ST-T Changes Research Articles

C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes

Abstract Background Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina. Case Summary A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention. Discussion Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.

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.

C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes

Abstract Background Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina. Case Summary A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention. Discussion Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.

Abstract 12505: Clinical Characteristics of Patients With Vasospastic Angina Subjected to the Spasm Provocation Test Involving the Unavoidable Use of Nitroglycerin

Introduction: Multivessel spasm (MVS) has a prognostic impact in patients with vasospastic angina (VSA). Thus, assessing for the presence of MVS in both left coronary artery and right coronary artery is preferable in the spasm provocation test (SPT). The use of nitroglycerin is necessary to avoid the complications related to SPT; however, this unavoidable use of NTG (U-NTG) may decrease the detection of MVS. Hypothesis: We investigated the frequency of U-NTG during SPT and clarified the clinical characteristics in VSA patients, with U-NTG during STP. Methods: Total 142 patients with positive SPT were evaluated. A positive SPT was defined as >90% constriction in coronary arteries, accompanied by the chest symptoms and/or ischemic ST-T changes. When a coronary spasm occurred, we usually waited for the spontaneous relief of the coronary spasm. However, if a prolonged coronary spasm or unstable hemodynamics occurred, NTG was administered to relieve the coronary spasm promptly (U-NTG). Even when U-NTG was administered in one coronary artery, an additional SPT was performed on another coronary artery. The patients were divided into two groups according to U-NTG: U-NTG(+) (n = 42) and U-NTG(-), (n = 100). The clinical characteristics and frequencies of MVS and complications (unstable hemodynamics) during the SPT were compared between the groups. Results: Except for smoking status, all other clinical characteristics status did not differ significantly between the groups. More current smokers were observed in the U-NTG(+) group (29%) compared with that in the U-NTG(-) group (12%, p = 0.03). The frequency of MVD did not vary significantly between the groups, with 64% in the U-NTG(+) and 52% in the U-NTG(-). No significant difference was found between the groups in the frequency of severe complications during SPT, with 5% in U-NTG(+) and 3% in U-NTG(-). In U-NTG(+), the positive induction of coronary spasm in another coronary artery was 40% (17/42). Conclusions: Our results show that U-NTG occurred in ~30% of VSA patients, especially in current smokers, and that it did not decrease the detection of MVS and prevented severe complications during SPT. Therefore, U-NTG is acceptable during SPT, after which, another test may be performed to assess the presence of MVS.

Abstract 10435: A Plea for Inclusion of Surface Echocardiography for Acute Coronary Syndrome in the Advanced Cardiac Life Support Algorithm

Background: The AHA/ACC guidelines algorithm for Acute Coronary Syndrome (ACS) does not include echocardiographic evaluation in the assessment of chest pain. Such patients may be subjected to interventions based on ECG leading invasive procedures which may prove unnecessary. This study was performed to determine if a bedside echocardiography would help identify the conditions that do not need intervention and might possibly change the treatment pathway at the right time. Methods: In a prospective observational study design, adult patients presenting to acute emergency care with chest pain were included in the study. Patients exhibiting a significant ST change on a 12-lead ECG were subjected to bedside echocardiography, i.e. 2D transthoracic echocardiography (2D-TTE) The findings of echocardiography were correlated with ECG and coronary angiography for possible percutaneous coronary intervention. Results: Among the 385 patients in the study, 312 suffered acute coronary syndrome. In 18.7% patients presented to acute emergency care with chest pain, ST-T changes and were found to have causes other than ACS; and bedside echocardiography (2D-TTE) was able to identify 90.4% of those cases. From this study we conclude that bedside echocardiography had high specificity (90.4%) and sensitivity (97.43%) in identifying regional wall motion abnormality (RWMA) due to ACS and exclude non-ischemic causes of chest pain. Conclusion: Bedside echocardiography is recommended in patients with chest pain and ST-segment abnormality to avoid unnecessary delay in diagnosis and invasive interventions in non-acute coronary syndrome (ACS). Hence it is reasonable to include bedside echocardiography in either box 3 or 4 in the ACS algorithm.

