ST-T Wave Abnormalities Research Articles

Prevalence and Risk Factors of Heart Failure with Preserved Ejection Fraction in Middle-Aged Maintenance Haemodialysis Patients on a Twice-Weekly Schedule: Experience from a Single Indian Centre.

Background. Data on the prevalence of cardiac failure with preserved ejection in the haemodialysis population, which impacts treatment strategy, mortality, and morbidity, are scarce. Aims and Objectives. Estimate the prevalence of heart failure with preserved ejection fraction (HFpEF) in haemodialysis patients Classify cardiac failure and ascertain the risk factors influencing HFpEF in haemodialysis patients. Methods. All consenting individuals on haemodialysis over 18 years of age were included. Lung ultrasound was performed as per the LUST study protocol, and the labs were documented. Echocardiographic parameters were measured using two-dimensional (2D ECHO). Results. A total of 102 patients consented to participate in the study, which included 63 males (61.8%) and 39 females (38.2%). The mean patient age was 53 ± 13.1 years. The dialysis vintage of the participants was 38.92 ± 6.947 months. 47 (46.1%) patients had diabetes and 88 (80.4%) had hypertension. ECG findings included sinus rhythm (51/102, 50%), sinus tachycardia (22/102, 21.6%), ST-T wave abnormalities (18/102, 17.6%), and atrial fibrillation (11/102, 10.8%). Heart failure with preserved ejection fraction (HFpEF) was present in 44/102 (43.14%), heart failure with mid-range EF in 14/102 (13.72%), and heart failure with reduced EF in 13/102 (12.7%) patients. The ejection fraction was positively associated with haemoglobin (r = 0.23; p = 0.044), and calcium levels (r = 0.25; p =0 .03). E/lateral e' ratio was positively correlated with NT pro-BNP (r = 0.63; p < 0.001), systolic blood pressure (r = 0.44; p = 0.003) and age (r = 0.353; p = 0.003) and negatively correlated with transferrin saturation (r = -0.353; p = 0.027) and diastolic blood pressure (r = -0.31; p = 0.040). Binary logistic regression analysis revealed that the odds of diastolic dysfunction increased by 2.3 times with each unit increase of creatinine, and diabetics have 7.66 times higher risk for diastolic dysfunction. Binary logistic regression involving ejection fraction (EF) and all laboratory and clinical parameters revealed odds of HFpEF increased by 1.93 times with each unit increase in age, odds of HFpEF increases by 1.53 times with each unit increase in phosphorous and odds of HFpEF increased by 1.1 times with a unit increase of systolic blood pressure. Conclusion. HFpEF is the predominant form of heart failure in haemodialysis patients. Haemoglobin and calcium were positively associated with ejection fraction. Advancing age, elevated creatinine and diabetes mellitus levels are independent predictors of diastolic dysfunction in haemodialysis patients.

Electrocardiographic changes in pneumothorax: an updated review

ECG changes in pneumothorax have gained recognition as important indicators of cardiopulmonary interactions. This narrative review examines the existing literature to provide insights into the various ECG abnormalities observed in patients with pneumothorax, their underlying mechanisms, and clinical implications. The review highlights the commonly reported changes, including alterations in the electrical axis, ST segment deviations, T-wave abnormalities, and arrhythmias. The rightward shift of the electrical axis is attributed to cardiac displacement caused by increased intrathoracic pressure. ST segment deviations may reflect the influence of altered intrathoracic pressure on myocardial oxygen supply and demand. T-wave abnormalities may result from altered myocardial repolarization and hypoxemia. Arrhythmias, although varying in incidence and type, have been associated with pneumothorax. The clinical implications of these ECG changes are discussed, emphasizing their role in diagnosis, risk stratification, treatment optimization, and prognostication. Additionally, future research directions are outlined, including prospective studies, mechanistic investigations, and the integration of artificial intelligence. Enhancing our understanding of ECG changes in pneumothorax can lead to improved patient care, better management strategies, and the development of evidence-based guidelines. The objective of this review is to demonstrate the presence of various ECG abnormalities in patients with pneumothorax.

