Repolarization Abnormalities Research Articles

AN ISOLATED ACUTE RIGHT VENTRICULAR INFARCTION

Abstract Isolated right ventricular infarction occurs only in about 3% of the overall myocardial ischemic episodes. Clinical presentation is often insidious and variable case by case. The correct diagnosis is therefore crucial for a proper management, and a good prognosis in the short and long term. A 72–year–old patient suffering from arterial hypertension went to the emergency room of our hospital for malaise and asthenia for about 12 hours that have increased in 3–4 hours before the arrival. He was sweating, tachypneic with normal value of the oxygen saturation to the finger (SpO2:96%), with arterial hypotension (pressure values = 85/50 mmHg), turgor of the jugular veins in the absence of peripheral edema. Cardiac examination revealed no pathological noises and lung examination revealed clear lung fields. Electrocardiogram showed sinus tachycardia at a rate of 118 bpm, second degree atrioventricular (AV) block 2:1 type and an AV conduction delay with a first–degree AV block (P–Q interval: 320–330 msec). A pulmonary P wave was present and the QRS complex showed predominant R waves in V2–V3 with slight repolarization abnormalities (figure, panel A). An ST–elevation in right precordial leads, V3R and V4R was evident. (figure, panel B). Echocardiographic evaluation showed a hypertrophic left ventricle with normal volume and function, with marked enlarged right sections (figure, panels C–H). Moreover, we can observe the flattening of the interventricular septum with a D shaped left ventricle. Septal flattening occurred only in diastole, expression of RV volume overload (figure, panels F–H). After taking 180 mg of ticagrelor administrated orally and 150 mg of aspirin intravenously, the patient was immediately transferred to the catheterization laboratory for emergency coronary angiography. Coronary angiography highlighting an ostial thrombotic obstruction of a co–dominant right coronary artery (RCA) in the absence of significant stenosis of the left coronary circulation (figure, panels I–M). Primary percutaneous coronary intervention of RCA was performed with STENT implantation with a good postoperative result. (figure, panels L). During the hospital stay, the patient showed a good clinical status without any CV events, with progressively normalization of electrocardiographic abnormalities and persistent sinus rhythm. He was discharged after ten days.

THE APEX TALKS…CARDIAC METASTASIS MIMICKING ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Abstract A 78–year–old man with a recent diagnosis of lung squamous cell carcinoma was referred to our cardiology department for marked ECG abnormalities (ST segment elevation in V2–V4 and T waves inversion in the antero–lateral leads, Fig.1) in the absence of ischemic symptoms and for the detection of an intramyocardial mass at the apical segments on the CT scan. He had no significant previous cardiovascular history. A transthoracic echocardiogram (TTE) was performed and showed an isoechoic mass at the LV apical segments measuring 3 x 4 cm apparently incorporating the myocardial wall without a clear cleavage plane (Fig.2a). The EF was normal. No pericardial effusion present. The contrast echocardiography with Sonovue revealed a late uptake of the contrast (Fig.2b). Cardiac magnetic resonance (CMR) showed an ovular image in the para–apical area of 40 x 23 cm consistent with a secondary lesion (Fig.3). Unfortunately, the exam was interrupted early due to a patient’s claustrophobic crisis, without having acquired the post–contrast images. Due to infiltrative appearance of the mass and the oncology history, this formation was highly suspicious for metastasis. No complicated ventricular arrhythmias were detected on ECG monitoring. No symptoms of heart failure were reported. Due to the marked EKG repolarization abnormalities the patient underwent coronary angiography which excluded significant stenosis. FDG PET/CT showed areas of increased metabolism also at liver and adrenal left gland. Finally, the patient was transferred to the oncology department for specific management. Cardiac metastases are more common than primary cardiac malignancy and are more frequently related to primary lung cancer, followed by breast cancer and hematologic malignancies. Typical presentation includes arrhythmias or conduction disturbances. The imaging findings of cardiac metastases are non–specific but mostly infiltrative, heterogeneous, and multiple masses may be present. Echocardiography is the initial imaging test for the detection of cardiac metastasis, although CMR, CT and PET/CT may be helpful. Herein we described a case of cardiac metastasis with EKG mimicking acute coronary syndrome. This finding is not uncommon among these patients. EKG findings of myocardial ischemia or injury, particularly localized and prolonged ST elevation, in the absence of ischemic symptoms have been reported in previous studies as high specificity for cardiac metastasis in patients with malignancy.