Electrocardiographic findings in COVID-19: analysis of tele-ECGs in Moscow ECG IT Center

BACKGROUND: Coronavirus disease (COVID-19) affects the cardiovascular system and the primary damage to the respiratory system involved in the pathological process. However, in the available literature, the electrocardiography (ECG) analyses are based only on small-sample studies and case reports, which determine the relevance of larger-scale studies to clarify the nature and prevalence of ECG abnormalities in subjects with confirmed coronavirus infection.
 AIM: To determine the distribution of ECG changes in COVID-19 patients representing a non-selective population of Moscow residents.
 MATERIALS AND METHODS: We performed a retrospective analysis of ECGs from 42,799 patients from March 10, 2020 to March 10, 2021 with a verified diagnosis of COVID-19 was performed. The study included patients admitted to Moscow clinical hospitals connected to the ECG IT Center. A standard 12-lead ECG was obtained and transmitted via an Internet connection to the server of the ECG IT Center, where the ECG interpretation was performed.
 RESULTS: ECG changes were detected in 54% of patients. The most common cardiac arrhythmias were supraventricular extrasystole (12.6%) and atrial fibrillation (12.0%) reported in patients. Signs of the overloaded right heart were detected in 12.5% of cases, of which the ECG pattern of pulmonary embolism was confirmed in 485 patients (1.13%). Infarction ECG pattern was observed in 4.5% of patients, among which 3 cases of Brugada ECG pattern were reported. The incidence of ST-T changes was 2.2% of all study patients. Prolonged QT and QTc intervals were recorded in 540 patients (1.26%). In addition, individual cases of ventricular fibrillation, Frederick syndrome, and atrioventricular block of various degrees were reported.
 CONCLUSION: The distribution of incidence of ECG changes in COVID-19 was shown based on the data obtained. The high incidence of atrial fibrillation, which is a risk factor for thromboembolic complications, was confirmed. Moreover, a significant prevalence of ECG patterns of overloaded right heart was shown, some are associated with pulmonary embolism. Other reported ECG changes were characterized by a significantly lower prevalence, which does not reduce their clinical significance. The data obtained may be used to improve COVID-19 patient management strategy in the future.

Coronary microvascular function in patients with angina with no obstructive coronary artery disease-What factors affect it clinically or angiographically?

Abstract Background In the clinical setting, we have often experienced patients with angina with no obstructive coronary artery disease (ANOCA), and it has been proposed that the presence of coronary microvascular dysfunction (CMD) play a pivotal role in the pathogenesis of ANOCA. Thus, it is important to assess coronary microvascular function (CMF). However, it has not been clarified what clinical factors or lesion characteristics on coronary angiography (CAG) affect CMF. Thus, we investigated the relationship between CMF and clinical factors or lesion characteristics on CAG in patients with ANOCA. Methods Thirty-four patients with chest pain, who underwent CAG, spasm provocation test (SPT) and CMF test, were enrolled. We excluded patients who had moderate coronary stenosis (% stenosis >30%). In the SPT with acetylcholine for left coronary artery and right coronary artery (RCA), the coronary spasm was defined as >90% narrowing of coronary artery on CAG accompanied with chest symptoms and/or ST-T changes on ECG during SPT, and coronary microvascular spasm (MVS) was defined as ≤90% narrowing of coronary artery on CAG with accompanied with chest pain and ST-T changes during SPT. In each coronary artery, the presences of atherosclerosis (20%≤%stenosis≤30%), focal spasm (spasm occurred within one segment of AHA classification), diffuse spasm (spasm occurred over two segments of AHA classification) and MVS, were checked. In the CMF test with a pressure-wire during adenosine triphosphate infusion, the index of microvascular resistance (IMR) was measured. IMR values were obtained in 34 of the left anterior descending coronary artery (LAD) and 12 in RCA. In each patient, conventional coronary risk factors, blood chemical parameters, peripheral endothelial function such as flow-mediated dilation (FMD) of brachial artery and left ventricular mass index (LVMI) were checked. Results In 34 patients, clinical factors including blood chemical parameters, FMD and LVMI, except for smoking status did not affect IMR values on LAD. Only the smoking status was associated with IMR values as follows: median IMR values were 44, 22 and 25 in current smokers (n=5), past smokers (n=8) and never smokers (n=21, p=0.03), respectively. In 46 coronary arteries, the presence of atherosclerosis, the type of the coronary spasm, such as focal and diffuse spasm and MVS, did not affect the IMR values, however, it was significantly higher in the RCA (median 38) than that in the LAD (median 26, p=0.02). Conclusion These results suggest that smoking status affected CMF in patients with ANOCA, suggesting the possibility of improvement of CMF by stop smoking in such patients. In addition, in the assessment of CMF, it may be important to take into account which coronary artery being evaluated. Funding Acknowledgement Type of funding sources: None.

