Serial ECGs Research Articles

PO-04-103 WIDE COMPLEX TACHYCARDIA IN ACUTE ANTI-NMDA RECEPTOR ENCEPHALITIS

NA NA NA A 20-year-old male with no known past medical history presented with two months of episodic right-sided weakness. An extensive workup was notable for a lumbar puncture that was positive for antibodies to the N-methyl-D-aspartate (NMDA) receptor, confirming anti-NMDA receptor (NMDAR) encephalitis. Baseline cardiac workup included a transthoracic echocardiogram (TTE) that showed left ventricular (LV) hypokinesis with borderline ejection fraction (EF 52%), and an ECG showing sinus tachycardia (Figure-A). While admitted, the patient developed shock, necessitating intubation and vasopressors. Serial ECGs while in shock showed sinus tachycardia, a prolonged QTc, and broad sail-like T wave in V1 (similar to type 1 Brugada pattern), with ST elevations in aVR and diffuse ST depressions inferolaterally (Figure-B). Serial troponins were minimally elevated (0.11 ug/L) and TTE showed no regional wall motion abnormalities, so invasive coronary angiography was not pursued. During progressive shock, the patient developed a wide complex tachycardia (WCT, Figure-C), that was thought to most likely be LV outflow tract ventricular tachycardia. The patient became hemodynamically unstable with the WCT, necessitating amiodarone, lidocaine, and ultimately five cardioversions. Repeat TTE showed severe biventricular dysfunction, and the patient needed veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Ultimately, the patient’s biventricular function recovered, and he was able to be decannulated from VA-ECMO. He was managed with intravenous immunoglobulin, steroids and rituximab for his anti-NMDAR encephalitis. Cardiac arrhythmias are a known complication of anti-NMDAR encephalitis in up to one-third of patients. To the best of our knowledge, this is the first case of anti-NDMAR encephalitis associated with diffuse ST elevations suggestive of ischemia. Models suggest NMDA receptor-mediated signaling in the nervous system can alter the vagal outflow to the heart, leading to sinus brady/tachycardia. Other explanations for ECG changes in our patient include focal myocarditis/vasospasm. This is an unusual case of marked ST elevation and sustained VT in anti-NMDAR encephalitis. Pathogenesis and management of arrhythmias related to this condition warrant further study.

PO-04-078 WHEN THE Q RUNS AWAY FROM P: A CASE OF EXTREME MOBITZ TYPE I

Advanced infranodal conduction disease usually presents with Mobitz 2 pattern and normal or mildly prolonged conducted PR intervals, whereas advanced AV node disease presents with Mobitz 1 pattern and more pronounced PR prolongation of conducted beats. AV node conduction properties can vary, with some patients demonstrating markedly prolonged PR intervals. We present a case of extreme PR prolongation and highly unusual Mobitz 1 patterns. To emphasize the variable presentation of AV node disease. N/A A 60 year old man with a history of Tetralogy of Fallot had serial repair surgeries over the years, including a Blalock Tausig shunt, Tetralogy of Fallot repair with pulmonary valve replacement, tricuspid valvuloplasty with chordal re-attachment, and closure of a cleft in the septal tricuspid valve leaflet. He had a dual chamber pacemaker for second degree AV block and RBBB. Due to recurrent tricuspid valve dysfunction, his pacemaker and leads were explanted at the time of repeat tricuspid valve surgery. Post-operatively, the surgical temporary epicardial pacing wires were not initially used, and various forms of asymptomatic Mobitz type 1 AV block were seen on serial ECGs. Careful scrutiny of the ECGs showed that the PR interval ranged from 640 ms to over 1300 ms. The markedly prolonged PR intervals led to highly unusual AV relationships, including overlapping PR intervals, as well as 1:1 and 2:1 AV conduction patterns that could only be properly deciphered in the context of other ECGs. When 2:1 AV conduction was seen, temporary pacing was implemented. He subsequently underwent bi-v pacemaker implantation to achieve proper AV and VV synchrony, in the context of concurrent LV dysfunction. AV conduction patterns can become complex in the setting of AV node disease, and more dramatically so in the context of congenital heart disease and valve surgery. Associations between specific P waves and QRS complexes should be ascertained to properly appreciate AV node disease severity. In the presented case, cursory ECG assessment led the ICU clinical team to conclude that AV conduction in the post-op setting followed a simple Mobitz 1 pattern with typical PR intervals. Therefore surgical temporary pacing wires were not utilized until the patient developed 2:1 AV conduction with more marked bradycardia. With careful ECG analysis, the severity of AV node dysfunction could be properly assessed and managed.