TAKOTSUBO SYNDROME PRECEDING THE INDEX EVENT: A DANGEROUS CLINICAL SETTING

Abstract We describe the case of a 68–year–old patient who presented to the Emergency Department following an unwitnessed syncopal episode with slow recovery of consciousness. On admission, the patient had dyspnoea together with physical signs of pulmonary congestion. Cardiac ultrasound showed severe left ventricular dysfunction with an ejection fraction of 30%, and apical and paraapical akinesis. The admission electrocardiogram showed sinus tachycardia and diffuse repolarization abnormalities, hs TnI was elevated and BNP vl blood gas analysis were unremarkable. During observation in the Emergency Department, the patient experienced epileptic seizure, promptly resolved by intravenous Midazolam. Contrast–enhanced chest CT ruled out aortic dissection disclosing a clinically irrelevant subsegmental pulmonary embolism. A non–contrast CT scan of the brain yielded negative results. In consideration of the atypical clinical presentation and scattered evidence of an acute coronary syndrome, the patient was admitted to our Cardiac Intensive Care Unit (CICU) for additional diagnostic workup delaying coronary angiography in the presence of stable TnI elevation. Three hours after admission the patient continued showing altered consciousness and a subsequent brain CT was performed, demonstrating an intraparenchymal hemorrhagic spreading. Repeat ECGs showed precordial T wave inversion and prolongation of the QT interval. These data, together with LV apical dysfunction, raised the suspicion of Takotsubo syndrome secondary to an acute cerebrovascular event. During the hospital stay, recovery of consciousness, spontaneous absorption of the cerebral hemorrhagic spread and complete recovery of left ventricular function at repeat cardiac ultrasound examinations were observed, confirming the almost unequivocal diagnosis of Takotsubo syndrome. The patient was discharged uneventfully and was scheduled for an outpatient coronary CT scan. This case underscores the crucial importance of a thorough clinical assessment in the management of complex patients in the presence of nonunivocal clinical signs and misleading blood test and imaging data. Moreover, Takotsubo syndrome is a protean clinical entity that can precede the index event as in our patient, i.e. cerebral hemorrhage. Misclassification of these patients as having an acute coronary syndrome could have led to the initiation of antithrombotic therapy, with potential fatal outcomes for the patient.

Cardiac repolarization abnormalities and neurally mediated syncope: overlooked aspects in the diagnosis of pheochromocytoma

BackgroundPheochromocytoma is a rare catecholamine-producing tumour originating from adrenal chromaffin cells. Classic clinical presentation includes headache, diaphoresis and palpitation. Syncope is uncommon and may result from hypotension or arrhythmia. We report a case of neurally mediated syncope in pheochromocytoma associated with cardiac repolarization abnormalities, a unique presentation of the disease.Case presentationThis case report presents a 28 year-old woman, describing recurrent syncope usually preceded by prodromes such as headache, visual blurring, heart palpitations and psychomotor agitation. Firstly she was diagnosed with anxiety and depression, but there was no improvement of symptoms with psychiatric treatment. Previous Holter revealed long QT interval. Echocardiogram showed normal dimensions, preserved left ventricular function and no valvopathies. The patient was referred for a Head-up tilt test (HUTT) in order to investigate reflex syncope. The electrocardiogram (ECG) exhibited normal sinus rhythm and diffuse cardiac repolarisation abnormalities. HUTT was positive for vasodepressor type neurally mediated syncope and ECG showed U waves after a syncope episode. This electrocardiographic finding motivated further clinical investigation. The patient also described abdominal pain, increased abdominal volume, weight loss and blood pressure instability. Based on clinical history and ventricular repolarisation abnormalities uncovered by HUTT, pheochromocytoma was suspected. Urinary test was positive for catecholamines and the abdominal imaging revelead expansive lesion. She underwent surgery to remove the pheochromocytoma, confirmed by immunohistochemistry.ConclusionsAfter surgery she had no recurrency of symptoms, remaining asymptomatic after six years of follow-up, suggesting a cause-effect relationship between neurally mediated syncope and pheochromocytoma.

Prevalence of abnormal electrocardiographic findings and associated factors among patients with epilepsy at Jimma Medical Center, Ethiopia; Hospital-based cross-sectional study.

