken aVR in Evaluation of Tachyarrhythmias: A Reminder.

Mechanism of a regular, monomorphic Wide QRS Complex Tachycardia (WCT) is an important diagnostic challenge in day to day practice for the clinicians and affects further management and prognosis. Many of the WCT and Narrow Complex Tachycardia (NCT) produce certain characteristic changes in lead aVR by which we can differentiate between them. The present study was aimed to evaluate tachyarrhythmias in relation to lead aVR and to highlight the clinical significance of lead aVR, "The Neglected Lead". This is prospective study in which 55 consecutive cases of tachyarrhythmias excluding sinus tachycardia, atrial fibrillation and atrial flutter were taken for the study admitted in from ICCU of Department of Medicine at S.S. Medical College and S.G.M. Hospital Rewa (M.P.), India, during July 2014 to September 2015, fulfilling the required study protocol. The data was collected regarding detailed history, physical examination; necessary investigations (including ECG and echocardiography) were done. Among 55 patients, 30 were of WCT and 25 were of NCT. The most common cause of WCT was Ventricular Tachycardia (VT) (83.3%) and rest were Supra Ventricular Tachycardia (SVT) with aberrancy (16.7%). The most common cause of NCT was Atrioventricular Nodal Tachycardia (AVNRT) (84%) followed by Atrioventricular Reciprocating Tachycardia (AVRT) (16%). The present study observed that 38.1% of the AVNRT cases and 50% of AVRT cases showed positive 'p' wave in lead aVR. The present study observed that 75% cases of AVRT showed ST segment elevation in lead aVR while only 33.3% cases of AVNRT showed ST elevation. In the present study 80% of the patients with WCT were diagnosed to have VT using Brugada algorithm while using Vereckei's new aVR algorithm, 83.3% were diagnosed to have VT. Lead aVR, one of the most neglected leads on 12 lead ECG, is a very important diagnostic tool for identification and categorization of different type of tachyarrhythmias. The presence of ST elevation in lead aVR on ECG showing NCT is relatively sensitive for diagnosing AVRT. New aVR algorithm by Vereckei is more sensitive for differential diagnosis of WCT. One should pay careful attention to lead aVR which provides essential diagnostic information.

Insights into the Presentation of Myocarditis in New Zealand; a 10-Year Audit

Aim: To review the presenting characteristics of myocarditis patients and the significance of ST-elevation (STE) on ECG in a New Zealand DHB population. Method: Retrospective review of clinical records of patients >15 years old with a confirmed or suspected diagnosis of myocarditis at Waitemata DHB 2007-2016. Results: Over 10 years, 178 patients had a diagnosis of myocarditis. Most were male (71%) with a distribution to younger age groups (median age 39). Men were significantly younger than women (37.5 vs 50.9 years, p < 0.05). Ethnicity was concordant with the demographics of Waitemata DHB; Europeans (69%), Maori (12%), Pacific Islanders (10%). Presenting symptoms included chest pain (73%), dyspnoea (32%) and fever (25%). Men had both higher presenting troponin I levels (5938 ng/L vs 3307 ng/L, p < 0.05) and maximum troponin I levels (8661 ng/L vs 3946 ng/L, p < 0.05) than women. Eighty-one patients had ECG changes: 59% STE, 6% ST-depression and 35% other changes. Patients with STE were more likely than those with non-STE to be male (85% vs 66%, p < 0.05), younger (mean age 35.4 vs 43.5 years, p < 0.05) and to have chest pain (94% vs 65%, p < 0.05). Patients with STE had higher troponin I levels both on presentation (8537 ng/L vs 3931 ng/L, p < 0.05) and at peak (13313 ng/L vs 5067 ng/L, p < 0.05). STE and non-STE groups had similar rates of coronary angiography (48% vs 47%), echocardiography (83% vs 92%), and cardiac MRI (54% vs 52%) (p = ns for all). Conclusion: There was an apparent predilection for males, and the gender differences in presenting symptoms and biomarker elevation were unexpected. The usage rates of invasive and non-invasive imaging were not affected by the presence of STE. Further study is warranted to review the outcomes in these groups of patients.

