Transient ECG Changes Research Articles

Toxic Myocarditis with Brugada Phenocopy in a Case of Aluminum Phosphide Poisoning

Brugada phenocopy is considered when a Brugada-type ECG pattern is present but with a low likelihood of true Brugada syndrome, as indicated by negative family history, genetic testing, or provocative testing with drugs, or ECG normalization after the removal of precipitants. Brugada phenocopy has been reported due to various causes such as fever and electrolyte imbalance. We describe a 22-year-old man who presented with aluminum phosphide poisoning, resulting in severe metabolic acidosis, myocarditis, and profound myocardial depression. He developed transient Brugada-like ECG changes and multiorgan dysfunction, requiring intensive management, including mechanical ventilation and inotropes. Brugada phenocopy is a rare manifestation of aluminum phosphide-associated toxic myocarditis. After a week of treatment, there was a significant improvement in cardiac function and overall clinical status.

Brugada phenocopy associated with multiple psychotic drugs

Brugada phenocopy (BrP) is a clinical condition characterized by transient ECG changes of Brugada syndrome (BrS), which can be due to various clinical conditions. We describe a case report of BrP due to psychotic drugs.

Abstract 154: Limitation of Troponin T In Identifying the Cause of Out-of-hospital Cardiac Arrest

Introduction: High Sense-Troponin T (HS-TnT) is a key determinant for presence or absence of acute MI in chest pain patients (pts). Its value for acute MI diagnosis in pts with out-of-hospital cardiac arrest (OHCA) needs assessment because myocardial ischemia may be the cause but also a consequence of cardiac arrest causing global ischemia during no and low flow periods. Methods: Data were prospectively collected. From pts included in the ARREST registry who survived OHCA to discharge with VF as initial rhythm, the cause of OHCA and peak HS-TnT were analyzed. Cause of OHCA was determined independently by researchers, from history, admission and serial ECG, coronary angiography (CAG), cardiac imaging and genetics as available and indicated, without using HS-TnT information. MI diagnosis was made according to the 4 th universal definition of MI: type 1 MI (thrombotic STEMI/NSTEMI), type 2 MI (supply/demand imbalance) and no MI (short transient ECG changes and all non-ischemic causes). Results: From 2012 till 2018 in the study region 373 OHCA pts met the inclusion criteria and had a known peak HS-TnT. Of these, Type 1 MI was present in 109 STEMI and 39 NSTEMI pts, type 2 MI in 116 pts and no MI in 109 pts. No significant coronary stenosis or normal CAG was present in 81 pts: 11/106 (10%) with type 2 MI and 70/109 (64%) without MI. HS-TnT exceeded the conventional diagnostic threshold of 4 times upper limit of normal (4x14ng/L = 56 ng/L) in 99%, 95%, 95% and 89% of pts, respectively. Median peak HS-TnT levels in STEMI, NSTEMI, Type 2 and no AMI pts was 1890 ng/L, 480 ng/L, 300 ng/L and 261 ng/L, respectively. (Figure) Area Under the ROC-Curve of HS-TnT values to differentiate between type 1 NSTEMI and type 2 AMI was 0.649, between type 1 NSTEMI and no MI 0.684 and between type 2 MI and no AMI 0.555. Conclusion: Exclusion of diagnosis of MI in OHCA pts cannot be made with HS-TnT, nor a distinction between NSTEMI, type 2 MI and no AMI. Based on HS-TnT many OHCA pts without ischemic cause would classify as NSTEMI.