A person with epilepsy experiences recurrent seizures as a result of a persistent underlying disorder. About 50 million people globally are impacted by it, with 4 million of those being in Sub-Saharan Africa. One of the most frequent comorbidities that raise the mortality and morbidity rates of epileptic patients is abnormal Electrocardiographic (ECG) findings. Thus, the purpose of this study is to evaluate the prevalence of abnormal ECG findings in epileptic patients that might lead to increased risk of sudden cardiac death. A hospital based cross-sectional study was at Jimma Medical Center of Ethiopia on epileptic patients who were on follow-up at neurologic clinics during the data collection period. The malignant ECG characteristics and was identified using the ECG abnormality tool. To facilitate analysis, the gathered data was imported into Epidata version 3.1 and exported to the SPSS version 26. The factors of abnormal ECG and sudden death risk were examined using bivariate logistic regression. The study comprised 190 epileptic patients, with a mean age of 32 years. There were more men than women, making up 60.2%. A 43.2% (n = 80) frequency of ECG abnormalities was identified. According to the study, early repolarization abnormalities were the most common ECG abnormalities and increased with male sex and the length of time a person had seizures (AOR) of 4.751 and 95% CI (.273,.933), p = 0.029, compared to their female counterparts. The frequency of malignant ECG alterations in epileptic patients on follow-up at Jimma Medical Center in Ethiopia is described in the study. According to the study, there were significant ECG alterations in epileptic individuals. Male gender and longer duration of epilepsy raise the risk of abnormal ECG findings that could result in sudden cardiac death.

Evaluation of T-wave memory after accessory pathway ablation in pediatric patients with Wolff-Parkinson-White syndrome.

T-wave memory (TWM) is a rare cause of T-wave inversion (TWI). Alterations in ventricular activation due to abnormal depolarization may cause repolarization abnormalities on the ECG, even if myocardial conduction returns to normal. These repolarization changes are defined as TWM. In our study, we aimed to determine the frequency of TWM development and the predictors affecting it in the pediatric population who underwent accessory pathway (AP) ablation due to Wolff-Parkinson-White (WPW) syndrome. The data of patients with manifest AP who underwent electrophysiological studies and ablation between 2015 and 2021 were retrospectively analyzed. The study included 180 patients who were under 21 years of age and had at least one year of follow-up after ablation. Patients with structural heart disease, intermittent WPWs, recurrent ablation, other arrhythmia substrates, and those with less than one-year follow-up were excluded from the study. The ECG data of the patients before the procedure, in the first 24h after the procedure, three months, and in the first year were recorded. The standard ablation technique was used in all patients. Postprocedure TWM was observed in 116 (64.4%) patients. Ninety-three patients (51.7%) had a right-sided AP, and 87 patients (48.3%) had a left-sided AP. The presence of posteroseptal AP was found to be significantly higher in the group that developed TWM. Of these patients, 107 (93.1%) patients showed improvement at the end of the first year. Preprocedural absolute QRS-T angle, postprocedural PR interval, and right posteroseptal pathway location were identified as predictors of TWM. The development of TWM is particularly associated with the right-sided pathway location, especially the right posteroseptal pathway location. The predictors of TWM are the preprocedural QRS-T angle, the postprocedural PR interval, and the presence of the right posteroseptal AP.

Long-term treatment with insulin-like growth factor-1 in Phelan-McDermid syndrome: a case report

Phelan-McDermid syndrome (PMS) is a chromosomal microdeletion syndrome generally caused by loss-of-function variants or deletions affecting the SHANK3 gene. We report on a case of a 19-year-old woman with a diagnosis of PMS, autism, and developmental disability. She has been under clinical care since the age of 9 and received treatment with subcutaneous IGF-1 from 11 to 15 years of age. The treatment spanned 2 periods, totaling 35 months, interspersed with a 16-month off-treatment interval. Clinically significant improvement was evident during the treatment periods, particularly in the Social Responsiveness Scale, the Aberrant Behavior Checklist, and clinical assessments, contrasted with a clear deterioration during the off-treatment period. Sleep difficulties worsened during the first period, and EKG repolarization abnormalities emerged during the second period, ultimately leading to definitive treatment discontinuation. In conclusion, an experimental long-term on-off-on treatment with IGF-1 in an adolescent with PMS resulted in mixed results, showcasing positive clinical improvements alongside potentially severe adverse events in the long run.

Impact of Smokeless Tobacco on Cardiovascular Disease Risk in a Nigerian Metropolitan City.

