Transient ST-segment Elevation Research Articles

Comparative Efficacy and Safety of Pulsed Field Ablation Versus Radiofrequency Ablation of Idiopathic LV Arrhythmias

BackgroundComparative efficacy and safety data on radiofrequency ablation (RFA) versus pulsed field ablation (PFA) for common idiopathic left ventricular arrhythmia (LV-VAs) locations are lacking. ObjectivesThis study sough to compare RFA with PFA of common idiopathic LV-VAs locations. MethodsTen swine were randomized to PFA or RFA of LV interventricular septum, papillary muscle, LV summit via distal coronary sinus, and LV epicardium via subxiphoid approach. Ablations were delivered using an investigational dual-energy (RFA/PFA) contact force (CF) and local impedance-sensing catheter. After 1-week survival, animals were euthanized for lesion assessment. ResultsA total of 55 PFA (4 applications/site of 2.0 KV, target CF ≥10 g) and 36 RFA (CF ≥10 g, 25–50 W targeting ≥50 Ω local impedance drop, 60-second duration) were performed. LV interventricular septum: average PFA depth 7.8 mm vs RFA 7.9 mm (P = 0.78) and no adverse events. Papillary muscle: average PFA depth 8.1 mm vs RFA 4.5 mm (P < 0.01). Left ventricular summit: average PFA depth 5.6 mm vs RFA 2.7 mm (P < 0.01). Steam-pop and/or ventricular fibrillation in 4 of 12 RFA vs 0 of 12 PFA (P < 0.01), no ST-segment changes observed. Epicardium: average PFA depth 6.4 mm vs RFA 3.3 mm (P < 0.01). Transient ST-segment elevations/depressions occurred in 4 of 5 swine in the PFA arm vs 0 of 5 in the RFA arm (P < 0.01). Angiography acutely and at 7 days showed normal coronaries in all cases. ConclusionsIn this swine study, compared with RFA, PFA of common idiopathic LV-VAs locations produced deeper lesions with fewer steam pops. However, PFA was associated with higher rates of transient ST-segment elevations and depressions with direct epicardium ablation.

Multielectrode catheter-based pulsed field ablation of persistent and long-standing persistent atrial fibrillation

Abstract Background Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. Purpose We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via the multielectrode FarawaveTM pulsed field ablation (PFA) catheter in patients with persistent AF sustained beyond 6 months (PerAF&amp;gt;6m) and long-standing persistent AF (LSPAF). Methods The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia (AT) regionalization and ablation (Stage 3). Results Seventy-two [age:68±10y, 61.1%males; AF history: 25 (18-45) months] patients with PerAF&amp;gt;6m (52.8%) and LSPAF (47.2%) underwent their first PFA via the FarapulseTM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF termination occurred while ablating the mitral edge of the postero-lateral ridge (40.3%), the inferior left atrium above the proximal coronary sinus (27.4%), the interatrial septum (22.6%), the superior aspect of the postero-lateral ridge (6.5%), the base of the appendage (3.2%). AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The FarawaveTM catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit (Figure 1). Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112±25min and 59±22 min, respectively. Major complications occurred in 2 (2.8%) patients with pre-existing left ventricular systolic dysfunction (EF&amp;lt;35%) who required inotropic therapy due to acute heart failure. Hemodynamics normalized within 24h and both patients were discharged after 2 and 3 additional hospital days. Transient ST-segment elevation was documented in 4 patients after peri-mitral PFA; timely nitrate administration led to ECG normalization within 10 minutes. Single-procedure success rate was 81.8% after 13.3±1.9 months of follow-up; AF-free survival was 93.1% (Figure 2). A subgroup of 36 patients completed a follow-up transthoracic echocardiography study to assess left atrial mechanical contraction changes after ablation. Median A-wave velocity was 30 (IQR: 20-35) cm/s post-ablation and 50 (IQR: 41-70) cm/s after a mean of 7.3±1.8 months post-ablation. Conclusions In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favorable clinical outcomes were observed at one year of follow-up.Entrainment from the PFA Catheter.Kaplan-Meier Analysis.

Spontaneous reperfusion in STEMI: Its mechanisms and possible modulation.

