Transient ST-segment Elevation Research Articles

COMPLETE HEART BLOCK AND VENTRICULAR TACHYCARDIA: THE HIDDEN LINK

Vasospastic angina (VSA) is characterized by episodes of angina at rest with transient ST-segment elevations responding quickly to short-acting nitrates. VSA has been shown to be the culprit in stable angina, acute coronary syndrome, arrhythmias, syncope or sudden cardiac death, and yet it is still

In Hospital Complications of Atrial Septal Defect Device Closure at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Atrial deptal defect device closure has become the preferred method in the treatment of atrial septal defect. We aim to study the in-hospital complications of atrial septal defect device closure procedure. It was a single center, retrospective study conducted from Febuary 2016 to January 2019. Cardiac catheterization laboratory records of all consecutive patients who underwent atrial septal defect device closure was included and the in-hospital complications were been retrospectively reviewed. During the study period, a total of 566 patients were attempted for device closure. In 557 (98.4%) of cases device was implanted. Among the 557 patient in which device was implanted 401(71.9%) were female. Age ranged from 5 years to 72 years with the mean of 30.9 years. Transient ST segment elevation 15 (2.6 %)was the commonest complication followed by pericardial tamponade 4 (0.7%), and cardiac arrhythmias 3 (0.5%). Atrial deptal defect device closure can be done safely with a high success rate and a low complication rate.

Significance of ST-Segment Elevation Following Transseptal Catheterization

Objectives: The aim of this study was to evaluate the prevalence and course of ST-segment elevation following transseptal catheterization in patients referred for left-sided accessory pathway ablation. Background: Transient ST-segment elevation during transseptal catheterization has been reported previously. Methods: Patients undergoing transseptal catheterization for left-sided accessory pathwayablation were enrolled in this cohort study. During and following a transseptalpuncture, ST-segments of all 12 leads were constantly monitored. Results: A total of 140 patients were included in the study. Eleven patients (7.8%) experienced ST-segment elevation following transseptal catheterization. Mean time (from a transseptal puncture to ST elevation) was 38 seconds. The mean duration of ST-elevation was 109 seconds. All patients with ST-elevation had an elevation in lead III, 2 patients had ST elevation only inlead III, and one had ST elevation in III and aVF. Anterior lead ST elevation was not detected. Lead III seems to be the most sensitive lead for ST-elevation monitoring. Conclusion: Early and transient ST-segment elevation can occur in the inferior leads following transseptal catheterization. They are almost always self-limiting with conservative managements and typically resolve rapidly; however, close and continuous observation should be made during this situation and the procedure may be detained until ST-segment elevation fades away. Lead III seems to be the most sensitive lead for ST elevation monitoring. ST elevation in anterior leads, persistent ST elevation lasting for more than 3 minutes, and ST elevation at the end of the cardiac ablation procedure warrants immediate evaluation by diagnostic coronary angiography.

1-Year Outcomes of Delayed Versus Immediate Intervention in Patients With Transient ST-Segment Elevation Myocardial Infarction

ObjectivesThe aim of the present study was to determine the effect of a delayed versus an immediate invasive approach on final infarct size and clinical outcome up to 1 year. BackgroundUp to 24% of patients with acute coronary syndromes present with ST-segment elevation myocardial infarction (STEMI) but show complete resolution of ST-segment elevation and symptoms before revascularization. Current guidelines do not clearly state whether these patients with transient STEMI should be treated with a STEMI-like or non–ST-segment elevation acute coronary syndrome–like intervention strategy. MethodsIn this multicenter trial, 142 patients with transient STEMI were randomized 1:1 to either delayed or immediate coronary intervention. Cardiac magnetic resonance imaging was performed at 4 days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at 4 and 12 months. ResultsIn the delayed (22.7 h) and the immediate (0.4 h) invasive groups, final infarct size as a percentage of the left ventricle was very small (0.4% [interquartile range: 0.0% to 2.5%] vs. 0.4% [interquartile range: 0.0% to 3.5%]; p = 0.79), and left ventricular function was good (mean ejection fraction 59.3 ± 6.5% vs. 59.9 ± 5.4%; p = 0.63). In addition, the overall occurrence of major adverse cardiac events, consisting of death, recurrent infarction, and target lesion revascularization, up to 1 year was low and not different between both groups (5.7% vs. 4.4%, respectively; p = 1.00). ConclusionsAt follow-up, patients with transient STEMI have limited infarction and well-preserved myocardial function in general, and delayed or immediate revascularization has no effect on functional outcome and clinical events up to 1 year.

