ST-T Changes Research Articles

Abstract 4145822: The Enigma of Chest Pain: Rare Presentation of ALCAPA Syndrome in a Young Adult

Introduction: Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare congenital anomaly(incidence:1 in 300,000 live births) typically presenting during infancy. Adult presentations are even rarer due to a high mortality rate of nearly 90% in the first year of life without surgical intervention. This report examines an adult patient with exercise-induced chest pain who received a delayed diagnosis of ALCAPA via multimodal imaging. Case Summary: A 21-year-old male presented to the emergency department(ED) with severe retrosternal chest pain radiating to both shoulders and arms, which began during exercise 30 minutes prior. He had a history of similar, milder episodes during exercise, previously treated as musculoskeletal pain and gastroesophageal reflux disease in the ED. His medical, social, and family histories were unremarkable. Physical examination revealed a soft, continuous murmur along the left sternal border. During this visit, An EKG done showed sinus tachycardia at 110 bpm and deep T-wave inversions in the anterolateral leads, a dynamic ST-T changes from his baseline.Serial Cardiac biomarkers and a lipid profile were within normal ranges. Initially managed for acute coronary syndrome-unstable angina with antithrombotic therapy, beta-blockers, and nitrates, he underwent urgent coronary angiography. This revealed a dilated right coronary artery (RCA) with retrograde flow to the left coronary artery (LCA) into the main pulmonary artery (PA) via collaterals, with no evidence of atherosclerosis (Figure 1).Echocardiography (Figure 2) and coronary CT angiography (Figure 3) confirmed the diagnosis of ALCAPA. The patient underwent successful surgical repair with aortic reimplantation of the LCA and was discharged in good health. Discussion: In adult ALCAPA patients, good collateral circulation may develop; however, myocardial ischemia can occur due to the "coronary steal phenomenon" and poor collateral flow regulation, leading to angina, arrhythmias, and sudden cardiac death. ALCAPA should be considered a differential diagnosis in adults presenting with exercise intolerance, as most sudden cardiac death cases occur by the fourth decade. A high index of clinical suspicion and a multimodality imaging approach is essential for the early diagnosis of this rare coronary anomaly, underscoring the critical role of early surgical intervention in preventing catastrophic, life-threatening events.

Association Between Electrocardiographic Abnormalities and In-Hospital Adverse Outcome in COVID-19 Patients

Background: SARS-CoV-2 is increasingly recognized for its cardiovascular complications. To address the knowledge gap in our region, this study investigated the relationship between electrocardiographic (ECG) features and in-hospital mortality among COVID-19 patients. Methods: A prospective cohort study was conducted involving 140 RT-PCR-confirmed COVID-19 patients at Dhaka Medical College Hospital from August 2021 to July 2022. Patients were divided into two groups based on ECG findings: normal (Group A) and abnormal (Group B). Clinical data and ECG parameters were analyzed using SPSS 24.0. Results: Patients with abnormal ECGs were older, more likely male, and presented with higher rates of dyspnea and palpitations. They were also at increased risk of severe COVID-19 and had longer hospital stays. In-hospital mortality was significantly higher in Group B (21.4% vs.4.3%). ST-T changes and atrial fibrillation were associated with increased mortality. Independent predictors of in-hospital mortality included ECG abnormalities and admission SpO₂ < 90%. Conclusion: ECG abnormalities are significantly associated with adverse outcomes in COVID-19 patients. Further large-scale studies are warranted to strengthen these findings.

Transseptal Transition Patterns DuringLeft Bundle Branch Area LeadImplantation.

