Significant ST-T Changes Research Articles

Plaque rupture after coronary CT angiography.

A 61-year-old man presented to the emergency room with intermittent chest pain. Electrocardiography (ECG) showed no significant ST-T changes. Transthoracic echocardiography revealed regional left ventricular (LV) asynergy in the anterior septum, with an elevated cardiac troponin I level (68.1 pg/mL). Although urgent hospitalization and coronary angiography were recommended for the treatment of a suspected non-ST-segment elevation myocardial infarction, the patient refused as his symptoms had resolved. However, the patient agreed to undergo urgent coronary computed tomography angiography (CCTA). CCTA revealed severe stenosis with high-risk plaque features in the proximal left anterior descending artery (LAD) (Panel A−D).1 After the CCTA, he developed sudden-onset, severe chest pain in the emergency room. An additional ECG showed significant ST-segment elevation in the V2-V5 leads. The patient agreed to undergo urgent coronary angiography. Emergency coronary angiography revealed a lesion in the proximal LAD with complete occlusion (Panel E). Intravascular ultrasonography revealed an intraluminal thrombus secondary to plaque rupture (Panel F). The maximum cardiac enzyme levels were CK (467 IU/L), CK-MB (35 IU/L), and troponin I (8461 pg/mL). The patient had an improvement in LV asynergy at follow-up one-month post-discharge.

PO-626-07 VALIDATION OF A PORTABLE DEVICE FOR HF-ECG IN ISCHEMIA DETECTION DURING CORONARY BALLOON INFLATION IN ANGIOPLASTY - BRINGING THE PHYSIOLOGY LAB TO THE BEDSIDE !

High frequency QRS (HfQRS) analysis for rapid assessment of myocardial ischemia has never been evaluated owing to the logistical challenges of signal recording. We aim to evaluate, in a pilot study, the correlation between the HFQRS changes recorded on a novel wearable Sydäntek 12 lead ECG patch with balloon inflation induced ischaemia. To document utility of a portable device, Sydäntek, in ECG and HFECG during multiple balloon inflations. 10 patients (M:F = 8:2) undergoing coronary intervention for medically refractory chronic stable angina were screened for enrollment into the study ; 9/10 patients underwent the final recording. 1 patient was excluded owing to signal noise in the device due to reluctance in chest preparation. The mean recording time per case was 60+/-15 mins. ECG including HfQRS was recordable continuously during all intended times, using Sydäntek at 2k samples/secs. In 33 balloon inflation ischemia episodes , changes were seen on the HFQRS onset ∼ 10 secs, offset ∼45 secs after deflation . No significant changes were seen in the conventional ECG analysed for these upto ∼45 secs . Decrease in the amplitude of the HFQRS, and decrease in the real time RMS voltage of QRS in leads V2-V5 and the presence of RAZ ( reduced amplitude zone ) were considered to be changes suggestive of ischemia. RAZ disappeared ∼45 secs after the balloon deflation. The mean total ischemic was 1 +/-0.5 min per patient per balloon inflation. In this study , all 9 of the conventional ECGs were reported independently by 2 docs as not having significant ST-T changes of ischaemia. RAZ presence in HFQRS was seen in all 33 of complete coronary artery occlusion by balloon, in our study .There was reduction in the amplitude of HFQRS(mean 12+/-1 μV) and RMSv2-v5 (mean 7+/-0.5 μV) from the baseline during the inflation. Post intervention, both of the above parameters had a mean increase of 22+/-1 μV and 10+/-0.3 μV respectively. HFQRS measured using our novel, portable real time 12 lead ECG recording patch can reliably detect onset of coronary ischemia in a complete coronary occlusion even in absence of ST -T changes in 12 lead ECG . We submit this proof of concept for use in detecting ischemia in a variety of clinical situations including chest pain triage and post intervention monitoring.