Electrocardiographic abnormalities in patients with microtia

The main objective of this study was to investigate the incidence and characteristics of electrocardiographic abnormalities in patients with microtia, and to explore cardiac maldevelopment associated with microtia. This retrospective study analyzed a large cohort of microtia patients admitted to Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from September 2017 to August 2022. The routine electrocardiographic reports of these patients were reviewed to assess the incidence and characteristics of abnormalities. The study included a total of 10,151 patients (5598 in the microtia group and 4553 in the control group) who were admitted to the Plastic Surgery Hospital of Peking Union Medical College. The microtia group had a significantly higher incidence of abnormal electrocardiographies compared to the control group (18.3% vs. 13.6%, P < 0.01), even when excluding sinus irregularity (6.1% vs. 4.4%, P < 0.01). Among the 1025 cases of abnormal electrocardiographies in the microtia group, 686 cases were reported with simple sinus irregularity. After excluding sinus irregularity as abnormal, the most prevalent abnormalities was right bundle branch block (37.5%), followed by sinus bradycardia (17.4%), ST-T wave abnormalities (13.3%), atrial rhythm (9.1%), sinus tachycardia (8.3%), and ventricular high voltage (4.7%). Less common ECG abnormalities included atrial tachycardia (2.1%), ventricular premature contraction (2.4%), and ectopic atrial rhythm (1.8%). atrioventricular block and junctional rhythm were present in 1.2% and 0.9% of the cases, respectively. Wolff Parkinson White syndrome and dextrocardia had a lower prevalence, at 0.6% and 0.9%, respectively. The occurrence of electrocardiographic abnormalities in microtia patients was found to be higher compared to the control group. These findings highlight the potential congenital defect in cardiac electrophysiology beyond the presence of congenital heart defect that coincide with microtia.

Electrocardiography score based on the Minnesota code classification system predicts cardiovascular mortality in an asymptomatic low-risk population

Background The use of a single abnormal finding on electrocardiography (ECG) is not recommended for stratifying the risk of cardiovascular (CV) events in low-risk general populations because of its low discriminative power. However, the value of a scoring system containing multiple abnormal ECG findings for predicting CV death has not been sufficiently evaluated. Methods In a prospective community-based cohort study, 8417 participants without atherosclerotic CV diseases (ASCVDs) and any related symptoms were followed for 18 years. The standard 12-lead ECGs were recorded at baseline and the ECG findings were categorized using the Minnesota code classification. CV deaths were defined as death from myocardial infarction (MI), chronic ischemic heart disease, heart failure, fatal arrhythmia, cerebrovascular event, pulmonary thromboembolism, peripheral vascular disease and sudden cardiac arrest and identified using the Korean National Statistical Office (KOSTAT) database. Results In a multivariate Cox proportional hazard (CPH) model, major and minor ST-T wave abnormalities, atrial fibrillation (AF), Q waves in the anterior leads, the lack of Q waves in the posterior leads, high amplitudes of the left and right precordial leads, left axis deviation and sinus tachycardia were associated with higher risks of CV deaths. The ECG score consisted of these findings showed modest predictive values represented by C-statistics that ranged from 0.632 to 760 during the follow-up and performed better in the early follow-up period. The ECG score independently predicted CV death after adjustment for relevant covariates in a multivariate model, and improved the predictive performance of the 10-year ASCVD risk estimator and a model of conventional risk factors including age, diabetes and current smoking. The combined ECG score (Harrell’s C-index: 0.852, 95% confidence interval [CI], 0.828–0.876) composed of the ECG score and the conventional risk factors outperformed the 10-year ASCVD risk estimator (Harrell’s C-index: 0.806; 95% CI, 0.780–0.833) and the model of the conventional risk factors (Harrell’s C-index: 0.841, 95% CI, 0.817–0.865) and exhibited an excellent goodness of fit between the predicted and observed probabilities of CV death. Conclusions The ECG score could be useful to predict CV death independently and may add value to the conventional CV risk estimators regarding the risk stratification of CV death in asymptomatic low-risk general populations.

Whether and what abnormalities we find in ECG records and 24-hour Holter ECG in patients after COVID-19 without hospitalization with cardiac damage