Continuous deep septal pacing and signal recording during implantation of left bundle branch pacing (LBBP) lead enables to monitor beat-to-beat changes of electrocardiogram (ECG) and myocardial current of injury (COI) as the lead crosses the septum. This study aimed to characterize patterns of continuous QRS, ST-T, and COI change for monitoring of the lead depth and instantaneous determination of the obtained capture type (LBBP vs left ventricular septal pacing [LVSP]). The ECG and COI during lead implantation were scrutinized for sudden changes of V6 R-wave peak time, V1initial and terminal R-wave amplitude, V3-V6 R-wave amplitude, repolarization pattern and S-wave amplitude in I, V5-V6, and COI drop. The sudden and gradual transition patterns were diagnosed depending on the presence or absence of the above beat-to-beat ECG phenomena, respectively. A total of 212 pacemaker recipients were analyzed; LBBP and LVSP were obtained in 77.4% and 22.6%, respectively. There were 4.7 ± 2.1 and 0.2 ± 0.6 beat-to-beat phenomena in LBBP and LVSP patients, respectively. The sudden transition pattern, recognized in 80.7%, had sensitivity and specificity for LBBP diagnosis of 98.8% and 81.2%, respectively. A sudden drop of COI (29.4 ± 8.5mV to 12.8 ± 4.9mV) was observed in 53.9% patients (LBBP was simultaneously obtained in 92.7%). Capture of left bundle branch during lead penetration is a beat-to-beat phenomenon. Two transseptal transition patterns were identified: 1) sudden, which is typical for obtaining LBBP; and 2) gradual, which is typical for obtaining LVSP. A sudden COI drop, a very observable phenomenon, also identified reaching the left subendocardial area.

Pulmonary embolism (PE) diagnosed in a 19-year-old lady found to have underlying Antiphospholipid syndrome (APS)

ABSTRACT Background A 19-year-old woman visited a family medicine clinic to obtain her laboratory test results. This case highlights a close call involving a young woman with a potentially serious condition. Pulmonary embolism (PE) is often overlooked during initial assessments in emergency departments or primary care clinics. Case presentation The patient casually mentioned having a cough toward the end of the consultation, revealing she has been using a salbutamol inhaler due to a family history of asthma. Despite appearing well, she had an audible wheezy cough during the examination. Following a chest X-ray (CXR) that indicated a right lung opacity and possible cardiomegaly, an electrocardiogram (ECG) was arranged. The ECG showed an incomplete right bundle branch block (RBBB) and STT changes in leads V3-V6 and lead 3, prompting her transfer to the emergency department for suspected Pulmonary embolism (PE). Further evaluation confirmed acute on chronic PE, with a positive lupus screen leading to the diagnosis of antiphospholipid syndrome (APS) upon detection of anti-phospholipid antibodies in her serology. Discussion The patient’s case was unique, but a basic CXR was performed to investigate their exertional shortness of breath. This led to appropriate action being taken to ensure the patient’s safety. It is important to note that pulmonary embolism can occur in young individuals, highlighting the need for attentive and skilled healthcare professionals. Basic tests such as CXR and ECG can be crucial in cases of ongoing symptoms where uncertainty exists.

Diagnostic utility of electrocardiogram for screening of cardiac injury on cardiac magnetic resonance in post-hospitalised COVID-19 patients: a prospective multicenter study

BackgroundThe role of ECG in ruling out myocardial complications on cardiac magnetic resonance (CMR) is unclear. We examined the clinical utility of ECG in screening for cardiac abnormalities on CMR among post-hospitalised COVID-19 patients. MethodsPost-hospitalised patients (n = 212) and age, sex and comorbidity-matched controls (n = 38) underwent CMR and 12‑lead ECG in a prospective multicenter follow-up study. Participants were screened for routinely reported ECG abnormalities, including arrhythmia, conduction and R wave abnormalities and ST-T changes (excluding repolarisation intervals). Quantitative repolarisation analyses included corrected QT (QTc), corrected QT dispersion (QTc disp), corrected JT (JTc) and corrected T peak-end (cTPe) intervals. ResultsAt a median of 5.6 months, patients had a higher burden of ECG abnormalities (72.2% vs controls 42.1%, p = 0.001) and lower LVEF but a comparable cumulative burden of CMR abnormalities than controls. Patients with CMR abnormalities had more ECG abnormalities and longer repolarisation intervals than those with normal CMR and controls (82% vs 69% vs 42%, p < 0.001). Routinely reported ECG abnormalities had poor discriminative ability (area-under-the-receiver-operating curve: AUROC) for abnormal CMR, AUROC 0.56 (95% CI 0.47–0.65), p = 0.185; worse among female than male patients. Adding JTc and QTc disp improved the AUROC to 0.64 (95% CI 0.55–0.74), p = 0.002, the sensitivity of the ECG increased from 81.6% to 98.0%, negative predictive value from 84.7% to 96.3%, negative likelihood ratio from 0.60 to 0.13, and reduced sex-dependence variabilities of ECG diagnostic parameters. ConclusionPost-hospitalised COVID-19 patients have more ECG abnormalities than controls. Normal ECGs, including normal repolarisation intervals, reliably exclude CMR abnormalities in male and female patients.

