Signs Of Infarction Research Articles

Clinical and Imaging Features of Acute Cerebral Infarction in Non-small Cell Lung Cancer Patients with Trousseau Syndrome

背景与目的急性脑梗死是Trousseau综合征（Trousseau syndrome, TS）的一种表现形式，但相对少见，往往容易被临床医师忽视。本研究探讨非小细胞肺癌（non-small cell lung cancer, NSCLC）合并TS以急性脑梗死为表现的临床、实验室检查及影像学特点。方法回顾性收集25例以急性脑梗死为表现的NSCLC合并TS患者的临床资料、实验室检查和影像学资料，进行分析总结。结果25例患者中男性18例，女性7例，年龄39岁-78岁，其中腺癌22例、鳞癌2例和大细胞癌1例；所有患者均有急性脑梗死的临床症状和体征；血浆D-二聚体明显升高，凝血酶原时间及活化部分凝血活酶时间均有不同程度的缩短；所有患者在头部磁共振成像（magnetic resonance imaging, MRI）[扩散加权成像（diffusion-weighted imaging, DWI）序列]平扫上均表现为累及多个颅内动脉供血区的急性多发性脑梗死灶，头磁共振血管成像（MR angiography, MRA）上梗死灶对应的供血血管管腔未见中重度狭窄。结论NSCLC合并急性多发性脑梗死是TS的少见表现类型，其特点是累及多个动脉供血区的急性多发性脑梗死灶伴有明显高凝状态；提高对该病的早期认识可以为临床诊疗提供一定的帮助。

Focal ST-segment elevation without coronary occlusion: myocardial infarction with no obstructive coronary atherosclerosis associated with COVID-19-a case report.

BackgroundWhile it is understood that coronavirus disease 2019 (COVID-19) is primarily complicated by respiratory failure, more data are emerging on the cardiovascular complications of this disease. A subset of COVID-19 patients present with ST-elevations on electrocardiogram (ECG) yet normal coronary angiography, a presentation that can fit criteria for myocardial infarction with no obstructive coronary atherosclerosis (MINOCA). There is little known about non-coronary myocardial injury observed in patients with COVID-19, and we present a case that should encourage further conversation and study of this clinical challenge.Case summaryAn 86-year-old man presented to our institution with acute hypoxic respiratory failure and an ECG showing anteroseptal ST-segment elevation concerning for myocardial infarction. Mechanic ventilation was initiated prior to presentation, and emergent transthoracic echocardiography reported an ejection fraction of 50–55%, with no significant regional wall motion abnormalities. Next, emergent coronary angiography was performed, and no significant coronary artery disease was detected. The patient tested positive for COVID-19. Despite supportive management in the intensive care unit, the patient passed away.DiscussionWe present a case of COVID-19 that is likely associated with MINOCA. It is crucial to understand that in COVID-19 patients with signs of myocardial infarction, not all myocardial injury is due to obstructive coronary artery disease. In the case of COVID-19 pathophysiology, it is important to consider the cardiovascular effects of hypoxic respiratory failure, potential myocarditis, and significant systemic inflammation. Continued surveillance and research on the cardiovascular complications of COVID-19 is essential to further elucidate management and prognosis.

A Prominent R wave in V1 but not in V2 is a specific sign of a large lateral infarction: Algerian study

In the absence of right ventricular hypertrophy or bundle-branch block, a prominent R wave in V1 or V2 is considered to reflect a lateral myocardial infarction. We investigated the differences in infarct location and size between patients with prominent R wave in V1 and those with prominent R wave in V2. We studied 50 patients with a previous first infarction involving left ventricular inferior and/or lateral wall at myocardial scintigraphy A prominent R wave in V1 was present in 8 patients (16%), in V2 in 23 (46%). At myocardial scintigraphy, the infarction involved the inferior wall in 11 patients (22%), the lateral wall in 6 (12%), and both walls in 33 patients (66%). The sensitivity of a prominent R wave in V1 in detecting a lateral infarction was low (17.9%), while the specificity was high (90.9%). The sensitivity and specificity of a prominent R wave in V2 were 46.2% and 54.5%, respectively. In patients with a prominent R wave in V1, infarct size and lateral extent were greater than in patients without this pattern ( P < 0.005 and < 0.01 respectively). In patients with a prominent R wave in V2, infarct size, lateral extent were not different from patients without this pattern. Only a prominent R wave in V1 is a specific sign of large lateral infarction.