Abstract Funding Acknowledgements Type of funding sources: None. Cardiac arrhythmias and cardiac damage (CD) are more common in hospitalized patients with COVID-19. Many studies have shown that arrhythmias are an independent risk factor for death and the course of COVID-19 in these patients. However, there are no publications on the impact of the SARS CoV-2 on patients with a domestic course of COVID-19 without a previous history of cardiovascular disease. The aim of the study was to assess whether and what arrhythmias occur in patients in the early period after the course of COVID-19 without hospitalisation and to assess which of them may be predictors of heart damage after COVID-19. Methods In patients, in the post-COVID period (mean 12 ± 6 weeks) a standard 12-lead ECG (ECG) and 24-h Holter ECG (Holter) were performed. Following parameters were analysed: 1. in ECG: mean heart rate (mHR); PQ interval (PQ), QRS duration (QRSd); corrected QT interval (QTc); atrial fibrillation (AF); inappropriate sinus tachycardia (ITS), QRS duration &amp;gt; 120ms (QRS&amp;gt;120); LBBB, RBBB, QRS fragmentation (QRSf); STT wave abnormalities (STTabn); presence of premature supraventricular (SVES) and ventricular (VES) complexes; 2. in 24-h Holter ECG: sinus tachycardia (STach), new atrial fibrillation (AFHolter), SVES &amp;gt; 1000/24h (SVES&amp;gt;1000); supraventricular tachycardia (TSV), VES &amp;gt; 1000/24h (VES&amp;gt;1000), Couplet VES (VEScouplet), non-sustained ventricular tachycardia (nsVT); ventricular tachycardia (VT), block A-V 2nd typ 2 and/or block A-V 3rd grade (AVdist). Cardiac damage (CardD) was defined as EF&amp;lt;50% and/or any contraction abnormalities in ECHO and/or MRI examination. Patients were divided into two groups depending on the cardiac damage: Gr 1 without CardD and Gr 2 with CardD. Next ECG and Holter parameters were compared between both groups. Results A total of 1032 patients, (64% women and 36% men), mean age was 47.8± 16.5 were included in the analysis, of whom 91 pts (9,28%) met the cardiac damage criteria. The most frequent ECG abnormalities QRS fragmentations in 17,3% pts – noted in 17,3%. In no one pts VT and or VF was found. Comparison between groups in analysed parameters are shown IN Table 1 and Table 2 Multivariate regression analysis showed that: age (OR 1.02, 95%Cl 1.00-1.104; p=0.028), LBBB (OR 30.82; 95%Cl 1.99-475.80; p=0,014), VES&amp;gt;1000/24h (OR 7.97; 95%Cl 1.68 -37.78; p=0,008), nsVT (OR 6.20; 95%Cl 1.22-31.62; p=0,028) were associated with a higher risk of cardiac injury in the post COVID period However female were lower risk of cardiac damage (OR 0,27, 95%Cl 0.14-0.41; p&amp;lt;0.001) Conclusions Based on the obtained results, it can be concluded that the most common cardiac arrhythmias which predict cardiac damage in patients in the early period after the course of COVID-19 without hospitalization were LBBB, ventricular extrasystoles VES&amp;gt;1000/24h and non-sustained ventricular tachycardia. In addition, age (elderly people) and sex (male) predispose to myocardial damage after COVID-19.

Abstract 15208: Association Between Electrocardiographic St-t Wave Abnormalities and Stroke Risk in the Allhat Trial

Background: The presence of electrocardiographic (ECG) ST-T wave abnormalities has previously been shown to be associated with increased risk of coronary artery disease but their association with stroke incidence is unclear.Objective: We sought to investigate the relationship between ST-T wave abnormalities and stroke incidence in the ALLHAT trial. Methods: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized double-blinded clinical trial (n=33,357) conducted from 1994 through 2002, examining whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers incidence of CHD or CVD events compared to treatment with a diuretic. Major ST depression or T wave inversion on any ECG in the past 2 years were included in the study. One of the secondary outcomes included in the study was incident stroke. Hazard ratios (relative risks [RRs]) and 95% confidence intervals (CIs) were obtained using Cox proportional hazards regression model. All statistical analyses were performed using STATA 12 (Stata Corp., College Station, TX, USA). Results: Study participants were predominantly middle-aged, male, white, with prevalence of ST-T wave abnormality being 10.35% (N=3,420). Presence of ST-T wave abnormalities were not associated with a higher risk of stroke [hazard ratio 0.47 (95% CI, 0.91-1.22)] in unadjusted analyses. This relationship was not significant even after adjustment for prevalent cardiovascular disease (CABG, ASCVD) [0.51(95% CI, 0.91- 1.22)], cardiovascular risk factors (age, sex, diabetes, systolic blood pressure, diastolic blood pressure, cholesterol, BMI) [0.15 (95% CI, 0.96-1.31)] as well as randomized treatment groups in ALLHAT [0.15 (95% CI, 0.96-1.31)]. Conclusion: Presence of major ST-T wave abnormality does not predict incident stroke in the the ALLHAT trial, more observations from contemporary studies need to be elucidated.