Patients with transient ST-segment elevation myocardial infarction or spontaneous reperfusion, which occurs in approximately 20% of patients with ST-segment elevation myocardial infarction (STEMI), have smaller infarcts and more favorable clinical outcomes than patients without spontaneous reperfusion. Understanding the mechanisms underlying spontaneous reperfusion is therefore important since this may identify possible novel therapeutic targets to improve outcomes in patients with STEMI. In this review, we discuss some of the possible determinants of spontaneous reperfusion including pro-thrombotic profile, endogenous fibrinolytic status, lipoprotein(a) (Lp[a]), inflammatory markers, and neutrophil extracellular traps (NETs). Effective (rapid) endogenous fibrinolysis, as assessed in whole blood in vitro, using a point-of-care technique assessment of global thrombotic status, has been strongly linked to spontaneous reperfusion. Lp(a), which has a high degree of homology to plasminogen, may impair fibrinolysis through competitive inhibition of tissue plasminogen activator-mediated plasminogen activation as well as tissue plasminogen activator-mediated clot lysis and contribute to pathogenic clot properties by decreasing fibrin clot permeation. NETs appear to negatively modulate clot lysis by increasing thrombin fiber diameter and inhibiting plasmin-driven lysis of plasma clots. There are limited data that oral anticoagulation may modulate endogenous fibrinolysis but antiplatelet agents currently appear to have no impact. Phase III trials involving subcutaneous P2Y12 or glycoprotein IIb/IIIa inhibitors, oral factor XIa inhibitors, interleukin-6 inhibitors, and apolipoprotein(a) antisense oligonucleotides in patients with cardiovascular disease are ongoing. Future studies will be needed to determine the impact of these novel antithrombotic, anti-inflammatory, and lipid-lowering therapies on endogenous fibrinolysis and spontaneous reperfusion.

Guanfacine poisoning resulting in transient ST-segment elevation: a case report

BackgroundGuanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of guanfacine poisoning have also risen.Case presentationA 15-year-old male (height: 170 cm, weight: 48 kg), who was taking 2 mg/day of guanfacine for ADHD, was brought to our emergency department after ingesting 40 tablets of guanfacine due to poor exam results. He presented with impaired consciousness and sinus bradycardia on an electrocardiogram (ECG), leading to diagnosis of guanfacine poisoning. Gastric lavage (5 L) was performed, and activated charcoal was administered. Although his consciousness gradually recovered, he developed ST-segment elevation on the ECG. Despite the absence of chest pain and elevated myocardial enzymes, coronary artery stenosis was not observed on coronary artery computed tomography. As his blood guanfacine level decreased, his ECG returned to normal.ConclusionsThis case highlights the need for careful monitoring of guanfacine poisoning patients due to the potential for various cardiovascular events.

Vasospastic angina: a review on diagnostic approach and management.

Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.

Exploring the ECG "6+2" Phenomenon in Coronary Artery Disease and Coronary Artery Spasm: A Case Report Analysis and Treatment Implications.

BACKGROUND Although coronary artery disease and coronary artery spasm (CAS) can lead to acute myocardial infarction, there are clear differences in treatment between coronary heart disease and CAS, and the therapeutic schedule should not be confused. Furthermore, electrocardiogram (ECG) "6+2" phenomenon is recommend as a specific ECG indicator for lesions in the left main coronary artery or multiple vessels. Currently, no reports of this phenomenon in CAS exist. CASE REPORT A 72-year-old man had history of recurrent chest pain for over 6 years, with episodes lasting about 10 min and resolving with rest. He experienced symptom recurrence and exacerbation due to substance abuse. He was admitted to our Emergency Department for chest pain at rest. His emergency ECG revealed a 6+2 phenomenon, accompanied by troponin levels exceeding 18 times the reference value. Promptly, we conducted coronary angiography, with unexpected normal findings. Following thorough assessment, we postulated the patient could have CAS. Subsequent to medical team intervention, the patient's ECG normalized, leading to his discharge upon condition stabilization. CONCLUSIONS We report a case of CAS in a patient with ECG 6+2 phenomenon, without significant coronary artery stenosis. This differs from transient ST-segment elevation on ECG, a well-recognized hallmark of CAS; however, such a presentation has not been documented before. Additionally, treatment strategies for myocardial ischemic conditions stemming from coronary atherosclerosis diverge from those employed for CAS. Therefore, clinicians should advocate for coronary angiography whenever feasible. This approach serves to elucidate the underlying disease etiology and facilitates the administration of precision-targeted interventions for patients.