Острый инфаркт миокарда и коронавирусная инфекция (COVID-19)

The aim of the study is to describe a case of COVID-19 and myocardial infarction in an elderly patient. Material and methods. The analysis of medical documentation (outpatient card of the patient, medical history, postmortem report) was carried out. Studied macro- and micropreparations (staining with hematoxylin and eosin). Results. A 67-year-old patient, from 23.04.2020 to 26.04.2020, was hospitalized with a diagnosis of suspected coronavirus infection (COVID-19). On the background of the treatment, the patient's biological death occurred (26.04.2020). The sectional study revealed signs of bilateral total hemorrhagic pneumonia. The signs of acute transmural myocardial infarction of the anterior wall of the left ventricle were determined. Posthumously, SARS-CoV-2 RNA was detected in the lung tissue by nucleic acid amplification. In the described clinical case, a patient with concomitant cardiovascular diseases, such as arterial hypertension, coronary heart disease, developed complications against the background of COVID-19: hemorrhagic pneumonia and myocardial infarction with a fatal outcome. © Infectious Diseases: News, Opinions, Training.

Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: in-hospital outcomes. Part 2

To assess in-hospital outcomes of coronary artery bypass grafting in patients with acute coronary syndrome, depending on the presence or absence of myocardial infarction. Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and subjected to coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction, who underwent surgery at an average of 16 (11; 20) days after manifestation of the clinical signs of myocardial infarction. The endpoints of the study were major adverse cardiovascular events during the in-hospital period: death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization, septic complications, multiple organ failure syndrome, wound infectious complications, requirement for repeated surgical debridement, remediastinotomy due to haemorrhage, the frequency of extracorporeal membrane oxygenation and renal replacement therapy. The mortality rate in the compared groups was similar: 3% (n=3) and 3% (n=2), respectively. Perioperative myocardial infarction occurred in 1 (1%) patient of the first group, with no cases of this complication observed in the second group. The frequency of reoperations due to haemorrhage in the early postoperative period in the group of unstable angina pectoris amounted to 3% (n=3) and was associated with administration of dual antithrombotic therapy, with no cases of this complication in the group of myocardial infarction. Wound complication in the second group were observed in 7.6% (n=5) and in the first group in 4% (n=4) (p=0.33). The differences turned out to be statistically insignificant for such postoperative complications as multiple organ failure syndrome, requirement for repeated surgical debridement, renal replacement therapy, and extracorporeal membrane oxygenation. The residual SYNTAX Score in the group of myocardial infarction amounted to 2.3±2.8, whereas in the group of unstable angina pectoris to 2.3±3, thus suggesting complete revascularization in the total sample of patients with acute coronary syndrome. The average length of hospital stay (including the postoperative period) in the first group amounted to 26.3±6.6 days and in the second group to 27.4±7.2 days (p=0.53). The postoperative bed-day in the group with unstable angina pectoris was 12.6±3.2 and in the myocardial infarction group - 14.9±5.3 (p=0.06). The obtained in-hospital outcomes suggest that coronary artery bypass grafting may be an efficient and safe method of complete revascularization for patients with non-ST-elevation acute coronary syndrome, including that resulting in myocardial infarction, performed averagely on day 16 (11; 20) after the onset of clinical manifestations of myocardial infarction.