Prognostic role of diagnostic criteria of acute myocardial infarction

Abstract Background The term acute myocardial infarction (AMI) reflects cell death of cardiac myocytes caused by ischaemia. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined AMI by a typical rise and fall in the level of biochemical markers of myocardial necrosis together with criteria of myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored. Purpose To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI. Methods We enrolled all consecutive patients with AMI admitted from 2016 to 2019. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new LBBB); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, in our study evaluated by transthoracic echocardiogram. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and its association were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events. Results 2386 patients were evaluated. The median follow-up time was 23.3±14.5 months. The total number of events was 703 (29.3%). Kaplan-Meier curves showed that major adverse cardiac events (MACE) were statistically different depending on the diagnostic criteria of AMI at admission. Particularly, clinical criteria alone showed a better predictive value (p<0.001) than other diagnostic AMI criteria. Multivariable Cox-regression model demonstrated that clinical criteria was the independent predictor of good prognosis in patients with AMI (HR=0.43; CI 95% 0.28–0.67; p<0.001). Conversely, the others diagnostic criteria (electrocardiographic and echocardiographic) and the combination of all diagnostic criteria were not independent prognostic factors of MACE (HR=1.1 CI 95% 0.6–2.4, p=0.6; HR=1.1 CI 95% 0.7–1.2, p=0.6; HR=0.9 CI 95% 0.7–1.0, p=0.8 respectively). Conclusions Our data suggest that the prognosis is considerably better among patients with a diagnosis of AMI if clinical criteria alone are present at admission. We also demonstrated that clinical criteria are a strong prognostic predictor of good outcomes in patients with AMI. We hypothesize that the absence of electrocardiographic and echocardiographic alterations could indirectly indicate a smaller infarct sizes that contribute to patients' outcome. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): None

Cardio-COVID clinic – a one-center experience

BackgroundPersistent symptoms affect a relatively large portion of coronavirus disease (COVID) survivors. Hence, specific clinics had been established in order to better characterize and manage this emerging entity of Post-COVID, among them our Cardio-COVID Clinic, which is dedicated to the cardiovascular (CV) aspects of the phenomenon.AimTo present the experience of our Cardio-COVID Clinic.MethodsIncluded in this report are 76 adult patients seen at the clinic between June 2020 and March 2021, who have recovered from a polymerase chain reaction (PCR)-confirmed COVID, and who were suspected by their referring physicians to experience ongoing cardiac sequelae. All participants underwent a structured assessment by a single cardiologist, which consisted of history taking, physical examination (PE), electrocardiogram (ECG), trans-thoracic echocardiogram (TTE), and further tests as deemed appropriate, including any combination of Holter, ischemic provocation test, cardiopulmonary exercise test (CPET), cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT).ResultsInitial visits occurred within a median of 131 days after diagnosis. Most participants (83%) were referred from our general Long-COVID Clinic. About half were males, and the mean age was 53 years. 18% of participants had prior CV conditions, and the majority (72%) had at least one CV risk factor, mostly dyslipidemia. Nearly all participants experienced a symptomatic acute illness, which was graded according to the National Institutes of Health (NIH) criteria as severe in 23% of the study cohort. As for Post-COVID, late symptoms were present in 97% of patients, the most common being dyspnea (57%). While PE was unremarkable in all but 3 patients who exhibited murmurs, ECG findings were revealed in 45% – mostly non-specific ST-T changes (31%) and conduction abnormalities (14%) – and TTE aberrations were discovered in 28% – including pericardial effusion (24%), reduced left ventricular ejection fraction (LVEF) (5%), grade 2 diastolic dysfunction (3%), moderate and up valvular dysfunction (1%), and systolic pulmonary hypertension (1%); right ventricular function was universally normal. Upon conclusion of the work-up, CV diagnoses were made in 8 (11%) patients – including myocarditis (4), myopericarditis (1), inappropriate sinus tachycardia (1), chronotropic incompetence (1), and an aberrant coronary (1). Of note, CPET and CMR had the highest diagnostic yield, in light of 57% positive results on each – followed by CCT, Holter, and provocation test. Interesting as well, among those with abnormal CMR findings, 40% had normal ECG's and TTE's. Also, none of the CV restraints on CPET translated to provocation test anomalies.ConclusionCV symptoms of Post-COVID are highly prevalent, but signify actual CV disease only in a minority of patients. Further research is needed that will help identify predictors for CV morbidity and define optimal clinical pathways.Funding AcknowledgementType of funding sources: None.