Abstract 15619: Smoking Towards Prinzmetal

Background: Vasospastic (Prinzmetal) angina is a result of coronary vasospasm leading to myocardial ischemia. It is defined by nitrate responsive angina, transient ischemic ECG changes, and coronary vasospasm. In this report, we highlight coronary angiographic findings of Prinzmetal angina and underscore tobacco use as a known risk factor. Case Presentation: A 62-year-old male with hypertension and tobacco use presented with acute substernal chest pain. Laboratory testing revealed elevated troponin to 17.4 mg/mL and ECG with new T-wave inversions in the lateral leads. Coronary angiogram revealed non-obstructive coronary artery disease (CAD) (Figure 1). He was discharged on medical therapy and instructed to stop smoking. Four days later, he returned with one day of chest pain that improved with sublingual nitroglycerin. Repeat troponin was elevated to 46.9 ng/mL and ECG revealed ST depressions in V2-V6. Repeat coronary angiogram revealed 99% narrowing in the proximal left circumflex (LCx) (Figure 2). Intra-arterial nitroglycerin administration led to resolution of the LCx narrowing (Figure 3). Conclusion: Prinzmetal angina can be precipitated by tobacco use. Clinicians ought to maintain a high degree of suspicion for Prinzmetal angina as an etiology of cardiac ischemia in patients who have non-obstructive CAD and concomitant tobacco use.

C103. Viral Myocarditis Mimicking Acute Myocardial Infarction: A Case Report

Abstract Background Acute myocarditis still challenging diagnosis in cardiology. Its entity is rarely recognized and its pathophysiology defectively understood. Viral infection remains the most commonly identified cause for myocarditis, but bacteria, fungi, protozoa, and helminths have also been implicated. Case Summary A 61 years old female was admitted to emergency department, complaining typical angina since 12 hours prior to admission. She also complains nausea, vomit, flu like syndrome, and low grade fever since 1 weeks prior to admission. She was a former smoker and had hypertension. ECG in 6 hours on admission ECG revealed sinus rhythm, ST-elevation anteroseptal, ischemic lateral-high lateral and there is no evolution compare to previous ECG which taken in other hospital. Laboratory findings showed increased of troponin enzyme. Coronary angiography was performed with result normal coroner. Echocardiography revealed normal all chambers, concentric LV remodelling, normal LV systolic function with ejection fraction 51% without regional wall motion abnormalities. On the next day, troponin levels decrease and the ECG remain abnormal without any changes. In order to get more data, CMR was planned, but she refused. Patients was discharged uneventful. Discussion Myocarditis is challenging diagnosis due to the heterogenicity clinical presentation. It presents in many different ways, ranging from mild “flu-like” symptoms, mild symptoms of chest pain and palpitations associated with transient ECG changes. Chest pain in acute myocarditis may mimic typical angina and be associated with electrocardiographic changes, including ST-segment elevation and often misdiagnosed as ACS until coronary angiography demonstrates normal or non-obstructive coronary arteries.

C103. Viral Myocarditis Mimicking Acute Myocardial Infarction: A Case Report

Abstract Background Acute myocarditis still challenging diagnosis in cardiology. Its entity is rarely recognized and its pathophysiology defectively understood. Viral infection remains the most commonly identified cause for myocarditis, but bacteria, fungi, protozoa, and helminths have also been implicated. Case Summary A 61 years old female was admitted to emergency department, complaining typical angina since 12 hours prior to admission. She also complains nausea, vomit, flu like syndrome, and low grade fever since 1 weeks prior to admission. She was a former smoker and had hypertension. ECG in 6 hours on admission ECG revealed sinus rhythm, ST-elevation anteroseptal, ischemic lateral-high lateral and there is no evolution compare to previous ECG which taken in other hospital. Laboratory findings showed increased of troponin enzyme. Coronary angiography was performed with result normal coroner. Echocardiography revealed normal all chambers, concentric LV remodelling, normal LV systolic function with ejection fraction 51% without regional wall motion abnormalities. On the next day, troponin levels decrease and the ECG remain abnormal without any changes. In order to get more data, CMR was planned, but she refused. Patients was discharged uneventful. Discussion Myocarditis is challenging diagnosis due to the heterogenicity clinical presentation. It presents in many different ways, ranging from mild “flu-like” symptoms, mild symptoms of chest pain and palpitations associated with transient ECG changes. Chest pain in acute myocarditis may mimic typical angina and be associated with electrocardiographic changes, including ST-segment elevation and often misdiagnosed as ACS until coronary angiography demonstrates normal or non-obstructive coronary arteries.