DELAYED LEAD PERFORATION OF THE RIGHT ATRIUM IN THE PRESENCE OF PERSISTENT LEFT SUPERIOR VENA CAVA: A RARE COINCIDENCE

DELAYED LEAD PERFORATION OF THE RIGHT ATRIUM IN THE PRESENCE OF PERSISTENT LEFT SUPERIOR VENA CAVA: A RARE COINCIDENCE

PO-713-04 PROGNOSTIC EFFECTS OF ELECTROCARDIOGRAPHIC ST-T WAVE ABNORMALITIES IN THE ALLHAT (ANTIHYPERTENSIVE AND LIPID-LOWERING TREATMENT TO PREVENT HEART ATTACK TRIAL)

Major electrocardiographic (ECG) ST-T wave abnormalities are widely seen in clinical practice, but the longitudinal significance in cardiovascular risk assessment within a contemporary hypertension treatment cohort remains unknown. We sought to investigate the relationship between ST-T wave abnormalities and the primary outcome (fatal coronary heart disease or nonfatal myocardial infarction) in the ALLHAT trial. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized double-blinded clinical trial (n=33,357) conducted during 1994- 2002, examining whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers incidence of CHD or CVD events compared to treatment with a diuretic. 33,357 participants aged 55 years or older with hypertension and at least 1 other CHD risk factor were included and followed up for 4-8 years. Major ST depression or T wave inversion on any ECG in past 2 years were included in the study. The primary outcome was combined fatal CHD or nonfatal myocardial infarction. Hazard ratios (relative risks [RRs]) and 95% confidence intervals (CIs) were obtained from the Cox proportional hazards regression model. Cumulative event rates were calculated using the Kaplan-Meier method. All statistical analyses were performed using STATA 12 (Stata Corp., College Station, TX, USA). Study participants were predominantly middle-aged, male, white, with prevalence of ST-T wave abnormality being 10.35% (N=3,420). Moreover, ST-T changes were associated with a higher risk of fatal CHD or nonfatal MI [hazard ratio 1.17 (95% CI, 1.05-1.29)] in unadjusted analyses. This relationship remained statistically significant after adjustment for prevalent cardiovascular disease (stroke, CABG, ASCVD) [1.15 (95% CI, 1.04- 1.28)], cardiovascular risk factors (age, sex, diabetes, systolic blood pressure, diastolic blood pressure, cholesterol, BMI) [1.21 (95% CI, 1.09-1.34)] as well as randomized treatment groups in ALLHAT [1.21 (95% CI, 1.09-1.34)]. Presence of major ST-T wave abnormality was significantly associated with fatal CHD or nonfatal MI, underscoring the potential prognostic value of these ECG findings in overall cardiovascular risk.

The prognostic implications of ST-segment and T-wave abnormalities in patients undergoing regadenoson stress SPECT myocardial perfusion imaging

BackgroundThe prognostic implications of ST-segment and T-wave (ST/T) abnormalities in patients undergoing stress SPECT-myocardial perfusion imaging (MPI) are not well defined. Methods and ResultsThis was a single-center, retrospective cohort study of consecutive patients who underwent regadenoson stress SPECT-MPI. Patients with baseline electrocardiogram (ECG) abnormalities that impede ST/T analysis or those with known coronary artery disease were excluded. Patients were categorized as having primary ST abnormalities, secondary ST/T abnormalities due to ventricular hypertrophy or right bundle branch block, T-wave abnormalities, or normal ECG. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of cardiac death or myocardial infarction. Among 6,059 subjects, 1912 (32%) had baseline ST/T abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST/T abnormalities compared to those with normal ECG (HR 2.05; 95% confidence interval [CI], 1.04-4.05; P = 0.039). No significant difference in MACE was observed among patients with primary ST abnormalities (HR 1.64; CI 0.87-3.06; P = 0.124) or T-wave abnormalities (HR 1.15; CI 0.62-2.16; P = 0.658) compared with patients who had normal ECG. Among patients with secondary ST/T changes, abnormal MPI was not associated with a significant increase in MACE rates compared to normal MPI (HR 1.18; CI 0.31-4.58; P = 0.808). However, abnormal MPI was associated with higher MACE rates among patients with primary ST abnormalities (HR 4.50; CI 1.44-14.10; P = 0.005) and T-wave abnormalities (HR 3.74; CI 1.20-11.68; P = 0.015). Similarly, myocardial ischemia on regadenoson stress SPECT-MPI was not associated with a significant increase in MACE rates in patients with secondary ST/T abnormalities (HR 1.45; CI 0.38-5.61; P = 0.588), while it was associated with a higher incidence of MACE in patients with primary ST abnormalities (HR 3.012; CI 0.95-9.53; P = 0.049) and T-wave abnormalities (HR 5.06; CI 1.60-15.96; P = 0.002). ConclusionWhile patients with secondary ST/T abnormalities had significantly higher MACE risk, abnormal MPI or presence of myocardial ischemia on regadenoson SPECT-MPI in this group does not add prognostic information. Patients with primary ST abnormalities and T-wave abnormalities do not seem to have a significantly higher MACE risk compared to those with normal ECG; however, abnormal MPI or presence of myocardial ischemia, in these groups, correlates with higher MACE rates.