Clinical characteristics and prognosis in patients with multi-vessel coronary spasm – comparison with those in patients with single-vessel coronary spasm

Abstract Background We have sometimes experienced patients with vasospastic angina (VSA), who showed multi-vessel spasm (MVS) on coronary angiography (CAG) and spasm provocation test (SPT). However, it has not been clarified what clinical characteristics VSA patients with MVS have or whether such patients have poor prognosis. Therefore, we compared the clinical characteristics and prognosis in VSA patients with MVS with those in VSA patients with single-vessel spasm (SVS). Methods One hundred and fifty-two patients (mean age: 67 yrs, 74 men and 78 women) with VSA, in which presence of coronary spasm was assessed in both left coronary artery (LCA) and right coronary artery (RCA) on SPT, were subjected. We defined VSA as the presence of more than 90% narrowing of the epicardial coronary artery on angiograms, accompanied by the usual chest symptoms and/or ischemic ST-T changes on electrocardiogram. On SPT, MVS was defined as the presence of spasm on ≥ two major coronary arteries. Base on the presence of MVS, patients were divided into the following 2 groups: MVS group and SVS group. The frequencies of conventional coronary risk factors, the average times of anginal attack (per month), the findings of SPT such as spasm provocation induced by low dose of acetylcholine (LDA) and total occlusion due to coronary spasm (TOC), the number of coronary vasodilators at discharge, and the major cardiovascular events (MACE) including death of any cause and readmission due to heart failure, acute coronary syndrome and unstable angina, were compared in the two groups. Results There were 98 patients (64%) in the MVS group and 54 patients (36%) in the SVS groups. The frequencies of conventional coronary risk factors and the average times of anginal attacks (4/month in both groups) were not different in the two groups. The frequencies of LDA (33% in MVS and 17% in SVS, p<0.05) and TOC (12% in MVS, 0% in SVS, p<0.01) were higher in the MVS group than in the SVS group. The average numbers of coronary vasodilators was higher in the MVS group (1.1±0.4) than in the SVS group (0.9±0.4, p<0.01). The frequency of MACE did not differ in the two groups as follows (figure). Conclusions These findings suggest that there was no clinical characteristic, suggesting the presence of MVS in VSA patients. Such patients may have higher VSA activity on SPT and have more aggressive medications, leading to the similar prognosis in VSA patient with SVS. Funding Acknowledgement Type of funding sources: None.

LIDOCAINE-INDUCED INTERMITTENT LEFT BUNDLE BRANCH BLOCK AND CHATTERJEE PHENOMENON

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: The frequency of new onset left bundle branch block (LBBB) during anaesthesia and surgery is rare. The most common causes for LBBB are structural heart diseases, acute myocardial infarction, dilated cardiomyopathy, heart failure, and exercise-induced LBBB[1]. We present a rare case of Lidocaine-induced Intermittent Left Bundle Branch Block. CASE PRESENTATION: A 63-year-old female with no medical history had hysterectomy/high uterosacral ligament suspension as an elective procedure for uterine prolapse. The baseline EKG was normal. She went to the operating room as scheduled, but after the injection of 100 mg local Lidocaine, she developed a LBBB on the EKG with ST-T changes (Figure-1). The surgery was aborted, and cardiology was consulted Cardiac enzymes were normal. Upon evaluation by the cardiology team, the patient had no particular complaints, and soon her LBBB had resolved spontaneously without any intervention. A follow-up EKG done a few hours later showed normal sinus rhythm with evidence of T-wave inversion suggestive of cardiac memory or "Chatterjee's phenomenon" (Figure-2). Echocardiogram and Nuclear stress testing were performed, and which were negative for ischemic changes. DISCUSSION: There have been several reports of adverse effects of lidocaine on cardiac conduction after standard doses of intravenous lidocaine. These have included the appearance of type II second-degree heart block, asystole, and complete heart block in an infant. One of the first cases of transient LBBB induced by lidocaine was reported back in 1989 by Tagliente et al[2]. It is not understood how lidocaine may induce a transient LBBB; however, the literature has suggested that lidocaine in high doses can cause a conduction delay within the Purkinje system and subsequently leading to a conduction block. Cardiac memory, or Chatterjee's phenomenon, first described in 1969 by Kanu Chatterjee et al., is defined as a deep inversion of T-wave with ST depression in the un-paced heart following ventricular pacing[3]. It has also been described to occur in other patients with abnormal electricity, including those with intermittent LBBB, WPW, and episodic tachycardia. CONCLUSIONS: On rare occasions, Lidocaine can induce intermittent left bundle branch block. REFERENCE #1: Sarter BH, Hook BG, Callans DJ, Marchlinski FE. Effect of bundle branch block on local electrogram morphologic features: implications for arrhythmia diagnosis by stored electrogram analysis. American heart journal. 1996;131(5):947-52. REFERENCE #2: Tagliente TM, Jayagopal S. Transient left bundle branch block following lidocaine. Anesthesia & Analgesia. 1989;69(4):545-7. REFERENCE #3: Chatterjee K, Harris A, Davies G, Leatham A. Electrocardiographic changes subsequent to artificial ventricular depolarization. British heart journal. 1969;31(6):770 DISCLOSURES: No relevant relationships by Mostafa Abohelwa, source=Web Response No relevant relationships by Monica Botros, source=Web Response No relevant relationships by Zeyad Elharabi, source=Web Response No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Sima Shahbandar, source=Web Response No relevant relationships by Victor Test, source=Web Response