Shark fin sign.

1. We demonstrate a case diffuse tombstone-like QRS-ST segment elevations in the inferior and anterolateral leads -shark Fin sign. The transient diffuse tombstone-like ECG changes (Shark fin sign) seen in our patient were most consistent with multivessel coronary vasospasm likely secondary to hemopericardium.

Bezpieczeństwo pacjentów poddawanych badaniu scyntygrafii perfuzyjnej mięśnia sercowego po obciążeniu dipirydamolem

Introduction. Myocardial perfusion scintigraphy (MPS) with dipyridamole is an accepted method for assessment of is- chaemic heart disease, in case of contraindication to exercise testing. However, very often we observe clinical symptoms and changes in ECG while monitoring patients during the study with pharmacologic stress with dipyridamole. The aim of this study was to investigate the safety of patients diagnosed with MPS with dipyridamole. Material and methods. Twenty-five patients with stable coronary artery disease participated in a 2-day protocol (0.56 mg/ kg dipyridamole i.v. and then rest) using Tc-MIBI imaging. Continuous clinical monitoring and 12-lead serial ECG has been used since the beginning of the MPS up to 20 minutes after the examination. High-sensitive cardiac troponin I (hscTnI) concentration was measured before, four hours and the next day after stress test. Primary endpoint included hscTnI concentration above 99th percentile of the upper reference limit in second or third measurement or new persistent ST-T segment changes. Secondary endpoints were: new persistent or transient ECG changes (ST-T segment elevation or depression or negative T waves, prolongation of QRS complex, PR interval or QTc), or any drug-related adverse event. Results. The concentrations of hscTnI were below 99th percentile of the upper limit among all the patients. Primary and secondary endpoint were observed in 6 (24%) and 23 (92%) patients, respectively. Transient ST-T segment elevation occurred in 4 (16%) patients, transient ST-T segment depression or negative T wave — in 7 (25%) patients, QRS complex prolongation — in 11 (44%) patients, PR interval prolongation — in 18 (75%) patients, QTc prolongation — in 22 (88%) patients, any clinical adverse event related to dipyridamole — in 16 (64%) patients. Following endpoints were correlated with positive MPS results: ST-T segment changes, RP interval prolongation, and with a history of chest pain: ST-T seg- ment changes, QRS complex and QTc prolongation. Conclusions. MPS with dipyridamole stress is relatively safe, as hscTnI concentration remains within normal in prolon- ged observation after the examination. While there is a significant risk of minor clinical and electrocardiographic adverse events it is not related with a myocardial necrosis.

Variant Angina and Aborted Sudden Cardiac Death.

Variant angina, which is characterized by recurrent chest pain and transient ECG changes along with angiographic evidence of coronary artery spasm, generally has a favorable prognosis. However, episodes of ischemia caused by vasospasm may lead to potentially life-threatening ventricular arrhythmias and cardiac arrest, even in patients with no history of prior cardiac disease. This review describes the epidemiology, pathogenesis, clinical spectrum, and management of variant angina, as well as outcomes in patients who present with aborted sudden cardiac death (ASCD). Contrary to prior opinions, evidence from recent observational studies indicate that patients with variant angina presenting with ASCD face a worse prognosis than those without this type of presentation. Predictors of ASCD include age, hypertension, hyperlipidemia, family history of sudden cardiac death, multi-vessel spasm, and left anterior descending artery spasm. Medical therapy alone with calcium channel blockers and nitrates may not be sufficiently protective in these patients and there is lack of concrete data on the optimal management strategy. Current guidelines recommend implantable cardiac defibrillator (ICD) therapy in patients who are survivors of cardiac arrest caused by ventricular fibrillation or unstable ventricular tachycardia after reversible causes are excluded, and should strongly be considered in these patients. Although medical therapy is absolutely imperative for patients with variant angina and a history of ASCD, ICD therapy in these patients is justified. Further large-scale studies are required to determine whether ICD therapy can improve survival in this high-risk group of patients.