Torsipulsion, a useful diagnostic sign in lateral medullary infarction

A number of ocular motility disturbances such as skew deviation, saccadic/smooth pursuit abnormalities, Horner's syndrome, and nystagmus have been reported in lateral medullary infarction. We report 3 patients who had torsipulsion as the main ocular movement abnormality directly attributable to lateral medullary infarction. Patients 1 and 2 had a clockwise torsional movement that was diagnosed on slit lamp. The movement was elicited on asking the patients to make a horizontal saccade. Both patients were noted to have dorsolateral medullary infarction on MRI of the brain. Neither patient had symptoms directly attributable to torsipulsion. Patient No. 3 was referred for non-resolving left 6th nerve palsy. He had infarcts in the left pons, cerebellum and dorsolateral medulla. Torsipulsion was the only ocular motility disorder caused by medullary infarction. Different pathways in the dorsolateral medulla have been implicated in the various ocular motility and neurological abnormalities seen in lateral medullary syndrome. It is possible that sparing of some and involvement of others could result in varied clinical presentations reported in literature. It is important for the ophthalmologist to be aware of torsipulsion as a diagnostic sign of lateral medullary infarction.

Expanding indications for endovascular thrombectomy-how to leave no patient behind.

Endovascular thrombectomy (EVT) has become standard of care for large vessel occlusion strokes but current guidelines exclude a large proportion of patients from this highly effective treatment. This review therefore focuses on expanding indications for EVT in several borderline indications such as patients in the extended time window, patients with extensive signs of infarction on admission imaging, elderly patients and patients with pre-existing deficits. It also discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT and EVT as primary therapy for distal vessel occlusions, for tandem occlusions, for basilar artery occlusions and in pediatric patients. We provide clear recommendations based on current guidelines and further literature.

Silent cerebral infarct in sickle cell anemia patients of southern Turkey

Background/aimSilent cerebral infarct (SCI) is an ischemic lesion seen before clinical signs of brain infarct and ischemic changes in brain tissue. This study aimed to detect SCI with noninvasive methods and to determine related risk factors in patients with sickle cell anemia (SCA).Materials and methodsFifty-four SCA patients who had no history of cerebral infarct and whose neurological examinations were normal were included in this study. Brain magnetic resonance imaging (MRI) and diffusion MRI were taken and the acquired data was compared statistically.ResultsSCI was detected in 11.1% (6/54) of the patients. No statistical differences in age, sex, physical examination findings, or treatments were detected between the 2 groups (with and without SCI). When examined in terms of HbS, the median (min–max) value in SCI-positive patients was 85.4 (80.5–92.1); the median value was 77.2 (49.0–96.7) in SCI-negative patients. The HbS values of the SCI group were statistically significantly higher than those of the group without SCI (P = 0.014). Patients with the HbSS or HbSβ0 genotypes had a significantly higher prevalence of SCI when compared with other sickle cell syndromes (P = 0.038).ConclusionSCI is not uncommon among SCA patients in Turkey. The presence of homozygote HbSS/Sβ0 genotype, high MCV, and HbS are risk factors for SCI.

Prevalence and clinical significance of electrocardiogram abnormalities in older civil aviation pilots

Abstract. Prevalence and clinical significance of electrocardiography findings was studied in 1189 older pilots in aged 55 years and older, who were consistently admitted to the Central Civil Aviation Hospital (Moscow) and examined on the regular bases. Resting 12-lead electrocardiogram was recorded in all subjects according to generally accepted methods. Normal electrocardiogram was found in 78,5% of older pilots. None of the examined showed signs of myocardial infarction. Minor electrocardiogram abnormalities was registered in 21,5% of pilots. Cardiac conduction disorders were predominated 16,1% of cases, most of them were intraventricular conduction disorders 13,7% of cases. Another electrocardiogram abnormalities were less common 4% of cases. Mixed electrocardiogram abnormalities were noted in a small number of observations in 1,4% of individuals. Thus, older civil aviation pilots are characterized a lower frequency of majority electrocardiogram deviations compared to a population of the same age. The evaluation of fitness to flight in some electrocardiogram deviations is depend of the presence or absence of cardiovascular disease, functional condition of the cardiovascular system and the data of additional examination methods. On the whole, the electrocardiogram use as a screening in asymptomatic individuals has some significant limitations - a number of detected abnormalities may be normal variants, as well as a normal electrocardiogram may be in significant narrowing of the coronary artery. Nevertheless, the need for electrocardiogram recording is recognized by aeromedical specialists of different countries, since this method is exclude a number of pathological changes, which are significant for flight safety.