High Level of Suspicion Based on Detailed Medical History and Focused Physical Examination: Important Tool to Diagnose Acute Myocarditis

The present study describes the case of a 39-year-old man who had acute retrosternal pain, history of upper tract infection and low-grade fever 3 days prior to presentation, elevated cardiac markers and electrocardiographic ST-T changes, which led to an original suspicion of acute myocarditis. The patient underwent coronary angiography after 36 hours to rule out coronary artery disease, which revealed normal coronary arteries.

An Effective Deep Learning Model for Automated Detection of Myocardial Infarction Based on Ultrashort-Term Heart Rate Variability Analysis

Myocardial infarction (MI), usually termed as heart attack, is one of the main cardiovascular diseases that occur due to the blockage of coronary arteries. This blockage reduces the blood supply to heart muscles, and a prolonged deficiency of blood supply causes the death of heart muscles leading to a heart attack that may cause death. An electrocardiogram (ECG) is used to diagnose MI as it causes variations like ST-T changes in the recorded ECG. Manual inspection of these variations is a tedious task and also requires expertise as the variations produced by MI are often very short in duration with a low amplitude. Hence, these changes may be misinterpreted, leading to delayed diagnosis and appropriate treatment. Therefore, computer-aided analysis of ECG may help to detect MI automatically. In this study, a robust deep learning model is proposed to detect MI based on heart rate variability (HRV) analysis of ECG signals from a single lead. Ultrashort-term HRV analysis is performed to compute HRV analysis features from time-domain and frequency-domain parameters through power spectral density estimations. Nonlinear HRV parameters are also computed using Poincare Plot, Recurrence Analysis, and Detrended Fluctuation Analysis. A finely tuned customized artificial neural network (ANN) algorithm is applied on 23 HRV features for MI detection and classification. The K-fold validation method is used to avoid any biases in results and reported 99.1% accuracy, 100% sensitivity, 98.1% specificity, and 99.0% F1 for MI detection, whereas 98.85% accuracy, 97.40% sensitivity, 99.05% specificity, and 97.70% F1 score is achieved for classification. Furthermore, the ANN algorithm completed its execution in just 59 seconds that indicates the efficiency of the proposed ANN model. The overall performance in terms of computed evaluation matrices and execution time indicates the robustness and cost-effectiveness of the proposed methodology. Thus, the proposed model can be used for high-performance MI detection, even in wearable devices.

ALPK3 gene-related pediatric cardiomyopathy with craniofacial-skeletal features: a report and literature review