A Case of Wellens Syndrome Combined with De Winter Syndrome

This paper reports a typical case of Wellens syndrome combined with De Winter syndrome. The male patient was admitted with "one day chest pain". He is 64 years old. He had chest pain without obvious inducement. Preliminary diagnosis: coronary heart disease unstable angina pectoris. The Electrocardiogram of this case is typical of Wellens syndrome. The patient's Electrocardiogram pseudonormalized during the onset of chest pain, and no significant ST-T changes were observed. After being admitted to hospital, chest pain was relieved. In the case of this case, when the chest pain occurred again, the electrocardiogram of the patient showed a 1-3mm depression of J point in lead V2-V6, followed by symmetrical high tip of T wave and normal ECG changes in QRS wave. Which was in line with the characteristics of electrocardiogram changes in De Winter syndrome. Coronary angiography results: right dominant type, no stenosis in LM, LCX and RCA, and 90%-95% stenosis in the middle part of LAD. The Electrocardiogram of the patient showed dynamic evolution of ST-T. Wellens syndrome and De Winter syndrome successively appeared. It suggests that severe proximal stenosis of the anterior descending artery is accompanied by coronary spasm and the possibility of spontaneous remission. Which will lead to changes of electrocardiograph in ST-T. For these patients, it is necessary to observe the changes of the condition closely and monitor the changes of electrocardiogram dynamically. It is likely to progress to acute extensive anterior wall myocardial infarction without further treatment. So it is necessary perform coronary intervention in time.

C101. Toxoplasmic Myocarditis in Immunocompetent Patient: A Rare Case Report

Abstract Background Toxoplasmosis is the most frequent protozoan infection among human. Primary acquired infections in immuno-competent hosts are usually asymptomatic or may cause only slight, self-resolving and not pathognomonic symptoms. Although often considered as benign, acute infections in young healthy adults can lead to heart inflammation, including acute myocarditis. Case Illustration A 28-year-old man was admitted to the hospital with a chief complaint of flu-like illness with intermittent fever and sharp chest pain. His physical examination was unremarkable. The electrocardiography showed no significant ST-T changes. His laboratory investigations gave the following results: elevated level of HsTrop T (571 ng/L; reference: <4 ng/dL), SGOT (112 U/L; reference: <41 U/L), SGOT (114 U/L; reference: <41 U/L). The echocardiography showed lateral pericardial thickening with preserved left ventricular function. He underwent cardiac MRI (cMRI). The cMRI showed myocardial edema without ischemic scar. The serological test is positive for recent Toxoplasma infection. Therefore, the patient was diagnosed with acute toxoplasmic myocarditis and subsequently treated with corticosteroid, ACE-I, beta blocker, and a combination of pyrimethamine and clindamycin. His symptoms was improved. Discussion We reported a case of an acute toxoplasmic myocarditis in an immunocompetent young man. This case demonstrates the importance of determining the etiology of myocarditis in order to start an appropriate therapy and prevent possible sequeale.

C101. Toxoplasmic Myocarditis in Immunocompetent Patient: A Rare Case Report

Abstract Background Toxoplasmosis is the most frequent protozoan infection among human. Primary acquired infections in immuno-competent hosts are usually asymptomatic or may cause only slight, self-resolving and not pathognomonic symptoms. Although often considered as benign, acute infections in young healthy adults can lead to heart inflammation, including acute myocarditis. Case Illustration A 28-year-old man was admitted to the hospital with a chief complaint of flu-like illness with intermittent fever and sharp chest pain. His physical examination was unremarkable. The electrocardiography showed no significant ST-T changes. His laboratory investigations gave the following results: elevated level of HsTrop T (571 ng/L; reference: <4 ng/dL), SGOT (112 U/L; reference: <41 U/L), SGOT (114 U/L; reference: <41 U/L). The echocardiography showed lateral pericardial thickening with preserved left ventricular function. He underwent cardiac MRI (cMRI). The cMRI showed myocardial edema without ischemic scar. The serological test is positive for recent Toxoplasma infection. Therefore, the patient was diagnosed with acute toxoplasmic myocarditis and subsequently treated with corticosteroid, ACE-I, beta blocker, and a combination of pyrimethamine and clindamycin. His symptoms was improved. Discussion We reported a case of an acute toxoplasmic myocarditis in an immunocompetent young man. This case demonstrates the importance of determining the etiology of myocarditis in order to start an appropriate therapy and prevent possible sequeale.