PO-04-048 LYME CARDITIS PRESENTING AS ACCELERATED JUNCTIONAL RHYTHM IN ADULT PATIENT

Lyme carditis occurs in 1.5%-10% untreated patients infected with Borrelia burgdorferi in United States and usually manifests as varying degrees of atrioventricular (AV) block, myopericarditis, and degenerative valve disease. Several cases of junctional tachycardia have been reported in children with Lyme disease, but there have not been any cases reported in the adult population. Here, we report a case of accelerated junctional tachycardia in a 42-year-old woman with Lyme carditis. To describe a case of a Lyme carditis presenting as accelerated junctional rhythm in a 42-year-old patient. N/A A 42-year-old woman with no significant past medical history presented with complaints of palpitations and lightheadedness. She had a tick bite on her left anterior upper thigh one month prior while working in her yard. The tick was removed after about 3 hours. At that time the patient had no fevers, arthralgias or rashes; however, a month later she developed symptoms of palpitations and lightheadedness. A 12-lead ECG showed accelerated junctional rhythm with AV and VA dissociation and was otherwise normal (Fig 1A). Her primary care physician conducted Lyme serology, which came back positive for both IgG and IgM. A diagnosis of Lyme carditis was made, and the patient was admitted to the hospital for IV antibiotics. Repeat ECG showed sinus with PR prolongation to 252 ms along with episodes of accelerated junctional rhythm (Figure 1B and 1C). She was started on intravenous ceftriaxone with continuous cardiac monitoring. Echocardiogram showed no abnormalities. A peripherally- inserted central catheter line was placed for a 4-week course of ceftriaxone. Her PR interval normalized within 2 weeks of treatment with no junctional rhythm or heart block on serial ECGs and Holter monitors (Figure 1D). Follow-up over the next year showed no recurrence of symptoms or arrhythmias and no other cardiac sequelae. To the best of our knowledge, accelerated junctional rhythm has not been previously reported in the setting of Lyme disease in adult patients. Herein, we report a case of a Lyme carditis presenting as symptomatic accelerated junctional rhythm in a 42-year-old patient, likely caused by inflammation of AV nodal tissue.

A viewpoint on evaluating ECG findings to assess heart issues: A clinical nursing review

The 12-lead EKG is a useful first-line diagnostic tool for detecting cardiovascular diseases, including arrhythmias, conduction abnormalities, and myocardial ischemia or infarction. This scoping review aims to discuss the ECG perspective for detecting heart problems. This study was conducted by following the narrative review and development framework. The literature search used ScienceDirect, Scopus, ProQuest, ClinicalKey, and SpringerLink data. The keywords used were "criteria" or "guidelines" and "ECG" or "ECG" or "electrocardiography" or "electrocardiogram" and "detection" and "heart problem" or "heart disease" or "heart problem" or "heart problem." The method uses a narrative review through eight articles spanning 2017–2022. The lighting method uses the PICO analysis framework. The results found four components, namely: 1) automatic diagnosis; 2) 3-D ECG with artificial intelligence (AI) classification; 3) use of the LSTM deep-learning model; and 4) leads using Tpeak-End (Tp-e). In patients with heart problems, the initial examination is an EKG. Thus, the ECG, with the addition of the automatic diagnosis feature, EKG-3D, and the use of a 12-lead ECG with a deep-learning LSTM model, also followed by high sensitivity and specificity, can be used as a tool to perform examinations on patients who require serial ECG examinations.
 Keywords: Electrocardiogram; nursing care; nursing review; clinical symptoms; nursing assessment

What Is the Truth Behind Abnormal ECG Changes?

What Is the Truth Behind Abnormal ECG Changes?

Changes of ECG parameters after BNT162b2 vaccine in the senior high school students.