Objective: To explore the clinical characteristics and mutation spectrum of ALPK3-related pediatric cardiomyopathy and craniofacial-skeletal abnormalities in children. Methods: The clinical data during a follow-up of 11 years including clinical features, echocardiogram, electrocardiogram, cardiac magnetic resonance, genetic testing, and other data of a child firstly diagnosed with ALPK3 gene-related cardiomyopathy and craniofacial-skeletal abnormalities in China were collected retrospectively. The literatures containing the keyword of "ALPK3 gene" published in the China National Knowledge Infrastructure, Wanfang database and PubMed were collected up to November 2020. Then, the clinical features and gene mutations of ALPK3 gene-related pediatric cardiomyopathy with craniofacial-skeletal features were summarized. Results: A female patient aged 10 months who presented with an enlarged heart for 2 months, was admitted to the hospital and initially diagnosed with endocardial elastic fibrosis. The echocardiography showed features of dilated left ventricle (LV) and LV systolic dysfunction. Low-set ears, webbed neck, a grade 2/6 systolic murmur at lower left sternal area and bilateral absent flexion creases of dig were observed. After treatment, the size and function of the heart recovered to normal at age 13 months. However, the ventricular septum and LV wall were thicker than normal values. Then, the diagnosis was revised to hypertrophic cardiomyopathy(HCM) and suspected congenital malformation syndrome. LV hypertrophy (LVH) progressed slowly before the age of 8 years and then progressed rapidly. At age 9 years, compound heterozygous ALPK3 mutations (c.721dup, p.Y241Lfs*42(exon 1) and c.4840C>T, p.R1614*(exon 10)) were detected in the proband and the mutations had not been reported previously. Then, the final diagnosis of ALPK3 gene-related pediatric cardiomyopathy with craniofacial-skeletal features was made. During the follow up of 11 years, regular follow-up echocardiographic images showed progressive LVH. At age 11 years, electrocardiogram showed LVH, ST-T changes in multiple-lead, T wave inversion, and prolonged QT intervals. Cardiac magnetic resonance showed biventricular hypertrophy and late gadolinium enhancement showed non-uniform enhancement of left and right ventricular myocardium. A total of 7 articles published in English were retrieved, and no Chinese literature was found. Twenty-eight cases were reported in the articles plus the patient in this study. Twenty-four mutations were reported worldwide, 18 patients carried homozygous mutations and 10 patients compound heterozygous mutations. Eleven patients showed dilated cardiomyopathy (DCM) at early stage of disease, and 10 of them transitioned to HCM at the disease progression stage. Eight patients presented with HCM at early stage of disease. Nine patients initially exhibited a mixed phenotype of DCM and HCM, and 6 of them eventually progressed to HCM. Electrocardiogram showed prolonged QT interval. Extracardiac features included short stature, special face, cleft palate, webbed neck, joint contracture, and scoliosis, etc. Conclusions: Progressive myocardial hypertrophy is a major feature of ALPK3 gene-related cardiomyopathy with craniofacial-skeletal malformations. Precise diagnosis depends on molecular genetic techniques. More cases should be accumulated for further analysis on the genotype-phenotype correlation and prognosis assessment.

Abstract P137: Nonspecific ST-T Change In Electrocardiogram Was Associated With A Reduced Constructive Myocardial Work In Hypertensive Patients With Preserved Ejection Fraction

Background: Nonspecific ST-T change in electrocardiogram can be observed in hypertensive heart disease with preserved left ventricular ejection fraction (LVEF); however, the relationship between nonspecific ST-T change and global myocardial work in echocardiography was unclear. Methods: We evaluated global longitudinal strain (GLS), GWI (global work index), GCW (global constructive work), GWW (global wasted work), GWE (global work efficiency), using offline analyzing system (View Pal, GE) in 196 hypertensive patients with preserved LVEF (>50%). Nonspecific ST-T change and major ST-T change (depression of ST in V5 lead >1mV) was also evaluated in electrocardiogram. Results: Mean age was 79.3±8.2 years (men 37.8%). Compared with patients with no ST-T change, those with nonspecific and major ST-change had a smaller absolute value of GLS (-20±3, -18±4, -14±5%, P<0.001) and had smaller constructive work load [GWI (2140±488, 1915±472, 1523±776 mmHg%, P<0.001), GCW (2410±514, 2165±471, 1694±784 mmHg%, P<0.01)]. Additionally, those with nonspecific and major ST-T change had an increased wasted myocardial work [GWW (87±61, 109±58, 138±71 mmHg%, P<0.001)], and this resulted in reduction of myocardial work efficiency [GWE (95±4,93±3,87±12%,P<0.001)]. Even after adjustment for age, sex, diabetes, dyslipidemia, EF, LV mass index, relative wall thickness, parameters of diastolic function (E/A, E/e’, left atrial volume index, tricuspid valve regurgitant flow velocity), and electrocardiogram LVH of Cornell product and Sokolow-Lyon voltage, the patients with nonspecific ST-T change had a significantly smaller LV global constructive work. [GWI (2243±41 vs. 1998±96 mmHg%, P=0.025), GCW (2501±45 vs. 2210±105 mmHg%, P=0.015)]. Conclusion: In hypertensive patients with preserved LVEF, nonspecific ST-T change in electrocardiogram was associated with a reduced constructive work in LV.