Association between Ischemic Electrocardiographic Changes during Acetylcholine Provocation Test and Long-Term Clinical Outcomes in Patients with Vasospastic Angina

Objectives Intracoronary injection of acetylcholine (Ach) has been shown to induce significant coronary artery spasm (CAS) in patients with vasospastic angina. Clinical significance and angiographic characteristics of patients with ischemic electrocardiogram (ECG) changes during the Ach provocation test are not clarified yet. Methods A total 4,418 consecutive patients underwent coronary angiography with Ach provocation tests from 2004 to 2012 were enrolled. Ischemic ECG changes were defined as transient ST-segment depression or elevation ( > 1 mm) and T inversion with/without chest pain. Finally, a total 2,293 patients (28.5% of total subjects) proven CAS were enrolled for this study. Results A total 119 patients (5.2%) showed ECG changes during Ach provocation tests. The baseline clinical and procedural characteristics are well balanced between the two groups. Ischemic ECG change group showed more frequent chest pain, higher incidence of baseline spasm, severe vasospasm, multi-vessel involvement, and more diffuse spasm ( > 30 mm) than those without ischemic ECG changes. At 5 years, the incidences of death, major adverse cardiac events (MACE) and major adverse cardiac and cerebral events (MACCE) were higher in the ischemic ECG change group despite of optimal medical therapy. Conclusions The patients with ischemic ECG changes during Ach provocation tests were associated with more frequent chest pain, baseline spasm, diffuse, severe and multi-vessel spasm than patients without ischemic ECG changes. At 5-years, the incidences of death, MACE and MACCE were higher in the ischemic ECG change group, suggesting more intensive medical therapy with close clinical follow up will be required.

ST-resolution and spontaneous reperfusion in patients with transient ST-segment elevation myocardial infarction.

ST-resolution and spontaneous reperfusion in patients with transient ST-segment elevation myocardial infarction.

Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial.

Patients with acute coronary syndrome who present initially with ST-elevation on the electrocardiogram but, subsequently, show complete normalization of the ST-segment and relief of symptoms before reperfusion therapy are referred to as transient ST-segment elevation myocardial infarction (STEMI) and pose a therapeutic challenge. It is unclear what the optimal timing of revascularization is for these patients and whether they should be treated with a STEMI-like or a non-ST-segment elevation myocardial infarction (NSTEMI)-like invasive approach. The aim of the study is to determine the effect of an immediate vs. a delayed invasive strategy on infarct size measured by cardiac magnetic resonance imaging (CMR). In a randomized clinical trial, 142 patients with transient STEMI with symptoms of any duration were randomized to an immediate (STEMI-like) [0.3 h; interquartile range (IQR) 0.2-0.7 h] or a delayed (NSTEMI-like) invasive strategy (22.7 h; IQR 18.2-27.3 h). Infarct size as percentage of the left ventricular myocardial mass measured by CMR at day four was generally small and not different between the immediate and the delayed invasive group (1.3%; IQR 0.0-3.5% vs. 1.5% IQR 0.0-4.1%, P = 0.48). By intention to treat, there was no difference in major adverse cardiac events (MACE), defined as death, reinfarction, or target vessel revascularization at 30 days (2.9% vs. 2.8%, P = 1.00). However, four additional patients (5.6%) in the delayed invasive strategy required urgent intervention due to signs and symptoms of reinfarction while awaiting angiography. Overall, infarct size in transient STEMI is small and is not influenced by an immediate or delayed invasive strategy. In addition, short-term MACE was low and not different between the treatment groups.

The association of chronic air pollutants with coronary artery spasm, vasospastic angina, and endothelial dysfunction.

We evaluated the effect of chronic exposure to air pollutants (APs) on coronary endothelial function and significant coronary artery spasm (CAS) as assessed by intracoronary acetylcholine (ACH) provocation test. A total of 6430 patients with typical or atypical chest pain who underwent intracoronary ACH provocation test were enrolled. We obtained data on APs from the Korean National Institute of Environmental Research (http://www.nier.go.kr/). APs are largely divided into two types: particulate matter with aerodynamic diameter of less than or equal to 10 µm in size (PM10) and gaseous pollutants such as nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone. The primary endpoint is the incidence of significant CAS and its associated parameters during ACH provocation test. The incidence of CAS was positively correlated with an exposure duration of PM10, whereas nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone were shown to be unrelated to CAS. During the ACH provocation test, as PM10 increased, the frequency of CAS was increased, and the incidence of transient ST-segment elevation was also increased. There was a trend toward higher incidence of spontaneous spasm as PM10 increased. The mean exposure level of PM10 was 51.3±25.4 µg/m. The CAS risk increased by 4% when the level of PM10 increased by 20 µg/m by an adjusted Cox regression analysis. CAS incidence is closely related to exposure to PMs but not to gaseous pollutants. Particularly, higher exposure concentrations and longer exposure duration of PM10 increased the risk of CAS. These important findings provide a plausible mechanism that links air pollution to vasospastic angina and provide new insights into environmental factors.