Combination of chronic myocarditis and progressive coronary artery disease: differential diagnosis and stepwise treatment

Aim. To assess the differential diagnosis in a patient with a combination of coronary artery disease and myocarditis and the results of stepwise treatment (including immunosuppressive therapy (IST), and coronary stenting).Material and methods. A 56-year-old female patient with hypertension, obesity (body mass index, 31,6 kg/m2), diabetes and psoriasis developed shortness of breath after a respiratory viral infection. Primary echocardiography revealed left heart dilatation, ejection fraction (EF) of 21%. Coronary angiography revealed anterior descending artery stenosis of 75%, circumflex artery — 80%, right coronary artery (RCA) — 70%. RCA stenting was performed and cardiovascular and diuretic therapy was started. However, shortness of breath and low exercise tolerance persisted.Results. In the blood test, anti-endothelial cell antibodies were 1:320, anticardiomyocyte and anti-smooth muscle antibodies — 1:80, anti-cardiac conduction system fibers — 1:320 (N≤1:40). During myocardial perfusion scintigraphy with computed tomography, an uneven distribution of the indicator was noted. Signs of myocardial scarring and indications for further revascularization were not revealed. Cardiac magnetic resonance imaging confirmed a decrease in left ventricular (LV) contractility (LVEF 37%) and moderate dilatation. Biopsy was not performed due to dual antiplatelet therapy. The condition is regarded as infectious-immune myocarditis. IST was started with azathioprine 150 mg/day. We noted dyspnea relief and a stable increase in LVEF to 50-52%. The clinical course was complicated by sick sinus syndrome with pauses up to 6 seconds and presyncope; a pacemaker was implanted. After 5 years from the onset of IST, dyspnea episodes reappeared without exacerbation of myocarditis. As their cause, ischemia was diagnosed due to the progression of coronary atherosclerosis. Symptoms regressed after repeated coronary stenting.Conclusion. The presence of moderate coronary atherosclerosis without signs of ischemia and myocardial infarction should not be considered as the only cause of severe systolic myocardial dysfunction. Diagnosis and treatment of myocarditis in combination with coronary artery disease is carried out according to the standard principles and can improve LV systolic function and control the heart failure symptoms.

Predicting cardiac risk in noncardiac surgery: a narrative review.

Risk stratification endeavors to categorize patients into groups based on the level of risk for each group. Improved perioperative screening tests using more sensitive cardiac biomarkers have revealed that about 68% of perioperative myocardial infarctions (MI) are asymptomatic and may only be detected by routine postoperative screening with troponin measurements. This is important since myocardial injury not meeting criteria for myocardial infarction is associated with increased risk of 30-day mortality (Botto et al. in Anesthesiology 120:564-578, 2014). Traditional risk indices including the revised cardiac risk index (RCRI) and the myocardial infarction cardiac arrest (MICA) index were developed based on overt clinical signs of myocardial infarction and significantly underestimate adverse cardiac events. Recently, brain type natriuretic peptides (BNP) and its precursor n- terminal pro-brain type natriuretic peptide (nt-proBNP) have been shown to be powerful prognostic markers. Incorporating serum biomarkers into updated clinical risk indices is likely to improve their performance. Further studies are needed to determine appropriate clinical interventions to treat isolated elevations in cardiac troponin levels and further mitigate the increased risk of morbidity and mortality. The objective of this review is to summarize the current literature on the clinical diagnoses of perioperative myocardial injury in the setting of noncardiac surgery.