Two Cases of Acute Myocarditis with Suspected Acute Myocardial Infarction

Case 1: The patient is a 19-year-old male who was admitted to the hospital with a cough for three days and chest pain for a day, aggravated for two hours. Electrocardiogram showed 1. Sinus tachycardia 2. First-degree atrioventricular block 3. ST-T changes, not excluding acute extensive anterior wall myocardial infarction. Case 2: The patient was a 47-year-old woman admitted to the hospital with a fever for three days. Electrocardiogram showed: 1. Sinus tachycardia, 2. Complete block of the right bundle branch, 3. ST-T changes, not excluding acute extensive anterior myocardial infarction. The study of these two cases strengthened the departmental staff’s knowledge of ECG in acute myocarditis and provided a rapid and accurate ECG diagnosis in the clinic.

Risk Factors of Cardiac Complications in Pregnant Women with Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a common inherited genetic cardiac disease during pregnancy. Studies of risk factors are of great significance for maternal and fetal outcomes. The aim of the study was to identify predictive risk factors for cardiac complications in pregnant women with HCM. One hundred patients with HCM who delivered at the Shanghai obstetrical cardiology intensive care center between January 2000 and December 2022 were retrospectively reviewed. A logistic regression model was used to identify independent risk factors for cardiac complications. Twenty-one cases were obstructive HCM (21%), 16 with cardiac function grade I and 5 with grade II; 79 cases were non-obstructive HCM (79%), 67 with cardiac function grade I, 11 with grade II, and 1 with grade III. Ninety-one cases had abnormal electrocardiogram (ECG) (91%), mainly with ST-T changes (77%). The average interventricular septum was 19.39 ± 6.13 mm by echocardiography (21.75 ± 5.86 mm for obstructive HCM and 18.73 ± 6.08 mm for non-obstructive HCM). The main cardiac complications were maternal death (n = 2, 2%), heart failure (n = 7, 7%), and sustained ventricular tachyarrhythmia (n = 1, 1%). Cardiac complications occur commonly during the third trimester and postpartum period. Three independent risk factors to predict cardiac complications in pregnant women with HCM were obstructive HCM (P = 0.036), New York Heart Association (NYHA) class ≥II (P = 0.022), and previous history of syncope (P = 0.037). HCM increases the risk of maternal death, heart failure, and malignant arrhythmia. More attention should be given to risk assessment and pregnancy management. Early detection of risk factors can reduce the incidence of maternal mortality and cardiac complications.

Arrhythmias and electrocardiographic characteristics in cancer patients treated with immune checkpoint inhibitors

Objective: To evaluate the incidence of arrhythmias and electrocardiographic (ECG) characteristics in cancer patients treated with immune checkpoint inhibitors (ICIs). Methods: This was a cohort study conducted in the Fourth Hospital of Hebei Medical University. Cancer patients initiating ICIs treatments from November 2020 to September 2022 were included in this study. Baseline 12-leads ECG before ICIs initiation and post-treatment ECG were analyzed. An abnormal ECG was defined as the presence of any of the following changes: sinus arrhythmias, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia, ventricular tachycardia, premature contractions, conduction disorder, and ST-T changes. Results: A total of 87 patients were enrolled, aged 63 (57, 68) years, with 66 (75.9%) males. And 44.8% (39/87) of patients presented with at least one confirmed cardiovascular disease or cardiovascular risk factor at baseline. The incidence of abnormal ECG increased from 31.0% (27/87) at baseline to 65.5% (57/87) after receiving (5.0±2.7) cycles of ICIs treatment (P<0.001). The incidence of sinus arrhythmias was significantly increased after ICIs treatment (23.0% (20/87) vs. 9.2% (8/87), P=0.023), of which only the incidence of sinus tachycardia was significantly increased (11.5% (10/87) vs. 2.3% (2/87), P=0.039). There was also a significantly increased incidence of ST-T changes after ICIs treatment (31.0% (27/87) vs. 17.2% (15/87), P=0.012), which mainly attributed to the T wave changes (29.9% (26/87) vs. 13.8% (12/87), P=0.001). The incidence of premature contractions was also significantly increased after ICIs treatment (9.2% (8/87) vs. 0, P=0.008). Additionally, compared with baseline, the P wave axis was significantly increased after ICIs treatment ((56.94±21.01)° vs. (52.00±22.69)°, P=0.043). After ICIs treatment, the heart rate was significantly increased ((79.07±15.37) beats/min vs. (75.64±13.37) beats/min, P=0.029). Sokolow-Lyon index ((2.21±0.81)mV vs. (2.33±0.75)mV, P=0.138), QTc interval ((431.44±36.04)ms vs. (428.00±30.05)ms, P=0.415) all showed signs of change after treatment, but did not reach the traditional significant level. Conclusions: The incidence of abnormal ECG is significantly increased after ICIs treatment, especially for sinus tachycardia, premature contractions and T wave changes; the P wave axis and heart rate is also significantly increased after treatment. It is important to perform regular ECG monitoring in patients receiving ICIs treatment.