The use of smokeless tobacco products (STP) as a substitute for tobacco smoking is driving increasing consumption of these products especially in developing countries. The study sought to make comparison of cardiovascular risk profile between chronic STP users and suitably matched tobacco-naïve controls. This is a preliminary report from the cross sectional part of a two-arm prospective study of Smokeless Tobacco Products Composition and Exposure Outcome in Enugu metropolis, Nigeria. Consecutively recruited current Smokeless tobacco users, who had no history of cigarette smoking, aged 18years and above, residing in selected communities in Enugu metropolis, Nigeria were recruited for the study from October 2022 to July 2023. Age and sex matched non-tobacco users from same localities as the study subjects served as controls. Written informed consent to participate in the study was obtained from all study participants. All participants were screened by the investigators, using the study case report forms, to obtain data on medical history, demographic, clinical, laboratory, and electrocardiographic evaluation. Data from 54 STP-users and 54 non-STP-users (mean age 56.58 ± 8.15years) were analyzed. Anthropometric parameters were similar in both groups. Smokeless tobacco users had higher erect and supine blood pressure indices as well asgreater postural drop in systolic blood pressure. The occurrence of diabetes mellitus (20.37% versus 5.56%) and hypertension (25.93%; 11.11%) was significantly higher in the STP-users than in the non-user population, (p = 0.02192 and 0.04751 respectively). Electrocardiographic evaluation showed significantly increased QTc and dispersions of P-wave, QRS and QT intervals as well as reduced PR interval in STP users. Electrocardiographic abnormalities observed in STP users include left ventricular hypertrophy, left atrial enlargement, ST-segment elevation, short PR interval and long QTc. Use of smokeless tobacco products is associated with increased risk burden of diabetes mellitus and hypertensive heart disease. Electrocardiographic findings linked to STP-use in this study are features consistent with arrhythmia, ventricular repolarization abnormality, myocardial hypertrophy and ischaemia, suggesting that smokeless tobacco products are not safe substitutes for tobacco smoking.

Arrhythmogenic Cardiomyopathy: Focus on Imaging

Abstract Arrhythmogenic cardiomyopathy (AC) is a broad term denoting subclinical or clinical heart muscle disease which presents predominantly with serious arrhythmias. Heart muscle disease or cardiomyopathy can present as an abnormal electrocardiogram, heart failure, syncope, arrhythmias, or sudden cardiac death. Ventricular arrhythmogenesis is the hallmark of this entity. A small but significant number of athletes experiencing sudden cardiac death have AC. AC has complex and ill-understood pathophysiology. Usually, arrhythmogenic cardiomyopathies are genetic or hereditary. In these patients, muscle hypertrophy, dilatation, cardiac fat metaplasia, and fibrosis provide the anatomic substrate for arrhythmias. Hereditary cardiomyopathies are considered primary diseases of the cardiac myocytes and their intercellular junctions. Secondary diseases of the myocardium due to coronary artery disease, hypertension, valvular heart disease, etc., are excluded from this nomenclature. Channelopathies are also not included in the spectrum of AC. Initially, AC was reported as a single phenotype and labeled arrhythmogenic right ventricular dysplasia, and it was considered a desmosomal disorder. Our current knowledge about this entity has expanded to include multiple variants of this entity with diverse genetic mutations. Its genotypes and phenotypes are still evolving. As of now, distinct desmosomal, cytoskeletal, nuclear, and sarcomeric ACs have been reported. Geography-specific syndromic ACs have also been described. It is a cell-to-cell disjunction cardiomyopathy impairing the inter- and intracellular signal transduction. Gap junctions make AC unique in the sense that arrhythmias precede structural alterations or heart failure in the vast majority. There is also a distinct arrhythmogenic atrial cardiomyopathy. Diagnostic algorithms include morphofunctional, depolarization and repolarization abnormalities, distinct genetic mutations, and typical arrhythmias which serve as the basis of scoring systems devised to diagnose AC. This review discusses salient aspects of AC focusing on imaging observations.

PREVALENCE AND PROGNOSTIC VALUE OF T-WAVE INVERSION IN HYPERTENSIVE PATIENTS: A 5-YEAR FOLLOW-UP STUDY

Objective: Data on prevalence and associated prognosis of repolarization abnormalities among hypertensive patients are limited. We investigated the presence and extent of ST-segment and T-wave changes in a hypertensive population and their predictive ability for cardiovascular disease. Design and method: We studied 1851 white Caucasian hypertensive patients (age 58±12years, 51% females) without a history of cardiovascular disease for a mean period of 5.3±3.4 years. At the baseline examination, all patients underwent standard 12-lead electrocardiography. T-wave inversion (TWI) was defined as T-wave deflection > -0.1 mV in > 2 contiguous leads, unless associated with bundle branch block. Anterior, lateral, or inferior TWI was defined as TWI in leads V2-V4 or V5, V6, I, AVL or II, aVF respectively. The depth in millimeters of TWI in each lead was recorded and the maximum depth per location was calculated. ST depression was defined as >1 mm in depth in two or more contiguous leads. During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was the incidence of cardiovascular morbidity set as the composite of non-fatal coronary artery disease and stroke. Results: In the entire population, prevalence of TWI was 3.8%, of which 39% presented with anterior TWI, 73% with lateral TWI and 11% with inferior TWI. ST depression was observed in 3.6% of patients (anterior in 0.8%, inferior in 0.9% and lateral in 2.6%). Incidence of the composite endpoint during follow-up was 4%. Cox regression analysis revealed that presence of TWI was associated with a significantly greater risk for cardiovascular events (HR: 2.6, 95% CI: 1.1-5.9, p=0.025). The association was stronger for lateral TWI (HR: 3.3, 95%: CI: 1.34-8.30, p=0.01) compared to other locations. In multivariate models controlling for standard confounders these associations were overall sustained. Depth of TWI and presence of ST depression were not associated with cardiovascular risk. Conclusions: Among hypertensive patients without cardiovascular disease, TWI is infrequent but significantly associated with future cardiovascular events. Lateral TWI carries the worse prognosis.