The purpose of this study is to determine the ECG parameter change and the efficacy of ECG screening for cardiac adverse effect after the second dose of BNT162b2 vaccine in young population. In December 2021, in cooperation with the school vaccination system of Taipei City government, we performed a ECG screening study during the second dose of BNT162b2 vaccines. Serial comparisons of ECGs and questionnaire survey were performed before and after vaccine in four male-predominant senior high schools. Among 7934 eligible students, 4928 (62.1%) were included in the study. The male/female ratio was 4576/352. In total, 763 students (17.1%) had at least one cardiac symptom after the second vaccine dose, mostly chest pain and palpitations. The depolarization and repolarization parameters (QRS duration and QT interval) decreased significantly after the vaccine with increasing heart rate. Abnormal ECGs were obtained in 51 (1.0%) of the students, of which 1 was diagnosed with mild myocarditis and another 4 were judged to have significant arrhythmia. None of the patients needed to be admitted to hospital and all of these symptoms improved spontaneously. Using these five students as a positive outcome, the sensitivity and specificity of this screening method were 100% and 99.1%, respectively. Conclusion: Cardiac symptoms are common after the second dose of BNT162b2 vaccine, but the incidences of significant arrhythmias and myocarditis are only 0.1%. The serial ECG screening method has high sensitivity and specificity for significant cardiac adverse effect but cost effect needs further discussed. What is Known: • The incidence of cardiac adverse effects was reported to be as high as 1.5 per 10 000 persons after the second dose BNT162b2 COVID-19 vaccine in the young male population based on the reporting system. What is New: • Through this mass ECG screening study after the second dose of BNT162b2 vaccine we found: (1) The depolarization and repolarization parameters (QRS duration and QT interval) decreased significantly after the vaccine with increasing heart rate; (2) the incidence of post-vaccine myocarditis and significant arrhythmia are 0.02% and 0.08%; (3) The serial ECG screening method has high sensitivity and specificity for significant cardiac adverse effect.

Improving Risk Stratification of Patients With Chest Pain in the Emergency Department.

The HEARTS3 score is used to predict acute coronary syndrome by evaluating the findings of chest pain patients at the end of the second hour. Additionally, the American College of Cardiology (ACC)/American Heart Association (AHA) 2014 non-ST elevation acute coronary syndrome (NSTE-ACS) management guideline suggests assessing cardiac troponin levels at the third and sixth hours as a class 1A recommendation. This study aimed to explore the value of the HEARTS3 score for the evaluation of patients withchest pain and its utility for determining whether a patient is eligible for early discharge from the emergency department. This study was prospectively conducted between March 1, 2016 to May 31, 2016 at the ED of the Research and Training Hospital in İstanbul. A total of 136 patients were evaluated, and HEARTS3 scores were calculated at the second, third, and sixth hours. Receiver operating characteristic (ROC) curves were used to calculate the specificity, sensitivity,negative predictive value (NPV) and positive predictive value (PPV) of these scores. The primary outcome was the occurrence of major adverse cardiac events (MACEs) within 30 days. In total, 29 patients with MACEs and 107 patients without MACEs were identified within 30 days. Based on the ROC curve, the cutoff value for early discharge was 6. The area under curve (AUC) values were 0.943, 0.963 and 0.976 at the second, third, and sixth hours, respectively. The sensitivity of the second-hour HEARTS3 score was 96.6%, and the NPV was 98.6%. Both the sensitivity and NPV reached 100% at the sixth hour. The HEARTS3 score was considered a feasible method for the prediction of MACEs. We concluded that a patient with a HEARTS3 score less than 6 may be discharged without serial troponin and ECG examination.