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

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

Simultaneous cardio-cerebral embolization associated with atrial fibrillation: a case report

BackgroundSimultaneous cerebral and myocardial infarction is called cardiocerebral infarction (CCI), and is rarely encountered. Because of the narrow time window and complex pathophysiology, CCI is challenging to immediately diagnose and treat.Case presentationA 73-year-old woman suddenly developed right hemiplegia and severe aphasia. Twelve-lead electrocardiography showed tachycardic atrial fibrillation without any significant ST-T change. Magnetic resonance imaging revealed a proximal middle cerebral artery occlusion. She was immediately treated with alteplase at the dosage approved for ischemic stroke followed by mechanical thrombectomy as bridging therapy, and complete recanalization was achieved. Aphasia improved and she began to complain of chest pain, and reported that she had experienced chest discomfort just prior to right limb weakness. Coronary angiography showed a partial filling defect in the right coronary artery with rapid and adequate distal flow, for which percutaneous coronary intervention was not required. Alteplase was suggested to have effectively resolved the coronary emboli. The occlusions of the cerebral and coronary arteries were assumed to have occurred nearly simultaneously and cardiogenic embolism due to atrial fibrillation was considered as the most likely etiology.ConclusionsAs seen in the present case, CCI may benefit from immediate treatment with intravenous tissue plasminogen activator (IV-tPA). Although which of percutaneous coronary intervention or cerebral thrombectomy should be performed first remains unclear, we must decide whether to rescue the brain or heart first in each patient within a limited window of time. This dilemma has recently become evident in this era with mechanical thrombectomy strongly established as an effective intervention for acute ischemic stroke. Close cooperation between stroke physicians and cardiologists is becoming more important.

Abstract 11275: ST-Segment Elevation in Lead aVR Strongly Predicts In-hospital Mortality in Patients With Type A Acute Aortic Dissection

Introduction: Early identification of high-risk patients is crucial for appropriate management in type A acute aortic dissection (AAD). ECG is useful for this purpose because it is readily available and rapidly interpretable at presentation. Hypothesis: In type A AAD, ischemic ST-T change at presentation is associated with poor outcomes. ST-segment elevation in lead aVR (ST↑aVR) is an ECG marker of severe acute myocardial ischemia, and therefore, may provide important prognostic information. Methods: We studied the relation of ECG findings to clinical features on admission and in-hospital death in 294 patients who were admitted within 12 h from symptom onset and underwent urgent surgery for type A AAD. Patients with bundle branch block or left ventricular hypertrophy were excluded. Patients were divided into the 3 groups according to admission ECG findings: no significant ST-T changes (n=99, G-A); the absence (n=151, G-B) or the presence (n=44, G-C) of ST↑aVR ≥0.5 mm with ST-T changes in other leads. Hemoglobin (Hb), creatinine (Cr), D-dimer, and cardiac-specific troponin were measured on admission. Results: There were no differences in age, sex, time to admission or Hb level in the 3 groups. In G-A, G-B, and G-C, systolic blood pressure was 130±23, 131±33, and 88±27 mmHg (p<0.01); heart rate was 70±14, 72±19, and 94±23 bpm (p<0.01); the levels of Cr were 0.9±0.6, 1.0±0.7, and 1.3±1.0 mg/dl (p=0.01); D-dimer was 26±43, 33±40, 62±50 μg/ml (p=0.02), the rates of positive-troponin were 3%, 14%, and 41% (p<0.01); shock were 2%, 21%, and 71% (p<0.01); cardiac tamponade was 3%, 19%, and 64% (p<0.01); moderate/severe aortic regurgitation was 4%, 28%, and 43% (p<0.01); coronary ostial involvement was 3%, 10%, and 32% (p<0.01); concomitant coronary artery bypass surgery was 2%, 7%, and 14% (p=0.03); in-hospital death was 1%, 6%, and 36% (p<0.01), respectively. Multivariate analysis showed that as compared with G-A, odds ratio (95%CI) for in-hospital death associated with G-B and G-C were 1.90 (0.68-4.08; p=0.19), and 34.4 (8.01-73.2; p<0.01), respectively. Conclusions: In patients with type A AAD, ST↑aVR on admission ECG strongly predicts in-hospital death. Our findings suggest that ST↑aVR is a simple but reliable tool for an early identification of high-risk patients.