The Who, What, Why, When, How and Where of Vasospastic Angina.

Ischemic heart disease involves both "structural" and/or "functional" disorders of the coronary circulation. Structural atherosclerotic coronary artery disease (CAD) is well recognized, with established diagnostic and treatment strategies. In contrast, "functional CAD" has received limited attention and is seldom actively pursued in the investigation of ischemic heart disease. Vasospastic angina encompasses "functional CAD" attributable to coronary artery spasm and this "state of the art" consensus statement reviews contemporary aspects of this disorder. Patients with vasospastic angina typically present with angina at rest that promptly responds to short-acting nitrates and is associated with transient ischemic ECG changes. Although spontaneous episodes may be documented, provocative spasm testing may be required to confirm the diagnosis. It is important to diagnose vasospastic angina because it may be associated with major adverse events that can be prevented with the use of appropriate vasodilator therapy (eg, calcium-channel blockers) and the avoidance of aggravating stimuli (eg, smoking). Future studies are required to clarify the underlying pathophysiology, natural history and effective treatments for patients refractory to conventional therapy.

Percutaneous microembolization of the left coronary artery to model ischemic heart disease in rats.

Small animal models of myocardial infarction are used for a wide variety of research purposes, but common techniques for generating such models require thoracic surgeries that increase mortality risk and damage important structures, such as the pericardial sac. Here, we describe a technique for modeling myocardial infarction in rats by selective coronary microembolization, which has hitherto been described only in large animals. This technique selectively catheterizes the left coronary artery using a custom-made catheter that is introduced and precisely placed under fluoroscopic guidance. Microspheres are then injected through the catheter to cause embolization. This process creates multiple simultaneous micro-infarcts that resemble those from clinical embolization after a percutaneous coronary intervention. As this technique does not require thoracic surgery, a low attrition rate was expected and once it was optimized, this technique had a low mortality rate of just 14% during experimental application. This technique creates infarcts that appear small but are associated with transient ECG changes and a persistently lower ejection fraction after embolization. Microspheres are retained in the myocardial tissue and are visible by epifluorescent microscopy after histological staining and recognizable as a distinct speckle pattern in ultrasound images.

Retrospective Evaluation Of Novel Percutaneous Left Atrial Appendage Ligation Using The LARIAT Suturing Device: Single Center Initial Experience.

The left atrial appendage (LAA) is the source of considerable thromboemboli responsible for embolic strokes in patients with atrial fibrillation (AF). The LARIAT™ suturing device has been used to ligate the LAA and negate the use of systemic anticoagulation. However, its efficacy and stroke outcome is still unknown. We retrospectively evaluated the clinical status and risk of occurrence of systemic emobolic events, strokes, transient ischemic attacks, and procedure related complications in patients after LAA ligation using the LARIAT™ device. Permanent suture was successfully delivered in 21 patients. Mean follow up time was 17.2+-3.3 months. The average HAS-BLED score was 3.3+/-1.1. Only 1 patient developed clinical symptoms of stroke 7 days post procedure. One patient had uncomplicated perioperative bleeding not requiring blood transfusion. One patient developed transient ECG changes of ischemia during mapping for ablation following the LAA ligation and subsequently, underwent bypass surgery. Three patient developed post-procedural pericarditis and were medically managed. Three patients died from non-LAA ligation related conditions including congestive heart failure, lung cancer, and severe coronary disease. We observed a 32% and 30% reduction in the annual risk of stroke when compared to the expected risk of stroke based on the CHADS2 and CHA2DS2-VASc score respectively. LAA ligation using the LARIAT™ suturing device is clinically feasible in carefully selected patients. This study has the longest follow up period to date, however further studies are required to determine the efficacy of stroke reduction and long-term clinical outcomes.