565 UNUSUAL LIFE-THREATENING FLECAINIDE TOXICITY: A CASE REPORT

Abstract Background Anti-arrhythmic drug therapy has often a narrow therapeutic index and could be responsible of toxic side effects including malignant arrhythmias and life-threatening hemodynamic deterioration. Flecainide toxicity can occur even at normal serum levels in the setting of electrolyte disturbances such as hyponatremia. We report a case of flecainide toxicity, likely due to dual mechanism: reduced excretion and potentiation of the toxic effects due to concomitant hyponatremia. Case description A 82-year-old woman was admitted to our hospital for syncope. The ECG at admission showed atrial fibrillation, complete atrio-ventricular (AV) block and a wide QRS escape rhythm. She has a history of hypertension, COPD and atrial fibrillation. She was currently taking flecainide at a dosage of 150 mg per die. Laboratory tests reported an elevated lactate concentration (4.6 mmol/L), hyponatremia (128 mmol/L), severe reduction of renal function (eGFR 19 ml/min), and NT-proB-type Natriuretic Peptide 17563 pg/ml, (ULN<450). Echocardiography showed a reduced left ventricular ejection fraction (EF=35%). Suspecting flecainide poisoning, we started intravenous sodium bicarbonate and temporary pacing for severe bradycardia and pauses. However, despite numerous attempts of lead reposition and the use of maximum output, we failed to document ventricular capture in the immediate post-operative. Half hour later, dopamine infusion was started for sustained severe hypotension. The day after we were able to obtain ventricular capture. At serial ECG examination, she also developed progressive QRS narrowing with concomitant clinical improvement. Discussion Flecainide toxicity is a rare but potentially life-threatening condition. The excess of sodium channel blockade causes in fact delayed conduction through the AV node, His-Purkinje system, and ventricles with possible AV block, ventricular tachycardia, ventricular fibrillation, and asystole. In addition, hemodynamic instability can develop rapidly in flecainide intoxication due to chronotropic and inotropic incompetence. The majority of flecainide intoxication reported cases are due to a drug overdose. However, flecainide toxicity can occur with serum levels within the range of normality. Particularly, this can occur in the setting of hyponatremia. The observed pacemaker malfunction was also due to flecainide intoxication. In our case, the patient was taking therapeutic doses of this drug. The toxic effect was probably due to the reduced excretion (secondary to kidney failure) and the simultaneous presence of hyponatremia. The main treatment for flecainide intoxication is sodium bicarbonate and supportive care. However, there is currently no recommended standardized protocol for flecainide toxicity. The inotropic agents could be helpful in case of cardiogenic shock, but their use may be limited by the rate-dependent effect of flecainide and the increased risk ventricular arrhythmias. Left ventricular assist devices have been also used to support hemodynamic through flecainide-induced cardiogenic shock.

Prinzmetal Angina with Pan Hypopituitarism- A Case Report

A 31yrs old female teacher came to our emergency department with the complaints of severe retro sternal & compressive type chest pain radiated to the left arm, back and jaw. Pain was partially relieved by rest and associated with vomiting & nausea but no breathlessness. She also reported episodes of angina in previous couple of months. On admission, there was ST-segment elevation that last for few minutes and later progressively resolved. But troponin level was high. Patient was undergone Coronary angiogram and was diagnosed as stress induced cardiomyopathy (SICM), as Coronary Angiogram showed normal epicardialcoronary arteries. Serial ECG was carried out which showed resolved ST elevation. Holter monitoring showed severe ST-segment changes during an angina episode. She had no history of substance abuse or recreational drug use.Before discharge we started oral calcium antagonist and there wasn’t any further episode of angina or ST changes on follow up after two months.
 University Heart Journal 2022; 18(2): 125-127

Abstract 154: Limitation of Troponin T In Identifying the Cause of Out-of-hospital Cardiac Arrest