Abstract 9919: ST-Segment Elevation in Lead aVR is the Strongest Predictor of 30-Day Mortality in Patients With Type A Acute Aortic Dissection

Introduction: We investigated the prognostic value of ST-segment elevation in lead aVR (ST↑aVR) at presentation ECG in type A acute aortic dissection (AAD). Hypothesis: In type A AAD, ischemic ST-T changes at presentation have been shown to be associated with poor outcomes. ST↑aVR, an ECG marker of severe acute myocardial ischemia, may provide important prognostic information. Methods: We studied the relation of ECG findings to clinical features on admission and 30-day mortality in 280 patients who were admitted within 6 h from symptom onset and underwent emergency surgery for type A AAD. Patients with bundle branch block or left ventricular hypertrophy were excluded. Patients were divided into the 3 groups according to admission ECG findings: no significant ST-T changes (n=96, G-A); the absence (n=142, G-B) or the presence (n=42, G-C) of ST↑aVR ≥0.5 mm with ST-T changes in other leads. Estimated glomerular filtration rate (eGFR) was measured on admission, and renal dysfunction was defined as an eGFR <60 ml/min per 1.73 m2. Results: There were no differences in age, sex or time from symptom onset to admission in the 3 groups. In G-A, G-B, and G-C, the rates of renal dysfunction were 41%, 56%, and 67% (p<0.01); shock were 2%, 22%, and 71% (p<0.01); cardiac tamponade was 3%, 18%, and 67% (p<0.01); moderate/severe aortic regurgitation was 4%, 28%, and 43% (p<0.01); coronary ostial involvement was 3%, 11%, and 32% (p<0.01); left coronary artery involvement was 2%, 1%, and 17% (p<0.01); right coronary artery involvement was 1%, 9%, and 10% (p<0.05); and both left and right coronary artery involvement was 0%, 1%, and 5% (p=0.10); coronary artery bypass surgery was 2%, 7%, and 12% (p=0.07); aortic valve repair/replacement was 1%, 6%, and 10% (p=0.06); 30-day mortality was 1%, 6%, and 33% (p<0.01), respectively. After adjusting baseline characteristics, multivariate analysis showed that ST↑aVR (OR 38.4, 95%CI 8.10-82.0, p<0.01) was the strongest predictor of 30-day death, followed by renal dysfunction (OR 5.85, 95%CI 1.70-20.1, p<0.01). Conclusions: In patients with type A AAD who underwent emergency surgery, ST↑aVR on admission ECG was the strongest predictor of 30-day mortality. Our findings suggest the importance of ST↑aVR in early risk stratification for type A AAD.

A Case of Heart Failure Due to Increasing of Mitral Regurgitation

A 66-year-old male was admitted to our hospital because of dyspnea on exersion. He has the past history of congestive heart failure several times. Chest X-ray showed severe congestion. EKG on admission showed sinus rhythm and no significant ST-T change. Echocardiography showed no dilation of the left ventricle, no myocardial hypertrophy, no apparent synergy, and no significant valvular lesions. However, follow-up echocardiography performed after cardiac rehabilitation revealed severe mitral regurgitation. Then, cardiac catheterization was performed. Only mild mitral regurgitation was recorded in the catheterization room. Coronary angiogram showed only moderate stenosis in the left circumflex coronary artery. Immediately after left ventriculography, however, pulmonary artery pressure and capillary wedge pressure was elevated, and severe mitral regurgitation was found. Intraaortic balloon pumping decreased pulmonary artery pressure and mitral regurgitation was decreased to mild range. It was speculated that acute severe mitral regurgitation induced by exersion or volume overload results in acute heart failure. A 66-year-old male was admitted to our hospital because of dyspnea on exersion. He has the past history of congestive heart failure several times. Chest X-ray showed severe congestion. EKG on admission showed sinus rhythm and no significant ST-T change. Echocardiography showed no dilation of the left ventricle, no myocardial hypertrophy, no apparent synergy, and no significant valvular lesions. However, follow-up echocardiography performed after cardiac rehabilitation revealed severe mitral regurgitation. Then, cardiac catheterization was performed. Only mild mitral regurgitation was recorded in the catheterization room. Coronary angiogram showed only moderate stenosis in the left circumflex coronary artery. Immediately after left ventriculography, however, pulmonary artery pressure and capillary wedge pressure was elevated, and severe mitral regurgitation was found. Intraaortic balloon pumping decreased pulmonary artery pressure and mitral regurgitation was decreased to mild range. It was speculated that acute severe mitral regurgitation induced by exersion or volume overload results in acute heart failure.