Serial ECG in suspected ACS

In the right clinical setting, ST segment elevation (STE) on electrocardiogram (ECG) is most concerning for acute injury due to transmural myocardial ischemia. This frequently points to significant epicardial coronary artery disease, mandating emergent cardiac intervention. In rare cases, cardiac metastases may cause transient STE. We present a case of a 28-year-old male patient with metastatic osteosarcoma with STE in three different ECG territories over ten months. Several transient, dynamic patterns of STE were noted: anteroseptal leads concerning for acute injury with reciprocal ST depressions in inferior leads, lateral leads, inferior leads with reciprocal ST depression in lateral leads, followed by STE again in lateral leads. Given the patient's young age, absence of cardiac history or symptoms, personal preference, bleeding risk, and cancer prognosis, cardiac catheterization was never pursued. We present this case to remind providers to include metastatic cancer in the differential diagnosis of STE on ECG, and that these changes can be dynamic.

A novel coronary artery healing pattern suggesting the axial progression of coronary plaques.

A 54-year-old man, current smoker, without previous cardiovascular history was admitted for an inferior transient ST-segment elevation myocardial infarction. An emergent coronary angiogram revealed an unstable, non-obstructive, thrombus-rich plaque in the mid segment of the right coronary artery (RCA) (Panel A). Optical coherence tomography (OCT) imaging disclosed a healthy vessel wall in the proximal RCA, along with a long, heterogenous plaque at the culprit lesion, where three distinct phenotypes were clearly recognized (Panels a-d, circle denotes wire artifact). First, the very proximal segment of the plaque showed a layered morphology with multiple high and low signal-rich strata, suggestive of an old healing process (Panels a and b, arrowheads). In the middle part of the plaque, a superficial, laden, organized circumferential thrombus was observed, probably reflecting an early healing stage (Panel c, asterisks). Finally, the most distal part of the lesion showed a plaque rupture with a large, ‘red’ fibrin-rich, fresh protruding thrombus (Panel d, star). Percutaneous coronary intervention with a new-generation stent obtained excellent results.

Pregnancy-Associated Spontaneous Coronary Artery Dissection: A Case Report and the Lessons from Practice

Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is one of the fatal conditions that most commonly causes pregnancy-associated myocardial infarction. We herein report a case of P-SCAD in a 26-year-old multigravida woman, who complained of angina postpartum with raised cardiac biomarkers and transient ST-segment elevation on electrocardiograms. We emphasize the importance of a high degree of suspicion in the diagnosis of P-SCAD, together with the common presentation, the management approach, and its psychological impacts on the patients.

Three, dynamic variants of ST segment elevations in a patient with osteosarcoma and cardiac metastasis

In the right clinical setting, ST segment elevation (STE) on electrocardiogram (ECG) is most concerning for acute injury due to transmural myocardial ischemia. This frequently points to significant epicardial coronary artery disease, mandating emergent cardiac intervention. In rare cases, cardiac metastases may cause transient STE. We present a case of a 28-year-old male patient with metastatic osteosarcoma with STE in three different ECG territories over ten months. Several transient, dynamic patterns of STE were noted: anteroseptal leads concerning for acute injury with reciprocal ST depressions in inferior leads, lateral leads, inferior leads with reciprocal ST depression in lateral leads, followed by STE again in lateral leads. Given the patient's young age, absence of cardiac history or symptoms, personal preference, bleeding risk, and cancer prognosis, cardiac catheterization was never pursued. We present this case to remind providers to include metastatic cancer in the differential diagnosis of STE on ECG, and that these changes can be dynamic.

Extremely dangerous hypopituitarism related long QT syndrome and transient ST-segment elevation: A case report

Acquired long QT syndrome caused by hypopituitarism and transient ST-segment elevation has not been reported in cardiac arrest patients. We report a case of extremely dangerous acquired long QT syndrome and transient ST-segment elevation. A 44-year-old Chinese woman with renal failure experienced sudden cardiac arrest in the haemodialysis room. Subsequent electrocardiogram showed QT prolongation and transient ST-segment elevation. This patient's medical history, subsequent laboratory results and pituitary magnetic resonance imaging suggested hypopituitarism. Transient ST-segment elevation on the electrocardiogram was considered to be caused by repeated direct current shocks. The patient was diagnosed with acquired long QT syndrome and was not taking any antiarrhythmic drugs. Her corrected QT interval normalized after hormone replacement therapy. This case highlights the importance of the awareness of hypopituitarism; early identification and intervention can prevent the occurrence of this life-threatening arrhythmia. ST-segment elevation is not always due to acute myocardial infarction, and a variety of other causes, especially electrical cardioversion, should be considered.