Factors predicting technical difficulties during endoscopic submucosal excavation for gastric submucosal tumor.

ObjectiveEndoscopic submucosal excavation (ESE) has been established as an effective method for removal of gastric submucosal tumors (SMTs). The aim of the present study was to explore risk factors for technical difficulties in ESE.MethodsIn this retrospective study, we collected clinical data from patients who underwent ESE for gastric SMTs. Difficult ESE was defined as a procedure time ≥90 minutes, piecemeal resection, and/or occurrence of major adverse events. Univariate and multivariate analyses were performed to explore the risk factors for a difficult ESE.ResultsESE was successfully performed in 96.5% (195/202) of patients from April 2011 to December 2019. The average tumor size was 17.41 mm, and en bloc resection was achieved in 97.4% of patients (190/195). Five patients (2.56%, 5/195) had complications, including two with delayed bleeding, two with fever, and one with chest pain accompanying ST-T changes in an electrocardiogram. Twenty-four patients (11.88%, 24/202) had a difficult ESE. Logistic analysis showed that outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.ConclusionESE may be safe and effective to treat patients with gastric SMTs. Outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.

Differences in clinical features of hypertrophic cardiomyopathy with or without left ventricular enlargement.

Few studies have focused on the clinical features of hypertrophic cardiomyopathy (HCM) with enlarged left ventricle (ELV). In this study, participants were patients with HCM (n=170), who were divided into two groups [ELV and normal left ventricle (NLV)] according to left ventricle size. Age at diagnosis, sex, complications, electrocardiogram (ECG), symptoms, drug treatment, and echocardiographic parameters were compared between the NLV (n=153) and ELV (n=17) groups. The incidence of end-stage HCM (ES-HCM) among all HCM patients was 5.29%, while that of ELV was 10.0%. For all patients with HCM and those with asymmetric septal HCM (ASHCM), there were more males with ELV than NLV. Of the patients with HCM and ASHCM, left ventricular ejection fraction (LVEF) was significantly lower in the ELV group than the NLV group; accordingly, the rates of diuretics use in the ELV group were higher than those in the NLV group. Among apical HCM (ApHCM) patients, the left atrial diameter (LAd), incidence of atrial fibrillation (Af) or ST-T change, and rate of angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use were all higher in the ELV group compared to the NLV group. These findings suggest that the prevalence of ES-HCM in HCM patients with ELV was higher than those with NLV. Additionally, ELV is more common in men than women and there are differences in the clinical features of different types of HCM with ELV.

Characteristics of Second-Line Investigations of Middle-Aged Athletes Who Failed Preparticipation Examinations.

The role of exercise testing during preparticipation examinations (PPEs) of middle-aged athletes is uncertain. This study examined the characteristics of disqualifications after an initial PPE that includes an exercise test in competitive athletes older than 30 years. We investigated disqualification rates and reasons, second-line investigations performed, and final decisions regarding competitive sports participation. Chart review. Sports medicine clinic. Athletes aged >30 years that performed an exercise test as part of their annual PPE at our sports medicine clinic (n = 866). Age, sex, height, weight, sport type, cardiovascular risk factors, and abnormal PPE findings. Additional investigations performed, approval/disqualification regarding competitive sports participation. The initial disqualification rate of athletes was 9.8%. Three (3.6%) athletes were disqualified following questionnaire and physical examination, 19 (22.4%) because of resting electrocardiogram findings, and 65 (76.5%) following the exercise test. After additional work-up, only 5 athletes (0.4%) were ultimately found ineligible for competitive sports. From those, only 2 athletes (0.2%) were disqualified because of exercise test findings, which were episodes of supraventricular tachycardia and not ischemia-related. The addition of an exercise test to the PPE of middle-aged athletes is of limited value. If exercise testing of older athletes is performed, arrhythmias are probably of higher significance than ST-T changes.

Twelve-Month Systemic Consequences of Coronavirus Disease 2019 (COVID-19) in Patients Discharged From Hospital: A Prospective Cohort Study in Wuhan, China.