Pseudo-ballooning of Radial Artery-An Artifact.

Transradial approach (TRA) for coronary intervention is rapidly increasing worldwide and therefore novel difficulties and complications are frequently observed. Most of these difficulties and complications can be dealt with new techniques and the procedure can be completed through the same artery and seldom needs change to femoral artery approach [1]. Among the various difficulties encountered through TRA, radial artery spasm either focal or diffuse is common and is observed in 14.7% of the cases [2]. Mostly the spasm is relieved completely by spasmolytic cocktails. Here, we describe a very unusual behavior of the radial artery where diffuse spasm was relieved only in the focal segment in spite of repeated spasmolytic cocktail. A 64-year-old hypertensive female presented with chest pain of 6 hours duration. She had significant past history of ischemic heart disease and underwent percutaneous coronary intervention (PCI) from right radial approach in left anterior descending coronary artery (LAD). A 12-lead electrocardiogram revealed no significant ST-T changes. Transthoracic echocardiography revealed mild left ventricular systolic dysfunction (LVEF ~ 40%). After informed consent, coronary angiography was planned through left radial approach as right radial artery was occluded because of the previous procedure. Left radial artery was punctured successfully but 0.025″ hydrophilic wire as well as floppy-tipped 0.014″ percutaneous transluminal coronary angioplasty (PTCA) wire could not be negotiated. Injection with diluted contrast through the cannula revealed diffuse spasm of the left radial artery [Table/Fig-1]. As a part of our protocol, 200 mcg of nitroglycerine and 5 mg of diltiazem was administered through the cannula but the radial spasm was not relieved, therefore the spasmolytic cocktail was repeated after 3 minutes. Contrast injection after second spasmolytic cocktail showed focal relief of diffuse spasm presenting an interesting image of ‘pseudoballooning’ of radial artery mimicking inflated PTCA balloon catheter [Table/Fig-2]. Despite administration of spasmolytic cocktail for third time, the diffuse spasm was not relieved and the coronary angiography was completed through femoral approach [Video-1]. [Table/Fig-1]: Diluted contrast injection through the intra-arterial cannula showing diffuse spasm of left radial artery [Table/Fig-2]: Repeat contrast injection after spasmolytic cocktail showing focal relief (Arrow) of diffuse spasm mimicking “pseudo-ballooning of radial artery”

Case Report of Midventricular Obstruction of Post-transplanted Heart

A 50s male patient with dilated phase of hypertrophic cardiomyopathy received heart transplant after 3 years' waiting with left ventricular assist device. He had been doing well and had no comoplaint till 6 months after transplant, when myocardial biopsy showed acute rejection grade OR, and coronary angiography showed no significant stenosis. However, the patient started to complain dyspnea and chest oppression during exercise after these follow up examination. HolterECG showed no significant ST-T change nor any arrhythmia during symptoms, and treadmill exercise test induced severe symptom without significant ECG change.

Frequency and Implication of ST-T Abnormalities on Hospital Admission Electrocardiograms in Patients With Type A Acute Aortic Dissection

Although patients with Stanford type A acute aortic dissection often show ST-T abnormalities at presentation, the frequency and implication of such findings remain unclear. To clarify these points, admission electrocardiograms from 233 patients admitted ≤6 hours after symptom onset who underwent emergency surgery for type A acute aortic dissection were studied. The prevalence of electrocardiographic (ECG) patterns was 51% for ST-T abnormalities (4% for ST-segment elevation and 47% for ST-segment depression and/or negative T waves), 30% for normal ECG findings or no significant ST-T changes, and 19% for ECG confounders such as bundle branch block or left ventricular hypertrophy. Patients with ST-T abnormalities had higher prevalence of pericardial effusion (48% vs 9% and 38%), cardiac tamponade (28% vs 3% and 18%), moderate or severe aortic regurgitation (28% vs 7% and 18%), shock on admission (34% vs 3% and 13%), coronary ostial involvement (14% vs 1% and 2%), concomitant coronary artery bypass surgery (9% vs 1% and 0%), and in-hospital mortality (11% vs 1% and 4%) compared with patients with normal ECG findings or no significant ST-T changes and those who had ECG confounders (p <0.05 for all). On multivariate analysis, ST-T abnormalities were the only independent predictor of in-hospital mortality (odds ratio 3.87, 95% confidence interval 1.02 to 14.7, p = 0.035). In conclusion, about 50% of patients who underwent emergency surgery for type A acute aortic dissection had ST-T abnormalities, characterized predominantly by ST-segment depression or negative T waves, in the acute phase. ST-T abnormalities were associated with more complicated features and independently predicted in-hospital death.