Abstract 9482: Coronary Spasm in a Patient With Argininosuccinic Aciduria

Case presentation: A 39-year-old male patient was referred for the treatment of hypertension. The patient had been treated for argininosuccinic aciduria (ASA) since eight months of age. Therapeutic drugs including, L-arginine, sodium phenylbutyrate and antiepileptic drugs had been administered. A detailed medical history taking revealed that the patient sometimes complained of chest discomfort under psychological stress. A 12-lead electrocardiogram showed abnormal q waves in lead III and aVF. Transthoracic echocardiography showed hypokinesis of left ventricular posterior wall. Endothelial function was quantified with brachial artery flow-mediated dilatation (FMD). The patient’s FMD value was 2.4% (normal cut off value 7.0%). Coronary computed tomography angiography showed no significant coronary stenosis. Cardiac magnetic resonance revealed transmural late gadolinium enhancement in the mid-ventricular level of the left ventricular posterior wall. The patient was suspected to have prior myocardial infarction. The patient was started on amlodipine and irbesartan, however, he continued to complain of chest discomfort at rest. Cardiac catheterization was performed to make a definitive diagnosis. The acetylcholine spasm provocation test revealed diffuse left and right coronary vasospasm. Transient ST-segment elevation with chest discomfort was observed. The patient was diagnosed as having coronary spastic angina. Chest discomfort was disappeared after additional administration of isosorbide mononitrate. Discussion: ASA is a genetic disorder of the urea cycle, caused by deficiency of argininosuccinate lyase (ASL). Specific laboratory findings are hyperammonemia, argininosuccinic acidemia and low plasma arginine levels. ASL is required to utilize extracellular arginine for NOS-dependent NO synthesis in endothelial cell. Reduction of ASL enzymatic activity leads to decline in NO production even if arginine is supplemented. Efficacy of NO supplementation for treatment of long-term complications in ASA patients has been reported. The precise mechanisms of coronary spasm remain to be elucidated. Our case report might support the significance of endothelial function in the pathogenesis of coronary spasm.

A Transient Inferolateral ST-Segment Elevation on the Electrocardiogram Due to an Iatrogenic Left-Sided Pneumothorax After an Urgent Tracheostomy in a Patient with Metastatic Hypopharynx Cancer.

The presence of ST-segment elevation on the electrocardiogram alerts physicians in patients with chest pain. Emergency coronary angiography is usually performed in these patients. However, there are many conditions that cause ST-segment elevation on the electrocardiogram, such as pericarditis, hyperkalemia, Brugada syndrome, hypothermia, and early repolarization. Pneumothorax is a rare complication of tracheostomy and its symptoms are sudden chest pain and dyspnea. Also, it has been known that pneumothorax may cause ST-segment changes on the electrocardiogram. We presented a transient inferolateral ST-segment elevation on the electrocardiogram due to an iatrogenic left-sided pneumothorax after an urgent tracheostomy in a patient with metastatic hypopharynx cancer and normal coronary angiogram.

Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation.

ObjectivesWe examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation.BackgroundThe incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results.MethodsWe identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation.ResultsAmong 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% (n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST‐segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST‐segment elevation (n = 20, 4.0%), and others.ConclusionsPH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.