Recognising the de Winter ECG pattern – A time critical electrocardiographic diagnosis in the Emergency Department

The de Winter ECG pattern is associated with proximal left anterior descending artery occlusion, being a significant risk factor for anterior wall ST elevation myocardial infarction. We present a case of a patient who attended our Emergency Department with chest pain and a prehospital ECG demonstrating transient infero-lateral lead ST segment elevation, which changed to the de Winter ECG pattern in our Emergency Department. She subsequently underwent primary PCI of the culprit lesion within the left anterior descending artery (LAD). Recognition of de Winter ECG pattern in the Emergency Department results in a time critical diagnosis for acute coronary occlusion and should be followed by emergency coronary revascularization.

A Reversible Cause of Complete Heart Block Causing Chest Pain and Syncope

Vasospastic angina (VSA), also known as variant or Prinzmetal’s angina, is a relatively uncommon cause of retrosternal chest pain with transient ST segment elevation, mainly due to vasospasm in the coronary arteries. This is a case of 37-year-old female who presented with chest pain and syncope. Her initial workup, including echocardiogram, was negative. Subsequently, she was sent home with an event monitor. During the next two weeks, she continued to have recurrent episodes of similar chest pains and presented to her cardiology appointment with a heart rate of 45 bpm and blood pressure of 100/60 mmHg and was taken to hospital emergency department. Event monitor review showed intermittent complete heart block. In the hospital, the electrocardiogram (EKG) showed complete heart block and inferior lead ST elevations concomitantly with the chest pains. Although suspicious for vasospastic angina, coronary artery disease had to be ruled out for which patient underwent coronary angiography without evidence of significant obstructive disease. Immediately thereafter, the patient underwent permanent pacemaker placement without recurrence of syncopal episodes. This case signifies complete heart block as one of the rare complications of vasospastic angina which otherwise can also lead to symptoms such as dizziness, shortness of breath, syncope, cardiac arrest, and sudden cardiac death.

Early Collapse of a Magnesium Bioresorbable Scaffold

A 56-year-old man with diabetes mellitus presented with inferior transient ST-segment elevation acute coronary syndrome. Coronary angiography showed a severe thrombotic lesion at the right coronary artery and a severe lesion at the left anterior descending artery. The lesion of the right coronary

Myocarditis Mimicking Acute Coronary Syndrome Secondary to Eosinophilia

Background: Eosinophilic myocarditis is a rare and under-recognized subtype of myocarditis. The signs and symptoms are non-specific, most often mimicking other diseases, leading to a late, and sometimes, incorrect diagnosis. This disease can be self-limiting, however, if not detected early, can progress to a fatal outcome. Case Presentation: A 33-year-old female, known asthmatic was admitted due to recurrent chest pain, dyspnea and abdominal pain. ECGs showed transient ST segment elevation. The cardiac enzymes, WBC and eosinophil counts were significantly elevated. Coronary angiogram was normal. 2D echocardiogram showed concentric hypertrophy with segmental hypokinesia, normal LV EF, severe mitral regurgitation, with signs of diastolic dysfunction. Cardiac MRI showed mild diffuse myocardi10.21767/2471-8505.100060al edema and a patchy subendocardial enhancement. After initiation of steroid therapy, there was dramatic improvement in the symptoms and peripheral eosinophilia. Repeat 2D echocardiogram after several months was normal. Early discontinuation of steroids resulted in recurrence of cardiac events. Conclusion: Eosinophilic myocarditis, though uncommon, should be considered as a differential diagnosis in patients with acute coronary syndrome-like symptoms, history of asthma and allergies, a normal coronary angiogram, with or without peripheral eosinophilia. An echocardiogram and a cardiac MRI can support the diagnosis, however, endomyocardial biopsy remains to be the gold standard. Prompt recognition and immediate steroid therapy are important keys in managing this rare disease.