Right-to-left T-wave discordance in acute myocardial infarction: A new electrocardiographic sign of apical and left lateral infarction

IntroductionA new ECG method producing Precordial Bipolar Leads (PBL) enables a computerized subtraction of the electrical activity detected by the precordial V1 lead from that of the V6 electrode (V6-V1 PBL). This calculation can also be performed manually using measurements from standard simultaneous 12 lead ECG (SS12LECG) tracings. We compared the magnitude of T-waves generated by PBL V6-V1 (measured by computer) to the SS12LECG V6-V1 T-waves (measured on the tracing) to determine whether these measurements are equivalent. Although Lead I and Lead V6-V1 PBL examine almost the same right-to-left axis, we noted that Lead I and Lead V6-V1 PBL sometimes have opposite T-wave polarities. We investigated this observation further using a database containing control and patient data. Material and methodsRecords of 79 patients and 52 controls from the Physionet database were used to generate the V6-V1 PBL for comparison to manual calculations from the V1 and V6 unipolar T-wave measurements on the tracings. The accuracy of these measurements was validated against the computer measurements by correlation and paired t-tests. ResultsThe T-wave automated and manual measurements in patients were strongly correlated (0.9895), consistent with the premise that measurements from tracings are accurate. The V6-V1 T-wave calculation was positive in 48 of the 52 control subjects. Nearly half of the acute myocardial infarction (AMI) patients had discordant T-wave polarity between Lead I and V6-V1 PBL; ventriculography results on 24 of these patients identified 13 patients with apical and 11 with lateral wall motion abnormalities. ConclusionA discordant T-wave in Lead I and in the V6-V1 PBL is a potential diagnostic criterion for apical or left-lateral infarction.

Infarct characteristics and outcome of patients with transient ST-segment elevation myocardial infarction compared to ST-segment and non-ST-segment elevation myocardial infarction

Abstract Background Up to one out of four patients with signs of ST-segment elevation myocardial infarction (STEMI) express complete normalization of ST elevation before primary revascularization procedure. This condition is commonly referred to as “transient ST-segment elevation myocardial infarction” (TSTEMI) and recent data suggests that this group of patients may have favorable outcome compared to STEMI patients. However, it is currently unknown how these patients compare to both STEMI and non-ST-segment elevation myocardial infarction (NSTEMI) patients with respect to infarct size characteristics and outcome. Objective This study aims to explore cardiac magnetic resonance (CMR) derived scar tissue and 1-year outcome in patients with TSTEMI by comparison to STEMI and NSTEMI. Methods Patients with STEMI were enrolled from two prospective studies (n=170); the patients with TSTEMI were recruited from the TRANSIENT trial (n=141); the patients with NSTEMI were prospectively and consecutively collected from local registries of Amsterdam UMC (n=57) and Maastricht UMC (n=51). All patients underwent CMR examination 2–8 days after the index event. Cine imaging was done for volume and function assessment. Late gadolinium enhancement imaging was performed to identify infarct size (in grams) and the presence of microvascular obstruction (MVO). All CMR images were processed in a single core laboratory (Amsterdam UMC). Clinical outcome after 1 year was measured by the incidence of major adverse cardiac events (MACE), defined as recurrent myocardial infarction (MI), revascularization and all cause death. Results The TSTEMI group demonstrated the lowest end-systolic left ventricular volume and highest left ventricular ejection fraction across the groups (overall p&amp;lt;0.001). Although there was a remarkably lower infarct size in TSTEMI patients compared to STEMI (1.41g [0.00–3.91] vs 13.48g [5.31–26.81], p&amp;lt;0.001), there was only a trend towards lower infarct size compared to NSTEMI patients (1.41g [0.00–3.91] vs 2.13g [0.00–8.64], p=0.06). Whilst MVO was observed less frequently in TSTEMI compared to STEMI patients (5 (4%) vs 53 (31%), p&amp;lt;0.001), no significant difference was seen between TSTEMI and NSTEMI patients (5 (4%) vs 5 (5%), p=0.72). Multivariable linear regression analysis identified infarct type, smoking, peak troponin-T and pre-PCI TIMI flow as predictors for infarct size (p=0.03, p=0.03, p&amp;lt;0.001 and p&amp;lt;0.001, respectively). One-year mortality rate was low in all 3 MI types (TSTEMI 3 (2.2%), NSTEMI 3 (3.1%), 4 (2.4%), log-rank test p=0.91). However, there was a significant difference in MACE at 1 year across the 3 MI types (TSTEMI 18 (13.2%), NSTEMI 19 (19.4%), STEMI 11 (6.7%), overall p&amp;lt;0.01). Conclusion In comparison to NSTEMI and STEMI, TSTEMI yielded favorable cardiac left ventricular function and scar mass. However, this did not lead to benefit in short term (1-year) outcome; further studies are needed with longer follow-up. Funding Acknowledgement Type of funding source: Other. Main funding source(s): European Association of Cardiovascular Imaging (EACVI) Research Grant