P76 A ‘PARACHUTE EFFECT’ MOCKINGLY SEALING A SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract We present a case of a 38–year–old female admitted for Non ST–Elevation Myocardial Infarction. 15 days before the patient experienced an inferior ST–Elevation Myocardial Infarction and underwent primary Percutaneous Coronary Intervention with 2 drug–eluting stent (DES) in the mid–Right Coronary Artery (RCA). At presentation ECG and echocardiogram was negative for myocardial ischemia. For the typical chest pain, an urgent coronary angiography (CA) was performed. The previously stented RCA did not show any significant stenosis but a posterolateral branch appeared occluded at the ostium, with a retrograde flow from the left anterior descending artery. However, suspecting a dissection distally to the stents previously implanted, an Optical Coherence Tomography (OCT) was performed after 2 guidewires placement. The presence of two guidewires and the contrast medium pushing from inside–out caused a ‘sealing effect’ of the intima to the media, hence hiding the presence of dissection. The day after, a new chest pain episode associated with transient ST–segment elevation in the inferior leads warranted a new CA. Another OCT of the RCA was performed, this time using a single guidewire: a clear imaging confirmed the spontaneous coronary artery dissection (SCAD) presence. To have a better understanding of the vessel morphology an Intravascular Ultrasound (IVUS) analysis was carried out and even this imaging modality confirmed the presence of a true and false lumen. The interventional cardiologist decided to treat the dissection with two overlapping drug–eluting stents and a TIMI–3 flow was restored, with the complete resolution of the symptoms The patient was discharged after 5 days with dual antiplatelet therapy and statin. At the 24 month follow–up she was still asymptomatic. SCAD expertise is of utmost importance in recognizing this entity and, perhaps, this is the reason why it is still underdiagnosed, also in view of the frequent absence of hallmarks at CA. This is a case in which a complete imaging evaluation (CA + OCT + IVUS) has discovered and documented a SCAD after a recent stent implantation and in which the exclusive acquisition of angiograms by inexperienced operators could have missed the dissection.

P312 A CASE OF TAKOTSUBO CARDIOMYOPATHY IN SARS–COV–2 INFECTION

Cardiovascular complications are a frequent occurrence in Sars–CoV–2 infection. Takotsubo cardiomyopathy is a possible cause of transient ST segment elevation (1–3% of total cases) and is characterized by a reversible left ventricular dysfunction with coronary arteries free from critical stenosis. The predominant echocardiographic pattern is an akinesia of the mid–apical myocardial segments with preserved kinetics of the basal segments. The incidence of Takotsubo cardiomyopathy showed a marked increase during the COVID–19 pandemic. Three factors mainly contribute to the onset of cardiomyopathy in patients with COVID–19: cytokine storm, adrenergic hyperactivation and microvascular dysfunction. A 79–year–old woman was hospitalized in the Pneumology department of our hospital for bilateral interstitial pneumonia Sars–CoV–2 related. In remote medical history: in 2010 diagnosis of breast cancer with negative follow–up for disease recovery, arterial hypertension, hypercholesterolemia and syndrome of reduced mobility as a result of a previous ischemic stroke. Non–invasive mechanical ventilation with c–PAP was started and, for the detection of anterolateral electrocardiographic anomalies (diffuse symmetrical negative T waves) and an increase in myocardionecrosis markers, echocardiographic evaluation was performed, which revealed an akinesia of the mid–apical segments of the left ventricle with preserved kinetics of the basal segments and severely depressed global systolic function (ejection fraction: 30%). BNP (18.100 pg /mL), interleukin–6 (339 pg /mL) and CRP (136 mg /L) were elevated on blood chemistry tests. In the suspicion of Takotsubo cardiomyopathy (InterTAK Score: 67, probability: 79.8%), cardioprotective therapy with ACE inhibitor, beta–blocker, diuretics, low molecular weight heparin, double antiaggregation and statin was started, deferring coronary angiography to improved clinical conditions. In the following days, due to the respiratory and haemodynamic worsening, the patient was transferred to an intensive setting, where she was intubated and treated with levosimendan and noradrenaline. Serial echocardiograms showed a progressive improvement of the global systolic function (ejection fraction at the last checkup: 55%), with complete regression of the kinetic anomalies, confirming of the diagnostic hypothesis of stress cardiomyopathy. For a pulmonary mycotic superinfection, complicated by iatrogenic pneumothorax, in the following days the patient died.