Introduction: High Sense-Troponin T (HS-TnT) is a key determinant for presence or absence of acute MI in chest pain patients (pts). Its value for acute MI diagnosis in pts with out-of-hospital cardiac arrest (OHCA) needs assessment because myocardial ischemia may be the cause but also a consequence of cardiac arrest causing global ischemia during no and low flow periods. Methods: Data were prospectively collected. From pts included in the ARREST registry who survived OHCA to discharge with VF as initial rhythm, the cause of OHCA and peak HS-TnT were analyzed. Cause of OHCA was determined independently by researchers, from history, admission and serial ECG, coronary angiography (CAG), cardiac imaging and genetics as available and indicated, without using HS-TnT information. MI diagnosis was made according to the 4 th universal definition of MI: type 1 MI (thrombotic STEMI/NSTEMI), type 2 MI (supply/demand imbalance) and no MI (short transient ECG changes and all non-ischemic causes). Results: From 2012 till 2018 in the study region 373 OHCA pts met the inclusion criteria and had a known peak HS-TnT. Of these, Type 1 MI was present in 109 STEMI and 39 NSTEMI pts, type 2 MI in 116 pts and no MI in 109 pts. No significant coronary stenosis or normal CAG was present in 81 pts: 11/106 (10%) with type 2 MI and 70/109 (64%) without MI. HS-TnT exceeded the conventional diagnostic threshold of 4 times upper limit of normal (4x14ng/L = 56 ng/L) in 99%, 95%, 95% and 89% of pts, respectively. Median peak HS-TnT levels in STEMI, NSTEMI, Type 2 and no AMI pts was 1890 ng/L, 480 ng/L, 300 ng/L and 261 ng/L, respectively. (Figure) Area Under the ROC-Curve of HS-TnT values to differentiate between type 1 NSTEMI and type 2 AMI was 0.649, between type 1 NSTEMI and no MI 0.684 and between type 2 MI and no AMI 0.555. Conclusion: Exclusion of diagnosis of MI in OHCA pts cannot be made with HS-TnT, nor a distinction between NSTEMI, type 2 MI and no AMI. Based on HS-TnT many OHCA pts without ischemic cause would classify as NSTEMI.

MIMICKER OF MYOCARDIAL INFARCTION (MI): PHENYLEPHRINE-ASSOCIATED CORONARY VASOSPASM

MIMICKER OF MYOCARDIAL INFARCTION (MI): PHENYLEPHRINE-ASSOCIATED CORONARY VASOSPASM

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

Automatic diagnosis of newly emerged heart failure from serial electrocardiography by repeated structuring & learning procedure

Heart failure (HF) diagnosis, typically visually performed by serial electrocardiography, may be supported by machine-learning approaches. Repeated structuring & learning procedure (RS&LP) is a constructive algorithm able to automatically create artificial neural networks (ANN); it relies on three parameters, namely maximal number of hidden layers (MNL), initializations (MNI) and confirmations (MNC), arbitrarily set by the user. The aim of this study is to evaluate RS&LP robustness to varying values of parameters and to identify an optimized combination of parameter values for HF diagnosis. To this aim, the Leiden University Medical Center HF database was used. The database is constituted by 129 serial ECG pairs acquired in patients who experienced myocardial infarction; 48 patients developed HF at follow-up (cases), while 81 remained clinically stable (controls). Overall, 15 ANNs were created by considering 13 serial ECG features as inputs (extracted from each serial ECG pair), 2 classes as outputs (cases/controls), and varying values of MNL (1, 2, 3, 4 and 10), MNI (50, 250, 500, 1000 and 1500) and MNC (2, 5, 10, 20 and 50). The area under the curve (AUC) of the receiver operating characteristic did not significantly vary with varying parameter values (P ≥ 0.09). The optimized combination of parameter values, identified as the one showing the highest AUC, was obtained for MNL = 3, MNI = 500 and MNC = 50 (AUC = 86 %; ANN structure: 3 hidden layers of 14, 14 and 13 neurons, respectively). Thus, RS&LP is robust, and the optimized ANN represents a potentially useful clinical tool for a reliable automatic HF diagnosis.

Electromechanical Association as a Stemi Mimicry - Case Report

Abstract Electromechanical association is a very unique physiological type of ECG artifact caused by the radial artery pulse tapping. ECG presentation of this artifact may imitate primary repolarization changes characteristic for acute coronary syndrome or electrolyte abnormalities. The peculiarity of electromechanical association is the synchronization with regular cardiac cycles, making a diagnostic challenge even for experience physicians. The present case is a rare example of an ECG artifact localized in a specific pattern mimics ECG changes of acute myocardial infarction with ST elevation (STEMI), including reciprocal ST depression. Moreover, serial prehospital ECGs verify evolution from hyperacute T waves to true ST elevation, as we seen in acute myocardial infarction. The key for artefact recognition was the knowledge about ECG leads derivation and identification the affected electrode. Electromechanical association frequency is unknown: it may be common, but often unrecognized finding. So far, electromechanical association in serial ECGs wasn’t reported, as per our knowledge.