QTc interval prolongation associated with inpatient azithromycin therapy for pneumonia.

In 2013, the US Food and Drug Administration issued a warning regarding the use of azithromycin and the risk of fatal dysrhythmias after a 14-year retrospective analysis showed increased risk of cardiovascular-related death in patients who had taken a 5-day course of azithromycin compared with those who took amoxicillin, ciprofloxacin, or no antibiotics. At the authors' institution, pneumonia is the most common diagnosis for which azithromycin is used as a treatment for patients who are hospitalized. To compare corrected QT (QTc) interval measurements on electrocardiogram (ECG) before and after inpatient azithromycin treatment for pneumonia. The authors retrospectively reviewed the medical records of 642 patients age 18 years and older who were diagnosed with pneumonia and treated with azithromycin at an academic teaching hospital between January 1, 2017 and December 31, 2017. Patients who had an ECG performed both before and after azithromycin treatment were included and divided into 2 groups: those who had 1 dose of azithromycin (Group 1) and those who had 2 doses (Group 2). Patients were excluded if they had a baseline QTc interval on initial ECG greater than or equal to 500ms, any signs of ischemia or myocardial infarction, any initial dysrhythmia or underlying ECG abnormalities, or absence of pre- and post-ECG results. Outcomes measures included a comparison of QTc intervals on ECG before and after azithromycin, and an analysis of the percentage of patients with a QTc interval measurement greater than 500ms on ECG after azithromycin treatment. Our primary outcome measurement was the QTc interval measurement on ECG before and after azithromycin in patients treated with azithromycin for community acquired pneumonia. Our secondary outcome measurement was the percentage of patients with a QTc interval measurement of greater than 500ms on ECG after azithromycin treatment. A Wilcoxon signed-rank test was used to evaluate repeated QTc measures of our primary outcome in Group 1 and Group 2. Our secondary outcome was reported as a percentage of total patients with a QTc interval of greater than 500ms after azithromycin doses on ECG. Of 642 patients, 142 had available pre- and post-EGC results available; 100 were included in Group 1 (1 dose) and 42 in Group 2 (2 doses). Mean QTc interval differences after 1 dose of azithromycin exhibited an increase compared to baseline values (424 vs 477ms). A Wilcoxon signed-rank test indicated a significant QTc prolongation after 1 dose of azithromycin (mean rank, 43.76; Z=-4.921; P<.001). QTc interval differences after 2 doses of azithromycin did not reach statistical significance when compared to baseline values (422 vs 444ms). A total of 10 patients (10%) in Group 1 and 4 patients (9.5%) in Group 2 had a QTc interval >500ms after azithromycin. There were no documented dysrhythmias during hospitalization in this study period. QTc interval increases were observed during inpatient azithromycin therapy for pneumonia, but were not found to be associated with cardiac dysrhythmias during hospitalization.