Predictive Value of Exercise Stress Test-Induced ST-Segment Changes in Leads V1 and avR in Determining Angiographic Coronary Involvement.

The significance of electrocardiographic changes during exercise tolerance testing for distinguishing occluded artery is not well known. We tried to determine the role of ST elevation in leads aVR and V1 during exercise in detecting stenosis of left main coronary artery and proximal left anterior descending artery. ST segment changes during exercise in 230 patients, who underwent diagnostic angiography, were documented. The association of ST elevation in lead aVR, V1 , leads aVR + V1 , and STE in leads aVR + V1 with ST depression in other leads with pattern of coronary stenosis were investigated. Left main and proximal left anterior artery stenosis were more common in patients with ST elevation in lead aVR (P < 0.001 for both). Similar association was found in the presence of ST elevation in lead V1 . The presence of ST elevation ≥1 mm in lead aVR had a sensitivity of 100% and 94.3% for detecting left main and left anterior descending artery stenosis, respectively. The specificity was 33.5% and 26.6%, respectively. ST elevation in leads aVR + V1 had a sensitivity of 74.4% and 65.9% and a specificity of 68.5% and 64.4% for detecting left main and left anterior descending arteries stenosis, respectively. ST elevation in lead aVR is highly sensitive for left main and proximal left anterior descending artery lesions. Using ST elevation in lead V1 in addition to lead aVR as a positive finding increases the specificity with a further decrease in sensitivity.

Type D personality is related to severity of acute coronary syndrome in patients with recurrent cardiovascular disease.

To investigate the relationship between Type D (distressed) personality and cardiac biomarkers of disease severity in patients with acute coronary syndrome. To identify potential mechanisms behind the effect of Type D personality on cardiovascular disease (CVD). Cross-sectional. Patients (N=215) with acute coronary syndrome completed a survey including a measure of Type D personality. Blood samples including a lipid profile and cardiac enzymes were taken within 3days after the cardiovascular event. Data were analysed using simple correlations, multiple regressions, and mediation analyses. Type D personality was more predictive of severity of the acute coronary syndrome among patients with previous CVD compared to patients without previous CVD. Among patients with previous CVD, Type D personality was associated with the presence of ST elevation (R(2) =.07) and more damage to the myocardium as indicated by higher troponin-I (R(2) =.05) and myoglobin (R(2) =.07) levels. These effects were independent from demographics, CV risk factors, and depression. Lower HDL cholesterol levels mediated the relationship between Type D personality and disease severity (Κ(2) =.12 [95% CI 0.02, 0.28]) for myoglobin and Κ(2) =.08 [95% CI 0.01, 0.21] for troponin-I). Type D personality was related to a worse lipid profile and more severe acute coronary syndrome in patients with previous history of CVD. Given the strong relationship between disease severity and subsequent mortality, these results suggest that severity of the myocardial infarction may be a potential mechanism explaining increased mortality in Type D patients with recurrent CVD. Statement of contribution What is already known on this subject? Type D personality has been related to worse outcomes in cardiac patients. However, recent studies show mixed results, suggesting the need to clarify potential mechanisms. What does this study add? Type D personality is related to severity of acute coronary syndrome in patients with previous history of cardiovascular disease. This effect is partially accounted for by lower HDL levels in Type D patients. Disease severity is a potential mechanism by which Type D personality may affect cardiovascular health of patients with recurrent CVD.

Predictors of inhospital mortality following out-of-hospital cardiac arrest: Insights from a single-centre consecutive case series

Purpose of the studyOut-of-hospital cardiac arrest (OHCA) has a poor prognosis despite bystander resuscitation and rapid transfer to hospital. Optimal management of patients after arrival to hospital continues to be...