Assessment of Repeated Electrocardiogram Findings in Pediatric Multisystem Inflammatory Syndrome Associated with COVID-19

Background: Cardiac involvement, stemming from the novel multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease-2019 (COVID-19), leads to common and severe complications. Objectives: The aim of this study is to compare and evaluate repetitive electrocardiogram (ECG) results and laboratory indicators in children diagnosed with MIS-C upon their initial hospital admission. Methods: This prospective, single-center study, conducted between December 2020 and October 2022, included repeated electrocardiographic and laboratory tests. Changes in the ECG over the course of the disease were regularly recorded for three months. Results: This study included 72 patients, 25 of whom were female. Mitral regurgitation and left ventricular systolic dysfunction were observed in 25% of the patients. Statistically significant differences (P &lt; 0.05) were detected among the serial measurements of absolute neutrophil-lymphocyte count, CRP, procalcitonin, ESR, D-dimer, troponin T, pro-BNP, ferritin, and interleukin-6. Significant differences were also observed in heart rate, PR interval, QRS duration, QT duration, Fredericia QTc, JT interval, presence of sinus tachycardia, presence of first-degree AV block, presence of wide QRS, abnormal QRS axis, abnormal T axis, long QTc, and ST-T changes (P &lt; 0.05). Additionally, significant differences were noted in the absolute lymphocyte count, troponin levels, and ferritin levels between patients with prolonged abnormal ECG findings and those whose ECG findings were normal or had returned to normal. Furthermore, statistically significant differences were observed in absolute lymphocyte count, ferritin, and fibrinogen levels among the other four groups (P &lt; 0.05). Conclusions: Electrocardiogram findings in patients measured serially appear to improve over time. Since patients with MIS-C may experience ECG abnormalities that could lead to arrhythmias, close monitoring and the establishment of standardized approaches are essential. Long-term ECG abnormalities were associated with a decrease in absolute lymphocyte count and elevated levels of troponin, ferritin, and fibrinogen.

Clinical Characteristics and Major Adverse Cardiovascular Events in Diabetic and Non-Diabetic Patients with Vasospastic Angina.

The clinical background and prognostic impact of diabetes mellitus (DM) on vasospastic angina (VSA) are unclear; thus, in this retrospective study, we investigated whether they differ based on the presence or absence of DM in patients with VSA. We included 272 Japanese patients with VSA diagnosed by coronary angiography (CAG) and the spasm provocation test (SPT). The diagnosis of DM was determined by measuring fasting blood glucose and hemoglobin A1C and by the patient's current oral medications. On CAG, the presence of atherosclerotic lesions (20%-50%) was checked. On SPT, the coronary spasm was defined as transient coronary vasoconstriction >90% on CAG, accompanied by chest symptoms and/or ST-T changes. Focal spasm was defined as coronary spasm occurring within one segment of the American Heart Association classification on CAG. Blood and urine tests and vascular endothelial function were also evaluated when possible. A major adverse cardiovascular event (MACE), which is defined as cardiac mortality and rehospitalization due to cardiovascular illness, was the basis for determining the prognosis. There were 49 patients (18%) in the DM group and 223 (82%) in the non-DM group. No significant differences in urinary albumin levels and peripheral vascular function were between groups. On CAG, atherosclerotic lesions were observed significantly more frequently in the DM group (63% vs 46%; P = 0.028). Results of SPT showed a trend toward fewer focal spasms in the DM group (24% vs 39%; P = 0.072). No significant differences in MACE were noted between groups in the primary analysis of DM, whereas sub-analyses of focal spasms showed lower MACE-free survival in the DM group (P = 0.042). The study results support the hypothesis that DM associated with VSA should be treated appropriately, especially in cases of focal spasm, which may require more attention in treatment.