Letter by Finsterer Regarding Article, “COVID-19-Associated Stress (Takotsubo) Cardiomyopathy”

HomeCirculation: Cardiovascular ImagingVol. 13, No. 10Letter by Finsterer Regarding Article, “COVID-19-Associated Stress (Takotsubo) Cardiomyopathy” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Finsterer Regarding Article, “COVID-19-Associated Stress (Takotsubo) Cardiomyopathy” Josef Finsterer, MD, PhD Josef FinstererJosef Finsterer https://orcid.org/0000-0003-2839-7305 Klinikum Landstrasse, Messerli Institute, Vienna, Austria. Search for more papers by this author Originally published23 Sep 2020https://doi.org/10.1161/CIRCIMAGING.120.011577Circulation: Cardiovascular Imaging. 2020;13:e011577To the Editor:With interest we read the article by Tsao et al1 about a 59-year-old obese but otherwise healthy woman who experienced a severe infection with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) manifesting as coronavirus disease 2019 (COVID-19) and complicated by the development of Takotsubo syndrome (TTS), also known as stress cardiomyopathy or broken-heart syndrome. The patient recovered from TTS despite the severe COVID-19 infection.1 We have the following comments and concerns.We do not agree with the notion that “TTS associated with COVID-19 has not been well described.”1 A literature search brought to light that at least 37 cases with TTS in the setting of an acute SARS-CoV-2 infection, including the index case, have been reported. The first patient with TTS triggered by a SARS-CoV-2 infection was an 83-year-old Swiss woman described by Meyer et al.2 She had a history of arterial hypertension and developed acute chest pain together with dry cough 3 days before admission.2 Transthoracic echocardiography revealed apical ballooning with hyperkinetic basal segments.2 On hospital day 3, she was tested positive for SARS-CoV-2. She recovered completely within 10 days upon conventional heart failure therapy.2 The most recently presented case was published by Sattar et al.3In the vast majority of the patients with SARS-CoV-2 associated TTS, TTS developed after onset of the SARS-CoV-2 infection. Age ranged between 39 and 87 years. The distribution between genders was almost equal, and the majority of patients presented with the classical type of TTS. Only 2 patients each presented with the midventricular, respectively, basal type of TTS. Treatment for TTS was quite variable, but most patients received β-blockers, diuretics, heparin, or acetyl-salicylic acid. Ten patients recovered; 3 patients died; and in 20 patients, the outcome was not reported.Since the infection with SARS-CoV-2 may go along with myocarditis4 and myocarditis may be misinterpreted as TTS,4 we should know how myocarditis was ruled in the index patient. Particularly, we should know whether the patient underwent cardiac magnetic resonance imaging with contrast medium or endomyocardial biopsy to see whether there was myocardial inflammation or not. Myocarditis on cardiac magnetic resonance imaging may show up as edema (pseudohypertrophy)4 or enhancement with contrast medium.4 Acute myocarditis on endomyocardial biopsy may show up as diffuse infiltration of the myocardium with T lymphocytes in the absence of any scars.4 Myocarditis in SARS-CoV-2–infected patients is usually virus negative but characterized by T-cell infiltration.4Interestingly, the prevalence of TTS generally increased during the COVID-19 crisis.5 The median length of hospitalization of these patients was longer than that during the non-COVID period.5 However, mortality and rehospitalization rate were the same as that before the crisis.5In summary, TTS is a well-recognized complication of COVID-19. Clinical presentation, epidemiology, treatment, and outcome of SARS-CoV-2–associated TTS are similar to COVID-19–unrelated TTS. Workup for TTS in patients with COVID-19 is indicated if they develop symptoms and signs of a myocardial infarction or heart failure in addition to the pulmonary compromise.AcknowledgmentsDr Finsterer contributed to the design, literature search, discussion, first draft, and critical comments.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

A man with headache and vertigo

A 63-year-old man presented to the emergency department with headache, vertigo, and inability to walk. The computed tomography scan was reported as a normal study by the radiologist despite showing an early sign of infarction. Nevertheless, the magnetic resonance imaging confirmed an acute infarction of the basilar artery. Thus, the patient received thrombolytic therapy with good prognosis.