The role of cardiac magnetic resonance in sports cardiology: results from a large cohort of athletes.

Cardiac magnetic resonance (CMR) provides information on morpho-functional abnormalities and myocardial tissue characterisation. Appropriate indications for CMR in athletes are uncertain. To analyse the CMR performed at our Institute to evaluate variables associated with pathologic findings in a large cohort of athletes presenting with different clinical conditions. All the CMR performed at our Institute in athletes aged > 14years were recruited. CMR indications were investigated. CMR was categorised as "positive" or "negative" based on the presence of morphological and/or functional abnormalities and/or the presence of late gadolinium enhancement (excluding the right ventricular insertion point), fat infiltration, or oedema. Variables associated with "positive" CMR were explored. A total of 503 CMR were included in the analysis. "Negative" and "positive" CMR were 61% and 39%, respectively. Uncommon ventricular arrhythmias (VAs) were the most frequent indications for CMR, but the proportion of positive results was low (37%), and only polymorphic ventricular patterns were associated with positive CMR (p = 0.006). T-wave inversion at 12-lead ECG, particularly on lateral and inferolateral leads, was associated with positive CMR in 34% of athletes (p = 0.05). Echocardiography abnormalities resulted in a large proportion (58%) of positive CMR, mostly cardiomyopathies. CMR is more efficient in identifying a pathologic cardiac substrate in athletes in case of VAs (i.e., polymorphic beats), abnormal ECG repolarisation (negative T-waves in inferolateral leads), and borderline echocardiographic findings (LV hypertrophy, mildly depressed LV function). On the other hand, CMR is associated with a large proportion of negative results. Therefore, a careful clinical selection is needed to indicate CMR in athletes appropriately.

Imaging Features of Arrhythmogenic Cardiomyopathies.

Arrhythmogenic cardiomyopathy (ACM) is a genetic disease characterized by replacement of ventricular myocardium with fibrofatty tissue, predisposing the patient to ventricular arrhythmias and/or sudden cardiac death. Most cases of ACM are associated with pathogenic variants in genes that encode desmosomal proteins, an important cell-to-cell adhesion complex present in both the heart and skin tissue. Although ACM was first described as a disease predominantly of the right ventricle, it is now acknowledged that it can also primarily involve the left ventricle or both ventricles. The original right-dominant phenotype is traditionally diagnosed using the 2010 task force criteria, a multifactorial algorithm divided into major and minor criteria consisting of structural criteria based on two-dimensional echocardiographic, cardiac MRI, or right ventricular angiographic findings; tissue characterization based on endomyocardial biopsy results; repolarization and depolarization abnormalities based on electrocardiographic findings; arrhythmic features; and family history. Shortfalls in the task force criteria due to the modern understanding of the disease have led to development of the Padua criteria, which include updated criteria for diagnosis of the right-dominant phenotype and new criteria for diagnosis of the left-predominant and biventricular phenotypes. In addition to incorporating cardiac MRI findings of ventricular dilatation, systolic dysfunction, and regional wall motion abnormalities, the new Padua criteria emphasize late gadolinium enhancement at cardiac MRI as a key feature in diagnosis and imaging-based tissue characterization. Conditions to consider in the differential diagnosis of the right-dominant phenotype include various other causes of right ventricular dilatation such as left-to-right shunts and variants of normal right ventricular anatomy that can be misinterpreted as abnormalities. The left-dominant phenotype can mimic myocarditis at imaging and clinical examination. Additional considerations for the differential diagnosis of ACM, particularly for the left-dominant phenotype, include sarcoidosis and dilated cardiomyopathy. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Myocardial injury in dogs: a retrospective analysis on etiological, echocardiographic, electrocardiographic, therapeutic, and outcome findings in 102 cases