The Effect of Sex on the Risk of Long-COVID and Cardiovascular Complications in Healthy Patients without Comorbidities: Data from a Polish Long-COVID Cardiovascular (PoLoCOV-CVD) Study.

Background: The prevalence of long-COVID (LC) presents a significant challenge to healthcare systems globally. There are still some discrepancies on the role of sex as an independent risk factor of LC complications. Thus, we aimed to determine the differences in clinical and cardiovascular complications between males and females without comorbidities after COVID-19. Methods: Clinical data on the course of the disease with the accompanying symptoms and post-COVID-19 symptoms were compiled from both male and female subjects with a minimum 12-week interval after COVID-19 recovery. Next, the patients were followed for 12 months. ECG, echocardiography, 24 h ECG monitoring, 24 h ambulatory blood pressure monitoring (ABPM), and selected biochemical tests were performed. LC was diagnosed based on the World Health Organization (WHO) definition. To reduce the impact of confounders, i.e., body mass index (BMI) and age, on the results of the study, the nearest neighbour (NN) propensity score matching (PSM) method with a 1:1 ratio was used. Results: The results were obtained following the removal of cases with comorbidities from the database consisting of 1237 males and 2192 females, and PSM of the new database included 886 cases (443 males and 443 females). At both the 3-month and 1-year post-recovery marks, females consistently reported a higher frequency of LC symptoms compared to males (p < 0.001 for both comparisons). Moreover, after 1 year of follow-up, females exhibited a higher prevalence of LC compared to males, with rates of 14% versus 8.3%, respectively (p = 0.013). The symptoms that significantly differed between females and males in the 12-month follow-up were hair loss (5.4 vs. 0.7%, p < 0.001), memory and concentration disturbances (8.4 vs. 4.3%, p = 0.013), and headaches (4.3 vs. 1.4%, p = 0.008). Females presented lower mean arterial pressure (MAP) [89 (83-95) mmHg versus (vs.) 94 (89-100); p < 0.001] and lower pulse pressure (PP) [46 (42-52) mmHg vs. 51 (48-57); p < 0.001] in 24 h ABPM and more elevated heart rates (HRs) in 24 h ECG monitoring as well as arrhythmia (p < 0.001 and p = 0.018, respectively). Males had a higher occurrence of ECG abnormalities such as QRS >= 120 ms, ST-T changes, T inversion, arrhythmia, and QRS fragmentation (27.3% vs. 19.2%; p = 0.004). No significant differences were observed between males and females concerning physical activity levels, stress, fatigue, alcohol consumption, and smoking habits. Conclusions: One year post-COVID-19 recovery, regardless of age and BMI, healthy females more often suffered from LC symptoms than males. They had lower MAP and PP in 24 h ABPM, more often had higher HRs and arrhythmia in 24 h ECG monitoring, and fewer ECG abnormalities than males.

Electrocardiographic abnormalities in patients with sickle cell disease: A systematic review and meta-analysis.

Previous studies have documented that electrocardiography (ECG) can reveal a range of abnormalities, offering valuable insights into the cardiac evaluation of patients with sickle cell disease (SCD). The objective of this study is to assess the patterns of ECG abnormalities observed in these patients with SCD, and to determine their prevalence. We systematically reviewed the literature using online databases of PubMed, Scopus, Web of Science, Embase, and Google Scholar to identify original studies that reported findings of standard ECG assessments in patients with SCD. Statistical analyses were performed using the random effects model. Additional analyses including sensitivity analysis and subgroup analysis were also conducted. Analysis of data from 59 studies involving 897,920 individuals with SCD revealed that 75% of these patients had abnormal ECG findings (67%-81%), which were predominantly nonspecific ST-T changes, left ventricular hypertrophy, T-wave changes, prolonged corrected QT (QTc) interval, and ischemic changes. Besides, it was shown that these patients had significantly higher odds of having any ECG abnormalities (OR of 17.50, 4.68-65.49), right atrial enlargement (6.09, 1.48-25.09), left ventricular hypertrophy (3.45, 1.73-6.89), right ventricular hypertrophy (7.18, 2.28-22.57), biventricular hypertrophy (10.11, 1.99-51.38), prolonged QTc interval (5.54, 2.44-12.59), ST depression (3.34, 1.87-5.97), and T-wave changes (5.41, 1.43-20.56). Moreover, the mean of QTc interval was significantly higher among those with SCD (23.51milliseconds, 16.08-30.94). Our meta-analysis showed a higher prevalence of abnormal ECG findings among individuals with SCD. A significant proportion of these patients had various ECG abnormalities, suggesting a potential need for regular ECG assessments for patients with SCD.