Acute coronary syndrome and transient global amnesia with sumatriptan

Triptans are potent serotoninergic vasoconstrictors. They are generally avoided in elderly patients age greater than 65 or in patients with a history of CAD. Although there are reported cases of Acute Coronary Syndrome (ACS) or Transient Global Amnesia (TGA) in patients after ingesting therapeutic doses of triptan or dihydroergotamine, this is the first case report, up to our knowledge, of a patient, who had no previous cardiac history, that was diagnosed with both ACS and TGA. A 59-year-old woman with a long-standing history of migraine, gastroesophageal reflux disease, and hypothyroidism, presented to the Emergency Department (ED) complaining of amnesia, chest pain, and left arm numbness after ingesting a single dose of oral sumatriptan approximately 1-2h prior to arrival. She had no recollection of the events that occurred after taking sumatriptan. No acute laboratory abnormalities were found except for an elevated troponin, which continued to trend upwards. Her EKG had no ST-T wave abnormalities. She was diagnosed with Acute Coronary Syndrome (ACS), non-ST elevation MI. She had a negative noncontrast CT head. Neurology was consulted for her amnesia and diagnosed her with Transient Global Amnesia (TGA). They recommended discontinuing sumatriptan and beginning topiramate as a prophylactic therapy. There is an increasing number of reports delineating sumatriptan's adverse effects. Emergency medicine physicians should promptly recognize the toxic effects and adverse reactions from triptans. Sumatriptan-induced vasoconstriction may lead to cardiac and cerebral ischemic events.

Electrocardiographic changes in non-hospitalised children with COVID-19.

Many children diagnosed with COVID-19 infections did not require hospitalisation. Our objective was to analyse electrocardiographic changes in children with asymptomatic, mild or moderate COVID-19 who did not require hospitalisation. All children are seen in a paediatric cardiology clinic who had asymptomatic, mild or moderate COVID-19 that did not require hospitalisation and had at least one electrocardiogram after their diagnosis were included in this retrospective analysis. Records were reviewed to determine COVID-19 disease severity and presence of Long COVID. Rhythm assessment, atrial enlargement, ventricular hypertrophy, PR/QRS/QT interval duration and ST-T wave abnormalities were analysed by a paediatric electrophysiologist. Clinically ordered echocardiograms were reviewed for signs of myopericarditis (left ventricular ejection fraction and pericardial effusion) on any subject with an electrocardiographic abnormality. Of the 82 children meeting inclusion criteria (14.4 years, range 1-18 years, 57% male), 17 patients (21%) demonstrated electrocardiographic changes. Ten patients (12%) had electrocardiogram of borderline significance, which included isolated mild PR prolongation or mild repolarisation abnormalities. The other seven patients (9%) had concerning electrocardiographic findings consisting of more significant repolarisation abnormalities. None of the patients with an abnormal electrocardiogram revealed any echocardiographic abnormality. All abnormal electrocardiograms normalised over time except in two cases. Across the entire cohort, greater COVID-19 disease severity and long COVID were not associated with electrocardiographic abnormalities. Electrocardiographic abnormalities are present in a minority of children with an asymptomatic, mild or moderate COVID-19 infection. Many of these changes resolved over time and no evidence of myopericarditis was present on echocardiography.

The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population.

Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners. Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics. Of 1196subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients. With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.