An Unusual Presentation of Coronary Artery Fistula in Athlete - Case Report

A 32-year-old active cyclist was referred fo r the evaluation because of syncope he had performed in preseason. He was found to be normostenic, acyanotic, normotensive with clear lungs and a regular pulse of 60 bp m, with normal dual heart sounds and a grade Levine 2/6 continuous diastolic murmu r in the second intercostal space of the left parasternal area. He had no family history of premature card iac death and his lipids were normal. Rest ECG showed a regular sinus rhythm of 62 bp m with inco mplete right bundle branch block and no significant ST-T changes. A transthoracic ECHO in parasternal short-axis view revealed an anomalous colour flow jet in diastole arising fro m the lateral wall into the main pulmonary artery and coronary artery fistula with non-significant left -to-right shunt (Qp/Qs ratio 1.2).came under suspicion. In contrast, it has not been confirmed clearly by the transoesophageal ECHO. Coronary angiography was without coronary stenosis and confirmed a 'serpentine' anomalous drainage supposedly from left anterior descending artery to the main pulmonary artery. A complex anato my of sacculary dilated fistula that originates fro m the pro ximal left anterio r descending artery and drainages the main pulmonary artery was showed in detail by a 64 slice MDCT scanning. Myocardial Tc-99m Myoview perfusion SPECT imag ing showed no perfusion defects in maximal physical stress and follo w-up without intervention was suggested. In addition, due to the results of holter ECG monitoring, head-up tilt testing, carotid sinus massage and programmed atrial stimulat ion syncope was concluded as vasovagal, but its nature still remains discussible. After a three year follow-up patient remains asympto matic and recently performed control myocardial perfusion SPECT showed no signs of stress related myo cardial ischemia. In conclusion, several imaging techniques are needed for an accurate diagnosis of coronary fistula and for the suggestion of proper further management. In some cases syncope may be the first man ifestation of CAF, but it is still unclear if it is directly related to the coronary anomaly.

An uncommon presentation of a rare disease – High-degree AV block with takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a type of non-ischemic cardiomyopathy in which there is sudden temporary left ventricular dysfunction. High-degree AV block and takotsubo cardiomyopathy have been reported together rarely in medical literature. Here we discuss a case of takotsubo cardiomyopathy presenting with complete heart block. A 72-year-old female presented with retrosternal chest pain. Electrocardiogram showed complete heart block without any significant ST-T changes. Echocardiogram revealed regional wall motion abnormality not consistent with coronary artery disease and was suggestive of apical ballooning. Coronary angiogram showed no significant coronary artery lesion. LV angiogram showed apical ballooning and LV systolic dysfunction. Patient underwent temporary pacemaker implantation. Since the complete heart block did not revert even after 18 days, she underwent a permanent pacemaker implantation.

Short- and Long-Term Prognostic Significance of ST-Segment Elevation in Lead aVR in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome

We sought to evaluate the prognostic significance of ST-segment elevation (STE) in lead aVR in unselected patients with non-STE acute coronary syndrome (NSTE-ACS). We enrolled 1,042 consecutive patients with NSTE-ACS. Patients were divided into 5 groups according to the following electrocardiographic (ECG) patterns on admission: (1) normal electrocardiogram or no significant ST-T changes, (2) inverted T waves, (3) isolated ST deviation (ST depression [STD] without STE in lead aVR or transient STE), (4) STD plus STE in lead aVR, and (5) ECG confounders (pacing, right or left bundle branch block). The main angiographic end point was left main coronary artery (LM) disease as the culprit artery. Clinical end points were in-hospital and 1-year cardiovascular death defined as the composite of cardiac death, fatal stroke, and fatal bleeding. Prevalence of STD plus STE in lead aVR was 13.4%. Rates of culprit LM disease and in-hospital cardiovascular death were 8.1% and 3.8%, respectively. On multivariable analysis, patients with STD plus STE in lead aVR (group 4) showed an increased risk of culprit LM disease (odds ratio 4.72, 95% confidence interval [CI] 2.31 to 9.64, p <0.001) and in-hospital cardiovascular mortality (odds ratio 5.58, 95% CI 2.35 to 13.24, p <0.001) compared to patients without any ST deviation (pooled groups 1, 2, and 5), whereas patients with isolated ST deviation (group 3) did not. At 1-year follow-up 127 patients (12.2%) died from cardiovascular causes. On multivariable analysis, STD plus STE in lead aVR was a stronger independent predictor of cardiovascular death (hazard ratio 2.29, 95% CI 1.44 to 3.64, p <0.001) than isolated ST deviation (hazard ratio 1.52, 95% CI 0.98 to 2.36, p = 0.06). In conclusion, STD plus STE in lead aVR is associated with high-risk coronary lesions and predicts in-hospital and 1-year cardiovascular deaths in patients with NSTE-ACS. Therefore, this promptly available ECG pattern could be useful to improve risk stratification and management of patients with NSTE-ACS.

Transcatheter coil embolization of multiple coronary artery-to-left ventricle fistulas: report of a rare case

Transcatheter coil embolization of multiple coronary artery-to-left ventricle fistulas: report of a rare case

Myocardial infarction in a young athlete with non-obstructive hypertrophic cardiomyopathy and normal coronary arteries

We describe an acute myocardial infarction in a young athlete with non-obstructive hypertrophic cardiomyopathy (HCM) and normal coronary arteries. A 18 year old athlete came to our attention for dispnoea and chest pain during effort. Echocardiography showed non-obstructive HCM, with restrictive physiology. Cardiac catheterization and coronary angiography showed elevated pulmonary artery pressure and normal coronary arteries. He was discharged on sotalol and diuretics. Nine months later, he was resuscitated from a cardiac arrest during mild effort. The ECG revealed a high rate of atrial fibrillation with significant ST-T changes, and echocardiography an akinesia of interventricular septum. Cardiac enzymes were elevated. The coronary angiogram showed normal coronary arteries. This case is important as a reminder that acute myocardial infarction is not only due to coronary artery disease, and that atrial fibrillation may represent a trigger of serious cardiovascular events in patients with HCM.

Myocardial perfusion quantification in patients suspected of cardiac syndrome X with positive and negative exercise testing: A [13N]ammonia positron emission tomography study

The combination of angina pectoris, angiographically normal coronary arteries, and a positive exercise stress test (EST) is referred to as cardiac syndrome X. However, a large group of patients suspected of syndrome X reveals a normal exercise stress test and weakens the diagnosis of syndrome X. Previous studies demonstrated an impaired coronary flow reserve on ammonia positron emission tomography (PET) in patients with syndrome X. To evaluate the coronary flow reserve in patients suspected of syndrome X with positive and negative EST findings, using [(13)N]ammonia PET as the diagnostic aid. Forty-two patients with chest pain and a normal coronary angiography, were analysed by exercise stress testing (EST) and the dypyridamole stress test (DST) on [(13)N]ammonia PET. Two subgroups were predefined, based on outcome of EST: an EST positive and negative group. A normal control group was used as the reference method. A total of 24 (57%) out of 42 patients had significant ST-T changes (EST positive). [(13)N]ammonia PET showed a significantly lower rest flow in the EST positive and EST negative group compared to controls (P<0.001 and P=0.0028, respectively). DST [(13)N]ammonia PET perfusion was significantly reduced in flow in both the EST positive and EST negative groups (P<0.001 both), as was the DST/rest [(13)N]ammonia perfusion reserve (P<0.001 for both), compared to normal controls. PET demonstrates a reduced coronary flow reserve in patients suspected of syndrome X, irrespective of the EST findings.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease

Background: Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear. Objective: We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis. Methods: Coronary artery ectasia was defined as 1.5–2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test. Results: Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group ( P=0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2–3 vessels) was found to be strongly related with ischemia ( P=0.005) with respect to local disease. Conclusion: Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.