Fragmented QRS complex could predict all-cause mortality in patients with connective tissue disease-associated pulmonary arterial hypertension.

To investigate the prognostic impact and pathophysiological characteristics of fragmented QRS complex (fQRS) on patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH). This was a multicentre retrospective study recruiting 141 patients with CTD-PAH diagnosed by right heart catheterization (114 cases in the discovery cohort and 27 cases in the validation cohort). fQRS and ST-T change were detected on conventional 12-lead electrocardiogram (ECG). Patients were followed up every 3 months to update their status and the primary end point was all-cause death. Clinical information and ECG characteristics were compared between survival and death groups and Kaplan-Meier curve was used for survival analysis. There were significant differences in age, gender, 6-min walk distance, NT-proBNP, WHO class, presence of fQRS and presence of ST-T change in inferior leads between survival group and death group. Inferior fQRS and ST-T change were significantly associated with right ventricular (RV) dilatation and reduced RV ejection fraction (RVEF). Kaplan-Meier curve showed that all-cause mortality was higher in CTD-PAH with fQRS (p= 0.003) and inferior ST-T change (p= 0.012). Low- and intermediate-risk CTD-PAH with inferior ST-T change had higher all-cause mortality (p= 0.005). The prognostic value of fQRS and inferior ST-T change was validated in external validation cohort. The presence of inferior fQRS and ST-T change could predict poor prognosis in CTD-PAH. NCT05980728, https://clinicaltrials.gov.

Importance of ECG findings in COVID-19 patients: Predictor of in-hospital prognosis.

Cardiac injury in COVID-19 patients confers a worse prognosis. The interpretation of electrocardiography can be beneficial in the early diagnosis of probable cardiac involvement. After adjusting for other variables, we sought to determine if the initial ECG on admission could add additional prognostic value. In this single-center cross-sectional study, 1165 patients with a positive COVID-19 PCR between Feb 2020 and Nov 2021 were enrolled in our study. Patients were grouped according to their admitted units, and survivors to hospital discharge or non-survivors. Predictors of ICU admission and in-hospital mortality were determined using univariate analysis and a logistic regression model. The mean age was 55.6 ± 16.2 years and 52% were male. Out of 1165 patients, 149 deaths (12.8%) were recorded during hospitalization. Sinus tachycardia was the most common dysrhythmia, followed by premature atrial and ventricular beats, sinus bradycardia, and atrial fibrillation (28.6%, 5.6%, 3.9%, and 2.1%, respectively). Age (p<0.001), sex (p=0.006), history of diabetes mellitus (p=0.002), hypertension (p=0.018), ischemic heart disease (p=0.004), and cancer (p<0.001) were more frequent among non-survivors. Among ECG findings, tachycardia, low voltage QRS, ST-T changes, and dysrhythmia were related to an increased mortality risk. However, in regression analysis, only sex (OR 1.89, 95% CI 1.2 to 2.9, p=0.004), age (OR 1.03, 95% CI 1.02 to 1.05, p<0.001), and initial tachycardia (OR 1.02, 95% CI 1.01 to 1.03, p<0.001) were independent predictors of in-hospital mortality. Our data suggest that initial electrocardiographic findings could be helpful in distinguishing patients with an increased risk for ICU admission or in-hospital death.

The impact of the COVID-19 pandemic on cardiovascular disease in the cardiovascular center of Kermanshah, in the west of Iran