Serial assessment of corrected qt interval and its clinical correlates in patients receiving psychotropic medications

Background & Aims: Psychotropic medications vary in propensity to cause QTC prolongation on electrocardiogram. It can be fatal sometimes. Prospective Indian studies in this area are lacking. Present study was conducted to prospectively assess the changes in QTC in patients receiving psychotropic medications. Settings and Design: Hospital based prospective observational study. Methods: A total of 150 patients aged 18-60 years, diagnosed as having any psychiatric illness and receiving psychotropic medications formed the sample. Psychiatric diagnosis was made according to DSM-5. Baseline ECG was done and psychotropic medications as per the diagnosis of the patient were started. Serial ECGs were performed on them up to one month post treatment. Results: Females constituted 54.7% of the sample. Major Depressive Disorder was the most common diagnosis. The duration of illness was less than 6 months in 47.3% of the patients. The dose of all psychotropic medications prescribed were in the therapeutic range and none of them exceeded the recommended maximum dose. Psychotropic medication was associated with increase in QTC from baseline. The prevalence of QTC prolongation was 1.40% at first follow up and 15% at second follow up. It ranged between 1 ms to 21 ms.

Association of Admission Glucose Level with Arrythmia and Heart Failure in Hyperglycemic Patients with Non-ST-Segment Elevation Myocardial Infarction

Background: Observetion of admission blood glucose level in non-ST elevation myocardial infarction is crucial to predict its outcome.Objective: To find out correlation of plasma glucose level with adverse events like arrythmia and heart failure in hyperglycemic patients with non-STsegment elevation myocardial infarction (NSTEMI).Methods: This prospective analytical study was conducted in the Department of Cardiology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh, between June 2016 and May 2017. A total of 130 (95 males and 35 females) patients having NSTEMI participated in the study. Detail history was taken and physical examination was done. Venous blood samples were obtained from all patients to determine their cardiac troponins, plasma blood glucose, HbA1C, lipid profile, serum creatinine, and other cardiac enzymes. Then, the study participants were categorized into two groups. A total of 67 included (44 males and 23 females) in Group I, as having NSTEMI with plasma glucose level 7.8-9.3 mmol/l. In Group II, 63 were included (51 males and 12 females) having NSTEMI with plasma glucose level ≥9.4 mmol/l. Follow up was done according to the standard protocol,i.e. serial ECG, echocardiography, monitoring pulse, blood pressure, and auscultation of the lungs’ base.Results: The mean age of the patients was 49.68±3.12 years. Incidence of arrhythmia was observed in 4(5.97%) and 20(31.75%) cases in group I and group II respectively, while heart failure was found in 6(8.96%) and 48(76.19%) cases respectively (P<0.001). A statistically significant moderate negative correlation with medium strength of association (r = -0.056) was observed between heart failure (as measured by LVEF and clinical status) and admission plasma glucose levels of the study participants suggesting that the higher was admission plasma glucose level (8.27±1.03 vs. 13.34±3.65; P<0.001),the lower was the LVEF (54.19±7.13 vs. 44.21±7.36; P<0.001), i.e. higher risks of heart failure. Conclusion: A higher admission plasma glucose level relates to a lower LVEF,i.e. higher incidence of arrythmia and heart failure in non ST-elevation MI patients.International Journal of Human and Health Sciences Vol. 06 No. 03 July’22 Page: 292-297

Revisiting QT prolongation in acute rheumatic fever – Relevance for hydroxychloroquine treatment

In-vitro evidence suggests hydroxychloroquine could be a potential immunomodulator for the inflammatory carditis of acute rheumatic fever (ARF). Hydroxychloroquine used as an anti-inflammatory agent has a low side effect profile but its use in the Covid-19 pandemic raised concerns about QTc interval prolongation and cardiac arrhythmias. The prolongation of QTc in ARF appears benign but has not been widely studied. We aim to report QTc intervals in a contemporary ARF population and consider implications for hydroxychloroquine use in ARF. The study cohort was 197 children <15 years of age with a clinical diagnosis of ARF. The QTc mean (SD) was 445 msec (28), range 370-545 msec. Eighteen percent of the cohort had a QTc > 99th percentile for normal by age and 8 patients (4%) had a QTc over 500 msec. There was no difference of QTc by age or gender. Inter-observer repeatability for QTc (n = 33) was 35 msec.The QTc is often prolonged in the early phase of ARF, meaning that QT prolonging medications should be used with caution in this setting. Serial ECG monitoring of the QT interval is recommended if hydroxycholoroquine is used in ARF.