Baseline and new‐onset morphologic ECG abnormalities in healthy volunteers in phase I studies receiving placebo: Changes over a 6‐week follow‐up period

Morphological ECG abnormalities occur in 5-12% healthy adults participating in early phase clinical trials. We retrospectively analyzed 16,472 12-lead ECGs recorded at multiple time points in 420 volunteers (282 males, 138 females; aged 18-76 years) randomized to receive placebo from 19 Phase I studies to see if some baseline ECG abnormalities may disappear or new abnormalities may appear during the study. One hundred forty-four (34.3%) subjects had abnormal baseline ECGs, of which 66 (44.8%) reverted to normal during follow-up. Of 276 (65.7%) subjects with normal baseline ECGs, 118 (42.8%) developed ECG abnormalities over the next 6 weeks. Common baseline abnormalities included sinus bradycardia, R wave transition abnormalities, right axis deviation, non-specific T wave changes and atrial premature complexes. On follow-up ECGs, prolonged QT interval, first-degree AV block, sinus bradycardia, short PR interval, and R wave transition abnormalities reverted to normal. Common new-onset abnormalities in subjects with normal baseline ECGs included sinus bradycardia, prolonged QT interval, non-specific T wave changes, R wave transition abnormalities, and sinus tachycardia. Thus, transient morphological ECG changes may occur in healthy volunteers possibly due to diurnal variation, effect of food, hormones, or autonomic changes. This should be considered when interpreting "treatment-emergent" ECG changes in clinical trials.

Predictors of obstructive coronary artery disease in otherwise ‘healthy’ individuals with ST-segment depression during paroxysms of atrial fibrillation

Paroxysmal atrial fibrillation Coronary artery disease Intima-media thickness C-reactive protein Ischemic ST-segment depression only during paroxysms of atrial fibrillation (AF), while the ECG appears unremarkable or non-specific during sinus rhythm, is not uncommon. This presentation is usually considered as a positive stress-test equivalent. However, we [1] and other investigators [2] have recently shown that in subjects without a history of cardiac disease, the presence of transient ischemic ECG changes during a paroxysm of AF, is not strongly associated with occult obstructive coronary artery disease (CAD). The present study aimed to investigate whether certain clinical factors or biochemical variables could predict the presence of underlying severe CAD in otherwise healthy individuals, who present with transient ischemic-type ST-depression only during AF, and have no evidence of profound structural heart disease or a concomitant acute cardiopulmonary event. Weassessedconsecutivepatientsolderthan40yearswhopresented to the emergency department with AF of recent onset (paroxysmal AF or persistent AF with duration of less than 30 days) and concomitant ischemic ST-segment depression. Ischemic ST-segment changes were defined according to exercise testing standards [3] .P atients with a history of CAD, other cardiac disοrders or severe co-morbidities were excluded from the study. Those who had biochemical and/or echocardiographic findings indicating an acute cardiopulmonary event or structural heart disorder were also excluded. Conversion to sinus rhythm was attempted in all admitted patients, either pharmaceutically or by synchronised transthoracic cardioversion, unless AF terminated spontaneously. Cardioverted patients with persistent ST-segment depression of more than 48h and patients in whom cardioversion was unsuccessful, were excluded. Patients who fulfilled all entry criteria and consented to the study protocol underwent the following investigations:

Infant Ventricular Fibrillation After ST-Segment Changes and QRS Widening

Background— Ventricular arrhythmia–related sudden cardiac arrest in infants with structurally normal hearts is rare. There have been no previously published reports of infants <3 months of age with ventricular fibrillation in which a primary diagnosis could not be defined. Methods and Results— Retrospective chart review of 3 unrelated infants <2 months of age from 3 different tertiary care centers within the United States and Australia was conducted. All 3 infants survived sudden cardiac arrest secondary to multiple episodes of polymorphic ventricular tachycardia and ventricular fibrillation. Each infant demonstrated unique and transient ECG findings consisting of ST changes and QRS widening before arrhythmia onset, which have not been previously reported. Amiodarone, sedation, sodium channel–blocking agents, and ventricular pacing were effective in suppressing acute events. Despite thorough investigation, including genetic testing, the cause of ventricular arrhythmias in each of these infants remains unclear. Conclusions— This is the first report of idiopathic ventricular fibrillation in young infants preceded by stereotypical transient ECG changes. These findings may represent a new, potentially treatable cause of sudden infant death. Recognition of these prodromal changes may be important in future management and survival of these infants.