BackgroundCardiovascular diseases (CVD) are known as the most common cause of mortality worldwide. Hence, exploring the impact of COVID-19 pandemic on CVD and its risk factors. This study aimed to explore clinical and echocardiographic characteristics and cardiac manifestations in COVID-19 patients. MethodsThis cross-sectional study was conducted on 386 patients with COVID-19 admitted to Imam Ali Hospital, the largest specialized cardiology hospital in western Iran. The checklist included information about age, gender, hypertension, BMI, diabetes, chronic renal disease, cigarette smoking, echocardiography and ECG findings, in-hospital MACE, venous and arterial thrombotic events. To analyze the data, SPSS23, paired-samples t-test, chi-square test and logistic regression analysis were used. ResultsOur findings showed 57 % of patients were male and 43 % were female. The paients' average age was 64.61 ± 14.21 years. Moreover, 25.9 % of patients had diabetes, 27.7 % had blood pressure, 11.7 % were cigarette smokers and 11.1 % had hyperlipidemia. The main electrocardiographic abnormalities were ST-T changes in 1.31 % of the patients, sinus tachycardia in 16.3 % and atrial fibrillation in 11.1 % of patients. Mild to moderate pericardial effusion was observed in 8.1 % and pleural effusion in 9.1 % of the sample. Common cardiac complications were ACS in 52.9 %, DHF in 24.4 %, and CHB in 4.4 % of patients. 19.4 % of patients died during hospitalization. Mild to moderate pericardial effusion (OR = 1.96, 95 % CI 1.18–2.14, P = 0.012) was an independent predictor of mortality in COVID-19 patients. ConclusionResults of the study showed it is essential to pay closer attention to elderly, diabetic and hypertensive patients, who are more prone to COVID-19 infection. Moreover, common cardiac complications were ACS and DHF, respectively.

Non-cardiac Chest Pain and Benign Palpitations Among Adult Patient Referred for Stress Electrocardiography (ECG) in the Cardiac Clinic in Southern Nigeria

Background Non-cardiac chest pain and benign palpitations are often seen in cardiac clinics, but they are usually not related to serious heart conditions. Exercise testing is usually used to detect cardiomyopathies; it is symptom-limited and may be stopped if patients report symptoms such as dyspnea, fatigue, chest pain or for medical reasons such as ischemic ST-segment changes, abnormal blood pressure response to exercise. With limited knowledge about these presenting symptoms on cardiomyopathies in developing country such as Nigeria, the study therefore aims to determine the stress ECG pattern among patients, reasons for interruption, and stress-induced changes in southern Nigeria. Materials and methods: This was a retrospective study of 60 adult patients (age 18-69 years) at Good Heart Medical Consultants Hospital from October 2019 to January 2023 referred with noncardiac chest pain and benign palpitations for stress ECG. Data collected was analyzed using the Bruce protocol. Results 83% presented with chest pain and 17% with palpitations. Mean ages were 50±20 for chest pain and 45±13 for palpitations. Majority 66.6% were 41-60 years old. Muscle fatigue 48.3% was the most common reason for interruption. ST-T changes had no significant difference. Stress-induced ischemia 10% and arrhythmia 12% were more prevalent among subjects with chest pain while stress-induced hypertension 10% was significant among subjects with palpitations. Conclusion Arrhythmia was rarely a reason for stopping the stress ECG test, as ST elevation and ischemia were minimal. Ischemic heart disease is becoming an increasing problem however, stress ECG is not commonly used in diagnosing this condition in our region.

Recurrent Palpitation in a Young Man with Systemic Lupus Erythematosus Undergoing Belimumab with Resolution After Switching to Telitacicept

Background Cardiovascular disease is a significant complication of SLE patients, leading to high risk of morbidity and mortality. Atherosclerosis is a major contributor. Belimumab can reduce disease relapses and indicated to be atheroprotective. As a new biologic agent telitacicept targets both BLys and APRIL and inhibits both B cells and plasma cells. It may become a better option. Methods This case report describes a male patient with SLE combined with refractory lupus nephritis. Belimumab was given on the basis of corticosteroids and MMF. His condition was partially improved but recurrent palpitation occurred. Coronary artery atherosclerosis was confirmed. After switching from belimumab to telitacicept, palpitation disappeared and the patient’s condition gradually improved. Results A 40-year-old man presented recurrent fatigue for 8 years. He is a non-smoker, BMI 24.07kg/m2, without family history of CAD. In October 2015, pancytopenia was found, with ANA, anti-dsDNA and U1-nRNP/Sm antibody positive. C3 decreased obviously. Coombs test was positive. 24h proteinuria was 11895 mg. SLE complicated with lupus nephritis was diagose and he was treated with pulse steroid, IVIG and CTX. Condition was improved, and he maitained steroid, MMF and hydroxychloroquine. In May 2023, he stopped MMF himself for fear of COVID-19 infection. Soon lower limbs edema developed. C3 0.37g/L, C4 0.02g/L, dsDNA 675.3 IU/ml, 24h-P 8444 mg was documented. SLEDAI score was 12. Renal pathology indicated ISN/RPS 2003 Class IV-G(A)+V Lupus Nephritis. He received pulse steroid (MP 500 mg per day) for 3 days, belimumab 720mg once and with MMF 750mg twice per day. Belimumab was regularly given after disease was controlled. Proteinuria decreased and remained about 3g. In August,2023, the patient began to feel palpitation repeatedly. LDH, HBDH and LDL increased. Holter showed sinus rhythm, accidental supraventricular premature beat, but no ST-T change. Coronary CTA showed non-calcified plaques in local section of RCA and the proximal section of branch of LAD, with slight stenosis. Rosuvastatin was prescribed. But palpitation reoccured after belimumab was given. Belimumab was stopped and changed to telitacicept 160mg every 4 weeks from 12 November, 2023. Till now, palpitation doesn’t occure. Prednisolone was tapered down to 7.5mg per day and MMF maintained 750mg twice a day. Complements rised. Proteinuria decreased to 1164.34mg. Conclusion Telitacicept is supposed to be a choice for refractory active SLE patient with atherosclerosis who has poor response to conventional therapy.