IntroductionIn dogs, myocardial injury (MI) is a poorly characterized clinical entity; therefore, this study aimed to provide a detailed description of dogs affected by this condition. Animals, materials, and methodsDogs diagnosed with MI according to the concentration of cardiac troponin I (cTnI) were retrospectively searched. Signalment, diagnostic, therapeutic, and outcome data were retrieved. Dogs were divided into six echocardiographic (dilated cardiomyopathy phenotype; hypertrophic cardiomyopathy phenotype; hypertrophic cardiomyopathy phenotype with systolic dysfunction; abnormal echogenicity only; endocarditis; and no echocardiographic abnormalities suggestive of MI), four electrocardiographic (abnormalities of impulse formation; abnormalities of impulse conduction; abnormalities of ventricular repolarization; and no electrocardiographic abnormalities suggestive of MI), and nine etiological (infective; inflammatory; neoplastic; metabolic; toxic; nutritional; immune-mediated; traumatic/mechanical; and unknown) categories. Statistical analysis was performed to compare cTnI values among different categories and analyze survival. ResultsOne hundred two dogs were included. The median cTnI value was 3.71 ng/mL (0.2–180 ng/mL). Echocardiographic and electrocardiographic abnormalities were documented in 86 of 102 and 89 of 102 dogs, respectively. Among echocardiographic and electrocardiographic categories, the dilated cardiomyopathy phenotype (n = 52) and abnormalities of impulse formation (n = 67) were overrepresented, respectively. Among dogs in which a suspected etiological trigger was identified (68/102), the infective category was overrepresented (n = 20). Among dogs belonging to different echocardiographic, electrocardiographic, and etiological categories, cTnI did not differ significantly. The median survival time was 603 days; only eight of 102 dogs died due to MI. ConclusionsDogs with MI often have an identifiable suspected trigger, show various echocardiographic and electrocardiographic abnormalities, and frequently survive to MI-related complications.

Does vitamin D deficiency affect ventricular repolarization in the elderly?

Introduction: The aim of the current study is to establish whether vitamin D deficiency interacts with the electrocardiographic indices of abnormal ventricular repolarization in elderly patients. Material and Methods: 138 patients were divided into three groups: patients with vitamin D deficiency, patients with vitamin D insufficiency, and patients with adequate vitamin D levels. 12-lead electrocardiography and laboratory data were collected. Results: The resting heart rate, PR interval, QRS duration, QTd, and Tp-e dispersion were similar among the groups. However, the QTc interval was significantly prolonged in patients with vitamin D deficiency, when compared to patients with sufficient vitamin D levels. Vitamin D level was found as the only independent predictor of the QTc interval. The cut-off value of Vitamin D level determining the significant prolongation of QTc interval was found to be 20 ng/ml on ROC analysis (Area Under Curve: 0,629±0.051 (95% CI: 0,530-0.728, p=0.013). Conclusion: Low vitamin D levels are associated with QTc prolongation in the elderly. Vitamin D-deficient elderly patients may benefit from routine ECG screening. Timely diagnosis and treatment of vitamin D deficiency may aid in reducing the rate of arrhythmias in this patient population.

A Study on electrographic abnormalities and troponin elevation in COVID-19 patients: A Bangladeshi Perspective

Background: In Bangladesh, COVID-19 patients frequently present with electrographic abnormalities and elevated troponin levels, indicative of cardiac stress. These observations highlight the virus's potential impact on cardiovascular health, necessitating vigilant monitoring and timely interventions to mitigate complications. Study Objective: This research aims to assess electrographic abnormalities and troponin elevation in COVID-19 patients within Bangladesh. Methods: Conducted retrospectively at a tertiary medical college and hospital, our study enrolled 100 consecutive adult COVID-19 patients. We analyzed baseline characteristics, lab results, and serial ECGs. Troponin I concentrations were measured using the Abbott Architect method (normal range: ≤0.05 ng/mL). Troponin levels were categorized as normal (0.00-0.05 ng/mL), mildly elevated (0.05-1 ng/mL), and significantly elevated (>1 ng/mL). ECGs were reviewed and interpreted. Results: The majority of patients (71%) were males aged 41-50. Common COVID-19 symptoms included dyspnea and cough (75%), followed by fever, fatigue, and malaise (80%). Gastrointestinal symptoms were seen in 20%, and 10% experienced anosmia or dysgeusia. Comorbidities included diabetes mellitus (65%), hypertension (60%), CKD (10%), coronary artery diseases (13%), and other cardiovascular diseases (5%). Abnormal LFTs were observed in 30%. Initial troponin levels averaged 0.18 ± 1.75 ng/mL, with a maximum of 2.55 ± 17.90 ng/mL. Mortality occurred in 25% of cases. Conclusion: Our findings suggest that ECG repolarization abnormalities may serve as markers of clinical severity, even in cases with mildly elevated troponin values in COVID-19 patients. Keywords: covid-19, electrographic abnormalities, troponin

Left Ventricular Trabeculation: Arrhythmogenic and Clinical Significance in Elite Athletes