Gender gap in study inclusion: Insights from the STAR-FIB cohort study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation Swiss Heart Foundation Background The underrepresentation of women in cardiovascular clinical trials is well described but cannot be fully explained by sex-specific differences in the prevalence of cardiovascular diseases. Data on potential sex- and gender-related differences in study exclusion reasons are scarce. The STAR-FIB cohort study aimed to estimate the age and sex-specific prevalence of screening-detected atrial fibrillation (AF) in 800 hospitalized patients aged 65-84 years using serial seven-day ECGs. Recruitment for study inclusion was stratified by sex (female/male, as stated in the patient’s records) and age (four age bands, ≥65 to &amp;lt;70, ≥70 to &amp;lt;75, ≥75 to &amp;lt;80, and ≥80 to &amp;lt;85 years), and was truncated for each subgroup after the inclusion of 100 participants. Purpose To assess sex and gender differences in patient recruitment for inclusion in the STAR-FIB cohort study. Methods A screening log containing sex-category, age, and reasons for exclusion was maintained. Exclusion criteria are shown in the figure. For the purpose of the present study, an explorative analysis of all exclusion criteria with respect to sex category was done. Results Overall, 11’470 patients were identified for eligibility, 795 patients (49% women; mean age 75 years) were enrolled, and 10’675 patients (52% women vs. 48% men, p =0.13) were not enrolled. The two major exclusion reasons were unwillingness to participate, which was more frequent in women (27.9% of women vs. 18.4% of men, p &amp;lt; 0.01), and the presence of clinical AF, which was more prevalent in men (27.1% of men vs. 20.5 % of women, p &amp;lt; 0.01). A detailed analysis of all exclusion criteria analysed by sex category is provided in the figure. Conclusions Clinical AF was more frequent in men, in accordance with the well described sex-driven (biological) higher prevalence of AF in men. In contrast, we found a higher percentage of women unwilling to participate in this study, which may represent a more gender-based (sociocultural) phenomenon. A further exploration of these findings should be performed and may help to identify and potentially overcome modifiable obstacles for study participation.

Recognizing Kounis Syndrome, the Unusual Possible Culprit of Acute Coronary Syndrome: A Rare Case Report

AbstractKounis syndrome encompasses acute coronary syndrome features associated with severe vasospasm of the coronary artery. It is related to allergic anaphylactic reaction triggered by the release of inflammatory cells and mediators. This entity, however, is often not properly diagnosed. In this report, we aimed to discuss a case of Kounis syndrome mimicking acute coronary syndrome. We presented a 58-year-old man with dyspnea, chest pain, dizziness, and itchiness 30 minutes following sodium diclofenac ingestion. His physical examination was remarkable for shock with hypoxia and features of anaphylactic reaction. An urgent electrocardiogram was obtained, manifesting deep ST-segment depression in anterolateral leads with ST elevation of aVR, which hinted a severe three-vessel disease or left main disease. Allergic acute coronary syndrome was suspected. Thus, the patient was managed with fluid resuscitation, epinephrine, and corticosteroid injection along with acute coronary syndrome treatment algorithm with a favorable clinical response. One-hour serial ECG showed complete resolution of ST depression with aVR normalization. This pointed to possible acute coronary spasm. No further coronary intervention was performed, the patient was discharged after 2 days in good condition and planned for further cardiac evaluation during follow-up. Kounis syndrome is an intriguing process caused by the presence of two disease entities that must be treated simultaneously. The difficulty in treating this condition stems from the fact that treating one of both entities may aggravate the other. Thus, a comprehensive approach and health education are strongly advised to ensure that this condition does not reoccur in the future.

Arrhythmia prevalence and sudden death risk in adults with the m.3243A>G mitochondrial disorder

AimsTo define the prevalence of non-sustained tachyarrhythmias and bradyarrhythmias in patients with the m.3243A>G mitochondrial genotype and a previously defined, profile, associated with ‘high sudden-death risk’.Methods and resultsPatients at high...