Safety of Electro-Convulsive Therapy in Combination with Duloxetine in Treatment-resistant Depressive Patients: A Randomized Clinical Trial

Background: There are several strategies in the management of treatment-resistant depression (TRD), including the administration of other antidepressants, augmentation therapy, electro-convulsive therapy (ECT), and a combination of ECT and antidepressants. The safety of ECT combined with any medication must be confirmed. The aim of this study was to assess the safety of duloxetine and ECT combination therapy. Materials and Methods: In this randomized clinical trial, the probable side effects of ECT plus duloxetine were compared with ECT plus sertraline in two groups of admitted TRD patients. Patients with general medical diseases and/or any contraindications to ECT or any of the two drugs were excluded. General side effects, including nausea, vomiting, and headache reported by patients (hours after ECT) as well as cardiotoxicity by electrocardiogram (immediately after any ECT episode), cognitive status by mini-mental state examination (MMSE, one month after the last ECT), and seizure duration were recorded for each patient. Results: No significant differences were observed in nausea, vomiting, headache, and myalgia between ECT+duloxetine and ECT+sertraline groups. Heart rate, QTc interval, ST-T change, and the incidence of arrhythmia were the same between the two arms of the study. Also, no prolonged seizures and status epilepticus were recorded among the studied patients. The MMSE revealed no marked differences in the cognitive status among patients of the two groups. Conclusion: ECT+duloxetine and ECT+sertraline were equally safe in patients with TRD.

Evaluation of myocardial infarction by a 12-lead routine electrocardiogram: a case report of an ST-segment elevation.

The spiked helmet sign (SHS) is a type of ST-segment elevation associated with critical cardiac disease and a high risk of death. We report a case of SHS caused by an ECG artifact. A 60-year-old male patient presented to the clinic after suffering an electric shock. The initial 12-lead routine elec-trocardiogram showed an SHS. The patient received appropriate intravenous fluid replacement therapy, and after 30 minutes, the ST-T changes of the 12-lead electrocardiogram were all restored to normal. The patient was discharged after a 24-hour observation period in the emergency room.Recent studies have pointed out that there may be two different types of SHS. One is the mechanical factor, and the other is the significant prolongation of the QT interval. The two types have different clinical significance. In our report, the radial artery of the patient’s right wrist pulsed strongly, and after the occurrence of SHS, the SHS disappeared after adjusting the contact position of the electrode in his right arm. This SHS caused by mechanical traction was an ECG artifact.Although the SHS may be an essential indicator of critical illness, there are mechanical factors that lead to the appearance of ECG artifacts. Therefore, in clinical work, obtaining a complete medical history and primary conditions of the patient at the time of ECG sampling is necessary to help the diagnosis and thus avoid er-roneous treatment.

The Role of Neutrophil to Lymphocytes Ratio and It's Common Clinical Outcomes Amount the Patient with Non ST Elevation Acute Coronary Syndrome

Objectives: To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital out-comes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients.&#x0D; Methodology: Methods: We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, inter- mediate, and high-risk based on &lt;3.0, 3.0e6.0, and &gt;6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded.&#x0D; Results: Results: Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high- risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively.&#x0D; Conclusion: A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.