BackgroundFollow-up study of coronavirus disease 2019 (COVID-19) survivors has rarely been reported. We aimed to investigate longitudinal changes in the characteristics of COVID-19 survivors after discharge.MethodsA total of 594 COVID-19 survivors discharged from Tongji Hospital in Wuhan from February 10 to April 30, 2020 were included and followed up until May 17, 2021. Laboratory and radiological findings, pulmonary function tests, electrocardiogram, symptoms and signs were analyzed. Results257 (51.2%) patients had at least one symptom at 3 months post-discharge, which decreased to 169 (40.0%) and 138 (28.4%) at 6-month and 12-month visit respectively. During follow-up period, insomnia, chest tightness, and fatigue were the most prevalent symptoms. Most laboratory parameters returned to normal, whereas increased incidence of abnormal liver and renal function and cardiovascular injury was evidenced after discharge. Fibrous stripes (213; 42.4%), pleural thickening and adhesions (188; 37.5%) and enlarged lymph nodes (120; 23.9%) were the most common radiographical findings at 3 months post-discharge. The abnormalities of pulmonary function included obstructive, restrictive, and mixed, which were 5.5%, 4.0%, 0.9% at 6 months post, and 1.9%, 4.7%, 0.2% at 12 months. Electrocardiogram abnormalities occurred in 256 (51.0%) patients at 3 months post-discharge, including arrhythmia, ST-T change and conduction block, which increased to 258 (61.1%) cases at 6-month visit and were maintained at high frequency (242;49.8%) at 12-month visit. ConclusionsPhysiological, laboratory, radiological, or electrocardiogram abnormalities, particularly those related to renal, cardiovascular, and liver functions are common in patients who recovered from coronavirus disease 2019 (COVID-19) up to 12 months post-discharge.

Study of Cardiovascular Manifestations in Patients with Thyroid dysfunction at Tertiary Care Center

Introduction: Thyroid hormones have effects on virtually every organ system. The heart is the major target organ for thyroid action. It was thought that thyroid disorder is a circulatory disorder and manifestations of thyroid disorders are due to changes in cardiac work. Over the period it has become clear that the explanation for the altered circulatory hemo-dynamics of thyroid disease is because of involvement of cardiovascular system. Aims and Objectives: To find out the incidence of overt and subclinical cardiac manifestations in patients with thyroid dysfunction and to compare the prevalence of overt and subclinical cardiac manifestations in two subsets of patients belonging to hyperthyroid and hypothyroid groups respectively. Materials and Methods: It was an observational study carried out at the Department of Medicine for the period of August 2017 to December 2019. In total, 230 newly diagnosed patients with thyroid dysfunction were included in the study. Focused clinical and detailed cardiovascular system examination, necessary biochemical investigations were done. All patients underwent detailed 12 lead electrocardiogram and 2D Echo-cardiography procedure. Incidence of overt and subclinical cardiac manifestations in Hyperthyroid and Hypothyroid cases was calculated; and the Prevalence of overt and subclinical manifestations in the two subsets of patients belonging to Hyperthyroid and Hypothyroid groups respectively was compared and data was analyesd. Results: Total hypothyroid patients were 115 and that of hyperthyroid were 115. Incidence of thyroid is much more common in females as compared to males (81% in hyperthyroidism and 92% in hypothyroidism). In hyperthyroid group, 92% patients showed cardiac involvement either in the form of ECG, CXR, 2D ECHO abnormalities and in hypothyroid patients it was 93%. Statistically significant patients presented with symptoms of congestive cardiac failure in hyperthyroid group (73%) but not in hypothyroid group. In the both groups, fatigue was the most commonest presenting symptom related to cardiovascular system. In hypothyroid group, most common cardiac sign was Pulse, Pressure<40 mm of Hg (73%) whereas in hyperthyroidism it was sinus tachycardia (73%). 73% hyperthyroid patients showed sinus tachycardia as the most common ECG finding where again 73% hypothyroid patients showed ST-T changes as a most common ECG finding. Nearly 70% hyperthyroid patients had ejection fraction more than 60% on Echocardiogrphy the procedure and almost all patients of hypothyroidism had ejection fraction less than 60%. Conclusion: Thyroid dysfunction was found to be more common in the females with 41-50 years of age group in hypothyroidism group and 21-30 years in the hyperthyroidism group. Cardiovascular manifestations were the major presenting factors in both the groups pointing towards the adverse effects of thyroid dysfunction, Dyspnea and fatigue were the major cardiac symptoms in the hypothyroidism group. While chest pain and fatigue were the major cardiac symptoms in the hyperthyroidism group. The ECG and 2D ECHO findings in the current study also suggested that in both the groups of thyroid dysfunction, cardiac manifestations are likely to have higher incidence.