Associations between changing patterns of ST-T waves morphologies in rest electrocardiography and cardiovascular risk in an asymptomatic low risk population: a report from Ansan-Ansung cohort study

Abstract Background While clinical significance of ST-T wave abnormalities (STA) in rest electrocardiography (ECG) on long-term cardiovascular outcomes has been on debate, few studies have been reported on the association between the changes in ST-T waves in rest ECG and cardiovascular outcomes in low risk populations. We investigate the changing patterns of STA in rest ECG and the predictive value of the changes in ST-T wave in rest ECG for cardiovascular events in an asymptomatic general population. Methods A longitudinal community-based cohort study was conducted for 12 years. Koreans aged 40–69 years were followed biennially through scheduled revisit for comprehensive assessments. Among 10,030 participants, 6,648 participants who did not have any cardiovascular diseases, angina-related symptoms or pathologic Q waves in rest ECG at baseline were included for analysis. Changes in STAs were defined using the changes between ECG at baseline and that at the first revisit. A major adverse cardiovascular events was defined as a composite of cardiac death, myocardial infarction, clinical diagnosis of coronary artery disease and stroke. Results Among 5,924 participants without STA at baseline, only 187 participants (3.2%) developed new STA. Among 724 patients (10.9%) with STA at baseline, 274 patients (37.8%) persistently showed STA at the first revisit. MACEs occurred more frequently in the participants persistently with STA and those with newly-developed STA than in the participants persistently without STA (Figure 1). Multivariate Cox-proportional hazard models showed that a higher risk of MACE was only associated with the persisted STA (HR 1.69; 95% CI 1.10–2.63). In participants with baseline STA, persisted T-wave flattening was associated with a higher risk of MACE, whereas T-wave inversion, either persisted or fluctuated was not associated with a higher risk of MACE, compared with persistent absence of STA (Figure 2). In the participants without baseline STAs, multivariate Cox-proportional hazard model showed that newly-developed T-wave flattening (HR 1.85; 95% CI 0.20–2.84), not T-wave inversion (HR 1.50; 95% CI 0.85–2.65) was associated with a higher risk of MACE. Survival receiver operating curve analysis showed that the changes in STAs had a C-index of 0.538 (95% CI 0.511–0.558), a sensitivity of 13.0% and a specificity of 92.5% and add only a small value to the predictive power of 10-year atherosclerotic cardiovascular diseases risk estimator (C-index without STA changes 0.708 [0.681–0.736] vs. C-index with STA changes 0.721 [0.694–0.748]). Conclusions STAs uncommonly developed while frequently disappeared spontaneously in the asymptomatic general population. Persisted STA and newly developed STA in rest ECG were predictive of future cardiovascular events in the asymptomatic general population. However, the changes in STAs did not significantly improve the predictive value of the conventional risk estimator, when added. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Foundation of Korea Figure 1Figure 2

243 Spontaneous Coronary Artery Dissection in the Emergency Department: The Elusive Dissection

Emergency physicians are well versed in the dangers of arterial dissection; however, there is one type of dissection that has proven to be particularly elusive. Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women. In a population that is otherwise considered low risk there is a danger of missed diagnosis. In this study we describe associated symptoms and initial diagnostic findings among those who have presented with SCAD. We aim to increase awareness of this potentially fatal diagnosis among emergency practitioners. Subjects were those who had consented to the Mayo Clinic “Virtual” Multicenter SCAD Registry with a SCAD diagnosis as confirmed by angiography. Data were collected from both medical records and surveys following the SCAD event. Data points regarding symptoms were abstracted from survey narrative responses. Exact words were extracted when possible; however, synonyms were also used to help classify (for example, “an elephant on my chest” was categorized as “pressure/weight on chest”). Of the 1196 subjects included, 95.6% were female and mean age was 46±9 years. Chest pain was reported during the initial SCAD event in 95.7% (3.8% report no chest pain, and 0.5% did not respond). The most common descriptors of chest symptoms were pain (as the only descriptor), pressure/weight on chest, and tightness with radiation most often mentioned in one or both arms or shoulders (85.1%, left more often than right). After chest symptoms, the next most frequently reported were nausea (18.9%), shortness of breath (17.8%), and diaphoresis (17.2%). Presentation included unstable angina (1.7%), non ST-elevation myocardial infarction (57.5%), ST-elevation myocardial infarction (38.5%), and cardiac arrest (8.8%), with some patients included in multiple categories in the setting of evolving changes. Most common electrocardiogram (ECG) findings reported were ST elevation (45.8%), T-wave abnormality (21.8%), and normal ECG (15.8%). Initial troponin values were negative in 20.1% of patients. There was no ECG or troponin data available in 9.8% and 14.5%, respectively. Our study, developed from the largest SCAD database to date, provides insight into how SCAD presents to the emergency department. With young healthy women often considered “low risk” for ACS and common risk calculators heavily relying on atherosclerotic risk factors, it is important to define this presentation and bring awareness to emergency physicians. The data shown here emphasizes the importance of including SCAD on the chest pain differential, as well as obtaining appropriate diagnostic workup including serial ECG and troponin levels in young women who present with chest pain.