Cardiac magnetic resonance imaging safety following percutaneous coronary intervention

In the first 8 weeks after percutaneous coronary intervention (PCI), possible negative interactions exist between the cardiac magnetic resonance (CMR) imaging environment and the weakly ferromagnetic material in coronary stents. There are circumstances when CMR would be indicated shortly following PCI, such as acute myocardial infarction (AMI). The purpose of this study is to demonstrate CMR safety shortly following stent PCI in AMI patients. We performed a retrospective analysis of safety data in AMI patients with recently placed coronary artery stents enrolled in a multi-center phase II trial for gadoversetamide. Patients underwent 1.5 T CMR within 16 days of PCI. Vital signs (blood pressure, heart rate, respiratory rate, and body temperature) and ECGs were taken pre-CMR, 1, 2, and 24 h post-CMR. Any major adverse cardiac event (MACE) or other serious adverse events in the first 24 h after MRI were recorded. There were 258 stents in 211 AMI patients. The mean delay to CMR following PCI was 6.5 ± 4 days, with 62 patients (29 %) receiving CMR within 3 days and 132 patients (63 %) within 1 week. Patients showed no significant vital sign changes following CMR. Ten patients (4.7 %) showed mild, transient ECG changes. Within the 24-h follow-up group, 4 patients (1.9 %) had moderate to severe events, including chest pain (1) and elevated cardiac enzymes (1), resolving in 24 h; heart failure (1) and ischemic stroke (1). There were no deaths. This study demonstrates fewer MACE in AMI patients undergoing 1.5 T CMR within 16 days of stent placement in comparison to post-stent event rate reported in the literature. This study adds to the CMR after stent PCI safety profile suggested by previous studies and is the largest and first study that uses multicenter data to assess stent safety following CMR examination.

How should I treat impaired systolic function and clinical deterioration after surgery of type A aortic dissection?

A 50-year-old male with diagnosis of acute type A aortic dissection underwent surgical repair. Immediately after surgery the patient had transient ECG changes, a raise in serum cardiac markers and physical signs of heart failure. Physical examination, electrocardiography, echocardiography (transthoracic and transoesophageal), coronary angiography, intravascular ultrasound. Type A aortic dissection. Surgical repair, coronary angiography, percutaneous coronary intervention.

Prospective, multicentre validation of a simple, patient-operated electrocardiographic system for the detection of arrhythmias and electrocardiographic changes

Electrocardiographic changes, e.g. arrhythmias causing syncope or palpitations, are often transient and therefore difficult to diagnose. Systematic and symptom-activated ECG recordings can increase diagnostic yield in such patients. We evaluated the diagnostic accuracy of a simple, leadless, patient-operated ECG device compared with a standard 12-lead ECG. We recorded a standard 12-lead surface ECG and a patient-activated ECG in direct succession in 508 consecutive patients enrolled in four centres. All ECGs were analysed by a single, blinded observer. ECGs were analysable in 505 (99.4%) patients (66% male, age 61 +/- 15 years, and body mass index 27 +/- 4). Analysis of the patient-activated ECG adequately detected a normal ECG (sensitivity 91% and specificity 95%), atrial fibrillation (AF) (sensitivity 99% and specificity 96%), and even T-wave abnormalities (sensitivity 90% and specificity 75%). Diagnostic accuracy for atrioventricular nodal block was moderate (sensitivity 79% and specificity 99%). Continuous parameters correlated well: (r(2) = 0.89 for heart rate, 0.83 for PR interval, 0.78 for QRS duration, and 0.89 for QTc). Recordings made by this patient-operated ECG device allow to detect arrhythmias and other ECG changes with high accuracy compared with a standard ECG. It may help to improve accurate diagnosis of transient ECG changes such as paroxysmal AF in palpitations or other unexplained cardiac symptoms.