Left ventricular (LV) trabeculations (LVTs) are common findings in athletes. Limited information exists regarding clinical significance, management, and outcome. The purpose of this study is to examine the prevalence and morphologic characteristics of LVTs in elite athletes, with a focus on clinical correlates and prognostic significance. We enrolled 1,492 Olympic elite athletes of different sports disciplines with electrocardiogram, echocardiogram, and exercise stress test. Individuals with a definite diagnosis of LV noncompaction (LVNC) were excluded; we focused on athletes with LVTs not meeting the criteria for LVNC. Four hundred thirty-five (29.1%) athletes presented with LVTs, which were more frequent in male athletes (62.1% vs 53.5%, P=.002) and Black athletes compared with Caucasian (7.1% vs 2.4%, P<.0001) and endurance athletes (P=.0005). No differences were found with relation to either the site or extent of trabeculations. Endurance athletes showed a higher proportion of LVTs and larger LV volumes (end-diastolic and end-systolic, respectively, 91.5±19.8mL vs 79.3±29.9mL, P=.002; and 33.1±10mL vs 28.6±11.7mL, P=.007) and diastolic pattern with higher E wave (P=.01) and e' septal velocities (P=.02). Ventricular arrhythmias were found in 14% of LVTs versus 11.6% of athletes without LVTs (P=.22). Neither the location nor the LVTs' extension were correlated to ventricular arrhythmias. At 52±32months of follow-up, no differences in arrhythmic burden were observed (11.1% in LVT athletes vs 10.2%, P=.51). Left ventricular trabeculations are quite common in athletes, mostly male, Black, and endurance, likely as the expression of adaptive remodeling. In the absence of associated clinical abnormalities, such as LV systolic and diastolic impairment, electrocardiogram repolarization abnormalities, or family evidence of cardiomyopathy, athletes with LVTs have benign clinical significance and should not require further investigation.

Are the Exacerbations of Chronic Obstructive Pulmonary Disease a Risk Factor for Cardiac Arrhythmia?

Aim: Hypoxemia, hypercapnia, and automaticity—which are dependent on exacerbation—increase the risk of arrhythmia by causing abnormal atrial and ventricular repolarization in chronic obstructive pulmonary disease (COPD). This study aimed to foresee the possibility of arrhythmia by evaluating the electrocardiograms (ECG) of patients having COPD attacks. Material and Method: In total, 120 patients (66 in the COPD group and 54 in the control group) were included. The differences between the two groups were statistically examined by determining (in milliseconds) QT and QTc interval maximum (max), minimum (min), and dispersion (disp); T-wave peak to end (Tp-e) max, min, and disp; Tp-e max/QT max, Tp-e max/QTc max proportions; and P wave max, min, and disp duration in the ECG parameters of the patients. Results: Forty-eight (64%) of the males included in the study were in the COPD group and 27 (36%) in the control group, whereas 18 (40%) of the females were in the COPD group and 27 (60%) in the control group. There was no significant difference between the ages of the patients and the levels of sodium and potassium (p = 0.189, 0.353, and 0.071). There was a significant difference between QT max and min in the groups, whereas there was no difference in terms of QT disp (p &lt; 0.001, p &lt; 0.001, and p = 0.490). There was a significant difference between the Tp-e max, min, and disp values in the COPD and control groups (p = 0.041, p &lt; 0.001, and p = 0.001, respectively). There was no significant difference between the groups in terms of the P max duration (p = 0.442), but significant differences between the two groups in P min and disp durations were determined (p = 0.003 and p &lt; 0.001, respectively). In receiver operating characteristic analysis made for P disp and Tp-e disp values in which a firm difference was made, 30 ms was determined as the cutoff for both parameters. Conclusion: To our knowledge, this is the first study that the rise of the dispersions of P wave and Tp-e intervals (without rise of QTc disp.) is detected on the evaluation of atrial and ventricular arrhythmia risks on COPD acute attacks.

Ventricular tachycardia ablation after myocardial infarction guided by cardiac magnetic resonance/multidetector computed tomography image integration