Prognostic value of myocardial injury-related findings on resting electrocardiography for cardiovascular risk in the asymptomatic general population: the 12-year follow-up report from the Ansan-Ansung cohort

Background: We investigated the predictive values of myocardial injury-related findings (MIFs) including ST-T wave abnormalities (STA) and pathologic Q waves (PQ) in electrocardiography for long-term cardiovascular outcomes in an asymptomatic general population.Methods: We observed 8444 subjects without cardiovascular diseases and related symptoms biennially over a 12-year period. Major cardiovascular adverse events (MACEs) were defined as a composite of cardiovascular death, myocardial infarction, coronary artery disease and stroke.Results: MACEs occurred more frequently in subjects with STA (9.1% vs. 5.2%, p < .001) and in those with anterior PQ (11.5% vs. 5.2%, p = .001) than in those without any MIFs, whereas anterolateral/posterior PQ were not associated with a higher incidence of MACEs. Multivariate Cox regression analyses showed that STA and anterior PQ were independently associated with the risk of MACEs. However, survival receiver operating characteristic curve analysis showed that the composite of STA and anterior PQ did not improve the predictive power of the conventional cardiovascular risk estimators when added to the models.Conclusions: The presence of STA or anterior PQ was associated with worse cardiovascular outcomes in the asymptomatic general population. However, the addition of MIFs to the conventional risk estimators was of limited value in the prediction of MACEs.Key MessagesMyocardial injury-related findings including ST-T wave abnormalities and anterior pathologic Q waves in resting electrocardiography predict long-term cardiovascular outcomes in an asymptomatic low-risk population.However, ST-T wave abnormalities and anterior pathologic Q waves add only limited value to conventional cardiovascular risk estimators in the prediction of cardiovascular outcomes.

Mitral valve prolapse and sudden cardiac death: a systematic review and meta-analysis.

Mitral valve prolapse (MVP) is commonly observed as a benign finding. However, the literature suggests that it may be associated with sudden cardiac death (SCD). We performed a meta-analysis and systematic review to determine the: (1) prevalence of MVP in the general population; (2) prevalence of MVP in all SCD and unexplained SCD; (3) incidence of SCD in MVP and (4) risk factors for SCD. The English medical literature was searched for: (1) MVP community prevalence; (2) MVP prevalence in SCD cohorts; (3) incidence SCD in MVP and (4) SCD risk factors in MVP. Thirty-four studies were identified for inclusion. This study was registered with PROSPERO (CRD42018089502). The prevalence of MVP was 1.2% (95% CI 0.5 to 2.0) in community populations. Among SCD victims, the cause of death remained undetermined in 22.1% (95% CI 13.4 to 30.7); of these, MVP was observed in 11.7% (95% CI 5.8 to 19.1). The incidence of SCD in the MVP population was 0.14% (95% CI 0.1 to 0.3) per year. Potential risk factors for SCD include bileaflet prolapse, ventricular fibrosis complex ventricular ectopy and ST-T wave abnormalities. The high prevalence of MVP in cohorts of unexplained SCD despite low population prevalence provides indirect evidence of an association of MVP with SCD. The absolute number of people exposed to the risk of SCD is significant, although the incidence of life-threatening arrhythmic events in the general MVP population remains low. High-risk features include bileaflet prolapse, ventricular fibrosis, ST-T wave abnormalities and frequent complex ventricular ectopy. PROSPERO (CRD42018089502).

Clinical Characteristics of Transient Cardiomyopathy in Patients with Surgically Resected Pheochromocytoma and Paraganglioma