HAVE INGUINAL INCISION AND LAPARASCOPY FOR UNDESCENDED IMPALPABLE TESTES BECOME OBSOLETE?

INTRODUCTION AND OBJECTIVE: Dorsal penile block is a widely performed procedure for peri-operative local anesthesia prior to minor penile surgery. Multiple studies have demonstrated improved periand post-operative analgesia attributed to the use of dorsal penile block. Due to its potency and long duration of action, bupivacaine is a commonly used agent, though it has been associated with cardiac toxicity when administered in high doses or inadvertently injected intravenously. Pediatric patients may be at particular risk for this complication due to the larger relative doses used in young children. We reviewed the operative records of all outpatient penile surgery cases over an 18 month period to look for signs of cardiac toxicity associated with the penile block. METHODS: After obtaining Instutional Review Board approval, we reviewed the records of all children who underwent penile surgery with a dorsal penile nerve block at Children’s Hospital Boston between January 2007 and June 2008. Dorsal penile blocks were performed in standard fashion prior to the surgical procedure using a 25-gauge needle inserted inferior to the pubic symphysis. The amount of bupivacaine used was determined by patient weight (maximum of 1 mL/kg of 0.25% bupivacaine). RESULTS: Four patients were noted to have evidence of cardiac toxicity with bupivacaine (Table 1). Two patients developed apnea and transient ECG changes (widened QRS with peaked T waves) that resolved spontaneously and were discharged home on the same day. One of these patients had received only a small portion of the total bupivacaine dose when these changes were noted, suggesting inadvertent intravascular injection. Two patients developed profound cardiac effects, one demonstrating ECG evidence of ST depression and decreased LV function on echocardiogram, and the other developed sustained atrial flutter. CONCLUSIONS: Dorsal penile blockade is widely used in pediatric urology for penile surgery. Although useful as a long-acting agent for regional anesthesia, bupivacaine is associated with cardiac toxicity and must be administered cautiously with close cardiac monitoring during surgery.

Early aggressive vs. initially conservative treatment in elderly patients with non-ST-elevation acute coronary syndrome: The Italian Elderly ACS study

Elderly patients represent one-third of all admissions for non-ST-elevation acute coronary syndrome (NSTEACS) in the coronary care units. Despite their high-risk characteristics and worse outcomes, compared with younger patients, the elderly receive less aggressive treatments, also due to less clear evidence regarding the most effective treatment strategy. The Italian Elderly ACS study includes patients older than 74 years of age with NSTEACS in a multicenter randomized clinical trial, comparing an early aggressive and an initially conservative approach. Patients not enrolled due to specific exclusion criteria or any other reason will be enrolled in a Registry. Centers with on-site interventional cathlab and centers without on-site cathlab refering patients to a cathlab within a consolidated percutaneous coronary intervention network. Patients admitted within 48 h of the most recent ischemic symptoms are eligible if they show transient ischemic ECG changes and/or CKMB/Tn elevation. Patients with secondary ischemia, ongoing ischemia, or heart failure, despite optimal therapy or recent coronary intervention, serum creatinine more than 2.5 mg/dl, high bleeding risk, and severe concomitant disease, are excluded from the study. Central randomization to a systematic early aggressive approach (coronary angiography within 48 h of admission and, when indicated, coronary revascularization) or an initially conservative approach (optimal medical therapy with coronary angiography in selected cases with refractory ischemia). Follow-up will include patient visits and ECG at 30 days, 6 months, and 1 year, post randomization. PRIMARY END POINT: The composite of all-cause mortality, myocardial (re)infarction, disabling stroke, and rehospitalization for cardiovascular diseases or severe bleeding within 6 months. Expected primary end point rates of 30% in the conservative arm vs. 20% in the invasive arm. According to these estimates, with two-tailed alpha of 0.05, power will be 80, 85, or 90% with 252, 289, and 338 patients per group, respectively. The goal is to enroll 700 patients from 50 centers.