Analysis and results of early revascularization in non-ST segment elevation acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Virgen Macarena Introduction The time to diagnostic coronary angiography in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) is considered one of the main prognostic factors in patients at higher risk. Purpose Our aim is to know whether early coronary angiography modifies the prognosis of high-risk patients with NSTEACS and to compare it with performing this procedure later. Methods We include patients admitted to the coronary unit of a 3rd level hospital from January-2015 to December-2021 due to NSTEACS. We plan to examine whether the clinical characteristics of patients in whom early coronary angiography (ECA) is performed, the one performed in the first 24 hours from the onset of symptoms, differ from those in whom it is performed later. Likewise, we analyze the clinical results obtained according to the strategy. Results 811 patients were included (73.4% men and 26.6% women), with an average age of 65, in which 229 (28.2%) of them underwent early coronary angiography. Initially, we found more smokers (44.5% vs 32.8, p = 0.006), a higher frequency of risk electrocardiographic changes (ST decrease&amp;gt; 2 mm in 2 contiguous leads, transient ST segment elevation, left main stem pattern) (p = 0.000), greater need for inotropic drugs (14.5% vs 9.6%, p = 0.045), worse Killip-Kimball (KK) during hospital stay (p = 0.002), as well as higher frequency of cardiogenic shock (p = 0.005) among the patients in whom ECA was performed. Although in-hospital mortality was higher in patients who underwent ECA, no statistically significant difference was found. No differences were obtained in the other cardiovascular risk factors, previous history of acute myocardial infarction, heart failure, stroke, coronary revascularization, initial KK presentation, or post-catheterization LVEF. Conclusions In our study, we observed that in patients admitted for NSTEACS, we performed ECA more frequently in patients with a worse prognosis (pathological alterations in the initial ECG, greater frequency of support with inotropics and worse KK during hospital admission), without observing significant differences in in-hospital mortality or in post-catheterization LVEF. The results suggest that ECA improves the prognosis in the group with the worst clinical profile.

Akutni koronarni sindrom bez perzistentne elevacije ST segmenta - šta su NAM donele nove preporuke

Acute myocardial infarction without persistent ST-segment elevation is a serious medical problem that significantly increases cardiovascular mortality and morbidity. Therefore, timely accurate diagnosis is crucial for adequate treatment of these patients, better survival and improved quality of life. It is characterized by a clinical picture of acute chest discomfort that may occur in the form of typical anginal problems or as the equivalent of acute chest pain. Changes in the electrocardiogram are varied, from transient ST-segment elevation, persistent or transient ST-segment depression, T-wave inversion, flattened T-wave, or pseudonormalization of the T-wave, to normal electrocardiographic recording. The latest guidelines of the European Society of Cardiology advise determining the value of cardio-specific enzymes from the patient's blood, namely high-sensitivity cardiac troponin T or I immediately upon admission to the health institution and repeated one hour after admission (0h / 1h algorithm). Echocardiographic examination is recommended in all patients as a routine procedure before admission or during hospitalization. Coronary CT angiography for the anatomical evaluation of coronary heart disease is important in patients with a low to moderate probability of an acute coronary event. Drug treatment in these patients involves the use of dual antiplatelet therapy to determine the ischemic risk of the patient as well as the risk of bleeding. Pre-treatment with the use of primarily P2Y12 receptor inhibitors is not recommended in routine clinical practice. In patients who have undergone revascularization and stent implantation, dual antiplatelet therapy is recommended for 12 months, except in cases where there are contraindications or increased hemorrhagic risk. Patients who require long-term use of oral anticoagulant therapy after a short period of triple antiplatelet therapy up to 1 week after the acute event, continue dual antiplatelet therapy, using new anticoagulants at the recommended dose to prevent stroke and one oral antiplatelet drug. Invasive coronary angiography can be performed according to the patient's risk immediately after admission to a health institution (within 2 hours) in very high-risk patients or as an early treatment strategy, within 24 hours of admission in high-risk patients. To perform an invasive intervention, a radial approach is advised, as well as the implantation of drug-coated stents. In patients in whom it is not possible to perform myocardial revascularization by percutaneous coronary intervention, revascularization with coronary artery bypass grafts is recommended. In the long-term follow-up of these patients, after an acute coronary event, it is advisable to change life habits with pharmacological treatment, which reduces mortality and improves the quality of life.