Background Because pheochromocytoma and paraganglioma (PPGL) release catecholamines into circulation and result in increased heart rate and blood pressure (BP), it can cause transient cardiomyopathy, so called catecholamine cardiomyopathy. Recently, widespread use of imaging studies can detect these tumors before the onset of symptoms. We investigated clinical profiles of transient cardiomyopathy in patients with surgically resected PPGLs. Methods From January 2005 to December 2017, all consecutive patients with surgically-resected PPGLs in two tertiary teaching hospitals in Korea were retrospectively enrolled and studied. Results One-hundred and eleven patients (54 men, 52 ± 16 years old) were included. PPGLs were detected during the work-up of cardiomyopathy in 7 patients (6.3%). Sixteen patients (14.4%) were confirmed during evaluation of paroxysmal BP elevation and the rest were diagnosed incidentally during routine screening. Clinical features of patients with PPGL-related cardiomyopathy were summarized in the Table. Chest pain was the main symptom and ST change and T-wave abnormalities were commonly found in the electrocardiogram. Four patients showed apical ballooning and three had inverted Takotsubo pattern (basal ballooning). All patients were recovered within 12 days (range: 3 ∼ 12 days). One patient had cardiogenic shock and treated with extracorporeal membrane oxygenator for 12 days and continuous renal replacement therapy for 25 days. Conclusions Because 7 patients (6.3%) had transient cardiomyopathy in 111 patients with surgically resected PPGLs, the presence of transient cardiomyopathy can be a clue for PPGLs and physicians should consider PPGL as a differential diagnosis.

Myocarditis in systemic lupus erythematosus diagnosed by 18F-fluorodeoxyglucose positron emission tomography

ObjectivesCardiovascular diseaseand heart failure (CHF) are leading causes of death in systemic lupus erythematosus (SLE). The underlying mechanisms for increased CHF in SLE are unclear but myocardial inflammation and lupus...

Progression of electrocardiographic abnormalities associated with initial ventricular fibrillation in asymptomatic patients with Brugada syndrome

Various risk stratifications in asymptomatic patients with Brugada syndrome (BrS) have been proposed, but the electrophysiological change that promotes ventricular fibrillation (VF) is still unknown. The aim of this study was to clarify the changes in electrocardiographic (ECG) markers at the onset of VF from ECGs recorded when patients were still asymptomatic. The subjects of this study included 14 patients with VF and 48 consecutive asymptomatic patients with BrS. We compared ECGs before the initial VF events (>6 months; early phase) with ECGs at the initial VF events (late phase). In asymptomatic patients, we evaluated ECGs at 2 time points with an interval of >6 months. We evaluated various ECG markers including type 1 ECG and fragmented QRS (fQRS; multiple spikes within the QRS complex). ECG parameters of the early and late phases were not different except for decreased ST voltage and low incidence of type 1 ECG in asymptomatic patients. There were no differences in ECG parameters of the early phase between patients with VF and asymptomatic patients. In patients with VF, ECGs at the late phase had longer QRS intervals and intervals between the peak and the end of the T wave and more frequent type 1 ECG and fQRS than did ECGs at the early phase. Those changes were associated with initial VF events (QRS widening: odds ratio [OR] 11.5, P < .01; interval between the peak and the end of the T wave: OR 11.6, P < .01; fQRS: odds ratio 15.3, P < .01; type 1 ECG: OR 6.6, P < .05). QRS and ST-T wave abnormalities developed in association with the initial VF events. Aggravation of the conduction disturbance in addition to BrS-ECG promotes VF.

Takotsubo Cardiomyopathy With a Rapidly Resolved Left Ventricular Thrombus.

This article presents the case of a 53-year-old man who presented with acute right superficial femoral and popliteal arterial thrombosis for which he underwent an emergent uncomplicated thrombectomy. He denied preceding cardiovascular or neurologic symptomatology and had no history of coronary or peripheral arterial disease, trauma, hypercoagulability, or malignancy. However, he reported having several days of intense emotional stress prior to presentation. His cardiac exam was normal, his electrocardiogram showed normal sinus rhythm and nonspecific ST-T wave abnormalities, and his troponin levels were normal. Transthoracic echocardiography (TTE) revealed a large (2.4 × 2 cm) apical left ventricle (LV) thrombus, LV apical akinesis, and LV ejection fraction of 40% to 45%. Coronary angiography revealed only luminal irregularities. A repeat TTE performed 3 days after initiating unfractionated heparin revealed complete resolution of the LV thrombus. The patient had an uneventful clinical course and was discharged home in stable condition on oral anticoagulants. The lower incidence of LV thrombus in takotsubo cardiomyopathy (TC) of 1.3% in comparison to 4% to 8% in acute myocardial infarction due to coronary artery disease in the current era of early reperfusion may be explained by the lower extent of ischemic myocardial necrosis associated with TC. This case suggests that the lower extent of myocardial necrosis in TC may also lead to faster resolution of LV thrombus. Therefore, earlier follow-up with TTE (within 2 weeks) and shorter duration of anticoagulation (<3 months) may be considered in patients with TC complicated by LV thrombus formation with or without systemic embolism.