Pulmonary embolism in obesity-hypoventilation syndrome.

Obesity-hypoventilation syndrome occurs with alveolar hypoventilation during sleeping and daytime. Obesitymay be ariskfactor for venous thromboembolism. However, the venous thromboembolism in the obesity-hypoventilation syndrome is not well characterized. This case series aimed to investigate the presence and clinical features of venous thromboembolism in patients with the obesity-hypoventilation syndrome. Data of eight case reports were collected. Ages ranged from 36 to 73 years. All patients had mosaic perfusion and enlarged main pulmonary artery, two had signs of infarction and mostly segmental and subsegmental filling defects. On the basis of this information some conclusions can be drawn carefully. Present cases indicate that pulmonary embolism are also very common in patients with obesity-hypoventilation syndrome, anticoagulant therapy is at least as important as the treatment of the current disease. Clinicians will frequently be faced with patients with obesity-hypoventilation syndrome suspected of PE.

Rethinking COVID-19 'pneumonia' - is this primarily a vaso-occlusive disease, and can early anticoagulation save the ventilator famine?

Rethinking COVID-19 'pneumonia' - is this primarily a vaso-occlusive disease, and can early anticoagulation save the ventilator famine?

Characterisation of patients with and without cardiac magnetic resonance imaging abnormalities presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA)

Objective The objective of the current study is to determine the characteristics of myocardial infarction with non-obstructive coronary arteries (MINOCA) patients with and without cardiac magnetic resonance (CMR) abnormalities. Methods We evaluated patients admitted with a presentation of acute myocardial infarction (MI) with no coronary obstruction on invasive angiography in our institution between 2012 and 2017. Patients with prior cardiac disease, myocarditis, Takotsubo cardiomyopathy and type 2 myocardial infarction were excluded. Myocardial fibrosis was determined by late gadolinium enhancement (LGE). Patients were divided into two groups based on the presence or absence of CMR abnormalities (LGE or oedema). Major adverse cardiovascular events (MACE) were defined as non-fatal MI, all-cause mortality, ventricular arrythmias or heart failure hospitalisation at follow-up. Results Thirty-four patients fulfilling the inclusion criteria were identified. Myocardial changes with CMR were observed in 20 (59%) patients with signs of subendocardial infarct by LGE in 13 (38%) patients, transmural infarct by LGE in 6 (18%) patients and one patient had myocardial oedema. ECG and echocardiographic features were similar between patients with and without CMR abnormalities. Troponin T was significantly higher among patients with CMR abnormalities. The median duration of follow-up was 702 (IQR 456–1394) days. Two patients had MACE (both heart failure). One of them had LGE changes. Conclusions A significant number of patients with MINOCA have ischaemic LGE changes or myocardial wall oedema. The patients with CMR abnormalities have similar ECG and echocardiographic features except higher biomarker, highlighting the role of CMR in patients with MINOCA.

Implications of Localized ST Depression in a Vascular Territory and Altered Precordial T-Wave Balance in Ischemic Heart Disease.

The incidence of acute coronary syndrome (ACS) is rising globally. Electrocardiography is still one of the best diagnostic modalities for it. Although some of the ECG changes of ACS are well known among medical practitioners, there are a handful of ECG changes that do not get the recognition they deserve. Among these are localized ST-segment depressions in a vascular territory and altered precordial T-wave balance. The urgency of management varies among the various subtypes of ACS, especially in low resource settings. ST-segment depression localized to a vascular territory is a sign of ST-elevation myocardial infarction (MI) in the reciprocal lead which may not always be evident and hence, requires emergent reperfusion therapy. On the other hand, altered precordial T-wave balance (T1 > T6, T-wave in V1 > 1.5 mm and upright T-wave in V1) may be predictive of significant coronary artery disease (CAD).