474 A case of Takotsubo cardiomyopathy in SARS-CoV-2 infection

Cardiovascular complications are a frequent occurrence in SARS-CoV-2 infection. Takotsubo cardiomyopathy (also known as stress cardiomyopathy) is a possible cause of transient ST segment elevation (1–3% of total cases) and is characterized by a reversible left ventricular dysfunction with coronary arteries free from critical stenosis. The predominant echocardiographic pattern of this cardiomyopathy is an akinesia of the mid-apical myocardial segments (‘apical ballooning’), with preserved kinetics of the basal segments. The incidence of Takotsubo cardiomyopathy showed a marked increase during the COVID-19 pandemic. The data showed that three factors mainly contribute to the onset of cardiomyopathy in patients with COVID-19: cytokine storm, adrenergic hyperactivation and microvascular dysfunction. A 79-year-old woman was hospitalized in the Pneumology department of our hospital for acute hypoxemic respiratory failure due to bilateral interstitial pneumonia SARS-CoV-2 related. In remote medical history: in 2010 diagnosis of breast cancer, treated with quadrantectomy, adjuvant chemo- and radiotherapy, with negative follow-up for disease recovery, systemic arterial hypertension, hypercholesterolaemia and from 2016 syndrome of reduced mobility as a result of a previous ischaemic stroke. Non-invasive mechanical ventilation with c-PAP was started in the ward and, for the detection of anterolateral electrocardiographic anomalies (diffuse symmetrical negative T waves. Figure) and an increase in myocardionecrosis markers (troponin I peak: 5.4 ng/ml), in the absence of chest pain or equivalent, echocardiographic evaluation was performed, which revealed an akinesia of the mid-apical segments of the left ventricle with preserved kinetics of the basal segments and severely depressed global systolic function (ejection fraction: 30%). BNP (18.100 pg/ml), interleukin-6 (339 pg/ml), and CRP (136 mg/l) were elevated on blood chemistry tests. In the suspicion of Takotsubo cardiomyopathy (InterTAK Score: 67, probability: 79.8%), cardioprotective therapy with ACE inhibitor, beta-blocker, diuretics, low molecular weight heparin, double antiaggregation, and statin was started, deferring coronary angiography to improve clinical conditions. In the following days, due to the respiratory and haemodynamic worsening, the patient was transferred to an intensive setting, where she was intubated and treated with levosimendan and noradrenaline. In the intensive care unit, serial echocardiograms (over 30 days) showed a progressive improvement, up to normalization, of the global systolic function (ejection fraction at the last checkup: 55%), with complete regression of the kinetic anomalies, confirming the diagnostic hypothesis of stress cardiomyopathy. For a pulmonary mycotic superinfection (positive bronchoaspirate for Candida albicans and Candida krusei), complicated by iatrogenic pneumothorax, in the following days the patient died.

735 Myocardial ischaemia: not just about obstructive coronary arteries

Abstract Aims A vast proportion of subjects with anginal symptoms undergoing invasive coronary angiography (ICA) suffer from ischaemia with non-obstructive coronary arteries (INOCA). This condition has many contributing mechanisms, including epicardial vasospasm caused by vasomotor disorder, which is characterized by ST-segment changes during the self-limiting chest pain episodes. The diagnosis of this condition is challenging. Although different provocative test could performed during ICA (e.g. intracoronary administration of acetylcholine or ergonovine), their use is uncommon. Methods and results Clinical case A 39-years old man, smoker, hypertensive and dyslipidemic, presented to the emergency department after a Holter dynamic ECG detecting transient ST-segment elevation in the D1 lead. He had recurrent rest angina despite medical therapy and a prior ICA performed one year before the current presentation documented a mild stenosis of the posterior descending artery, a moderate stenosis of a duplicated left anterior descending artery, and a chronic total occlusion of the left obtuse marginal, which was not revascularized because of the absence of inducible ischaemia on single-photon emission computed tomography. The new ICA performed at presentation revealed a significant progression of coronary artery disease at the level of the posterior descending artery, which was treated through percutaneous coronary intervention, while the other vessels were unchanged. During the procedure, the patient experienced severe angina with ST-segment elevation and angiographically evident vasospasm of left coronary artery. The instantaneous wave-free ratio measurement performed on the medial branch of the duplicated left anterior descending artery was 0.86, which quickly resolved after administration of nitrate (0.93). Calcium channel blockers were added to medical therapy and the patient was discharged asymptomatic. Conclusions Vasospastic angina can cause ischaemia both in the presence and in the absence of visible atherosclerosis. This cause of INOCA often remains undetected but it is relatively frequent especially among younger patients who continue experiencing angina leading to repeated hospitalizations. The chance of this condition should be always taken into account, and the correct diagnosis should be obtained not incidentally like in the present case, but following standardized intracoronary test in a proper setting.