Abstract INTRODUCTION The persistent challenge of ventricular tachycardia (VT) ablation lies in the elevated morbidity and mortality due to the underlying disease progression and the complexity of the arrhythmogenic substrate. As imaging methods are evolving, substrate-based VT ablation is moving closer to the realm of precision medicine. CASE PRESENTATION A 52-year-old patient with a history of hypertension, type II diabetes mellitus, hyperlipidemia, and stage IIIB chronic kidney disease was referred to our hospital for sustained monomorphic VT. Upon admission, the patient was hemodynamically stable. Laboratory results indicated mild anemia, moderate renal dysfunction, and normal myocardial enzymes. ECG during sinus rhythm showed widespread repolarization abnormalities in the apical and postero-lateral leads. Echocardiography revealed mild left ventricular dysfunction and coronary angiography confirmed significant lesions in multiple coronary arteries that were treated with drug-eluting stents (DES). Cardiac MRI showed relatively limited areas of old myocardial infarctions in the left circumflex artery and left anterior descending artery territories, therefore we decided to perform VT ablation. We used a Carto 3 Biosense Webster electro-anatomical mapping system (EAM) guided by fusion imaging (cardiac MRI and multidetector computed tomography - MDCT) with the aid of ADAS 3D software. The voltage map created during sinus rhythm, was concordant with the lesions identified on LGE-CMR. Radiofrequency (RF) catheter ablation targeted abnormal signals from the EAM, which were identified based on conduction channels (CCs) from the fusion imaging. There was complete VT non-inducibility at programmed ventricular stimulation (PVS). At the 3-month follow-up, echocardiography showed a slight improvement in LVEF and repeated PVS proved persistent ventricular arrhythmia non-inducibility. CONCLUSION Substrate-based VT ablation in structural heart disease has greatly improved by high-resolution substrate imaging with detailed anatomy, allowing successful personalized treatment. There is room for further improvement in the near future with the contribution of artificial intelligence, possibly with a more targeted and automated VT ablation.

Unraveling Complexities in Genetically Elusive Long QT Syndrome.

Genetic testing has become standard of care for patients with long QT syndrome (LQTS), providing diagnostic, prognostic, and therapeutic information for both probands and their family members. However, up to a quarter of patients with LQTS do not have identifiable Mendelian pathogenic variants in the currently known LQTS-associated genes. This absence of genetic confirmation, intriguingly, does not lessen the severity of LQTS, with the prognosis in these gene-elusive patients with unequivocal LQTS mirroring genotype-positive patients in the limited data available. Such a conundrum instigates an exploration into the causes of corrected QT interval (QTc) prolongation in these cases, unveiling a broad spectrum of potential scenarios and mechanisms. These include multiple environmental influences on QTc prolongation, exercise-induced repolarization abnormalities, and the profound implications of the constantly evolving nature of genetic testing and variant interpretation. In addition, the rapid advances in genetics have the potential to uncover new causal genes, and polygenic risk factors may aid in the diagnosis of high-risk patients. Navigating this multifaceted landscape requires a systematic approach and expert knowledge, integrating the dynamic nature of genetics and patient-specific influences for accurate diagnosis, management, and counseling of patients. The role of a subspecialized expert cardiogenetic clinic is paramount in evaluation to navigate this complexity. Amid these intricate aspects, this review outlines potential causes of gene-elusive LQTS. It also provides an outline for the evaluation of patients with negative and inconclusive genetic test results and underscores the need for ongoing adaptation and reassessment in our understanding of LQTS, as the complexities of gene-elusive LQTS are increasingly deciphered.

Rapid weather changes are associated with daily hospital visitors for atrial fibrillation accompanied by abnormal ECG repolarization: a case-crossover study

BackgroundAtrial fibrillation (AF) is highly prevalent in the population, yet the factors contributing to AF events in susceptible individuals remain partially understood. The potential relationship between meteorological factors and AF, particularly with abnormal electrocardiograph (ECG) repolarization, has not been adequately studied. This case-crossover study aims to investigate the association between meteorological factors and daily hospital visits for AF with abnormal ECG repolarization in Shanghai, China.MethodsThe study cohort comprised 10,325 patients with ECG-confirmed AF who sought treatment at Shanghai Sixth People's Hospital between 2015 and 2018. Meteorological and air pollutant concentration data were matched with the patient records. Using a case-crossover design, we analyzed the association between meteorological factors and the daily count of hospital visitors for AF with abnormal ECG repolarization at our AF center. Lag analysis models were applied to examine the temporal relationship between meteorological factors and AF events.ResultsThe analysis revealed statistically significant associations between AF occurrence and specific meteorological factors. AF events were significantly associated with average atmospheric pressure (lag 0 day, OR 0.9901, 95% CI 0.9825–0.9977, P < 0.05), average temperature (lag 1 day, OR 0.9890, 95% CI 0.9789–0.9992, P < 0.05), daily pressure range (lag 7 days, OR 1.0195, 95% CI 1.0079–1.0312, P < 0.01), and daily temperature range (lag 5 days, OR 1.0208, 95% CI 1.0087–1.0331, P < 0.01). Moreover, a significant correlation was observed between daily pressure range and daily temperature range with AF patients, particularly those with abnormal ECG repolarization, as evident in the case-crossover analysis.ConclusionThis study highlights a significant correlation between meteorological factors and daily hospital visits for AF accompanied by abnormal ECG repolarization in Shanghai, China. In addition, AF patients with abnormal ECG repolarization were found to be more vulnerable to rapid daily changes in pressure and temperature compared to AF patients without such repolarization abnormalities.