ST-Segment Elevation Disguised as Cholecystitis

Introduction: Chest pain accounts for around 6 million annual visits to emergency department (ED) in United States.Chest pain in these cases might be secondary to other cardiac conditions other than acute coronary events or extra cardiac causes. We present a rare case of ST-Segment elevation disguised as Cholecystitis. Case Report: A 43 year old female with a history of hypertension, gastroesophageal reflux, and obesity presented to the ED with severe sharp chest pain and abdominal pain which started one hour prior to presentation. On physical exam her BP 200/100 mm Hg, HR 96 bpm, RR 22 breaths and was temperature 100.5 F. She was alert but looked pale and diaphoretic. On cardiac exam there were no murmurs. Abdominal exam revealed positive murphy sign and right upper quadrant tenderness. EKG showed ST segment elevation in leads II, III, AVF with reciprocal changes in the lateral leads (Image 1). Her troponins were minimally elevated at 0.66. STEMI protocol was initiated and she was taken for urgent cardiac catheterization in keeping with the door to balloon time of 90 minutes. Cardiac catheterization revealed normal coronaries. Other lab work done showed WBC count of 14,000, liver enzymes, amylase and lipase were within normal limits. CT scan of abdomen was done given right upper quadrant pain which revealed emphysematous cholecystitis with no gall stones (Image 2). Surgery was consulted and she underwent a cholecystectomy. Repeat EKG no longer showed the ST elevation. The patient was discharged in stable condition. Conclusion: A 2.3% incidence of alternative conditions mimicking STEMI is found in patients referred for primary percutaneous coronary intervention.Abdominal etiologies like pancreatitis and cholecystitis can also cause troponin elevation. Release of pancreatic proteolytic enzymes causing transient myonecrosis and coronary vasospasm have been the hypothesized pathophysiologic mechanism. The electrocardiographic changes in patients with acute cholecystitis and pancreatitis which have been reported are mostly transient. These changes usually are in the form of T-wave inversion, ST-segment depression, and rarely ST-segment elevation in the absence of coronary artery disease. Physicians should therefore consider intra-abdominal etiologies when faced with transient inferior ST segment elevations in patient without significant coronary disease.Figure 1Figure 2

Massive J-waves in the context of intracranial hemorrhage

Transient ST-segment elevation may be caused by conditions other than myocardial ischemia, among them intracranial hemorrhage. Recognition of the underlying etiology of these ST-segment changes is key because of the vastly different therapies used to treat them. We describe the case of a patient with massive transient J-waves and ST-segment elevation in the context of an intracranial hemorrhage.

Early or late intervention in patients with transient ST-segment elevation acute coronary syndrome: Subgroup analysis of the ELISA-3 trial.

To investigate incidence and patient characteristics of transient ST-segment elevation (TSTE) ACS and to compare outcome of early versus late invasive treatment. Optimal timing of treatment in TSTE-ACS patients is not outlined in current guidelines and no prospective randomized trials have been done so far. Post hoc subgroup analysis of patients with TSTE randomized in the ELISA 3 trial. This study compared early (<12 h) versus late (>48 h) angiography and revascularization in 542 patients with high-risk NSTE-ACS. Primary endpoint was incidence of death, reinfarction, or recurrent ischemia at 30 days follow-up. TSTE was present in 129 patients (24.2%) and associated with male gender, smoking and younger age. The primary endpoint occurred in 8.9% of patients with and 13.0% of patients without TSTE (RR = 0.681, P = 0.214). Incidence of death or MI after 2 year follow-up was 5.7 and 14.6% respectively (RR = 0.384, P = 0.008). Within the group of patients with TSTE, incidence of the primary endpoint was 5.8% in the early and 12.7% in the late treatment group (RR = 0.455, P = 0.213), driven by reduction in recurrent ischemia. Enzymatic infarct size, bleeding and incidence of death or recurrent MI at 2 years follow-up was comparable between the treatment groups. In high-risk patients with NSTE-ACS, TSTE is frequently seen. Similar to findings in patients with high-risk NSTE-ACS, immediate angiography and revascularization in these patients is feasible but not superior to later treatment. Prospective randomized trials are needed to provide more evidence in the optimal timing of treatment in patients with TSTE-ACS. © 2016 Wiley Periodicals, Inc.

Clinical and ECG patterns of pseudoinfarction in a young man with type 1 diabetes, diabetic ketoacidosis and normokalaemia

Diabetic ketoacidosis (DKA) can cause changes in the electrocardiogram (ECG) in the form of transient ST-segment depression, QT prolongation, changes in T-wave morphology and the appearance of U wave, possibly due to changes in the serum potassium level. Occasional reports indicate the possibility of transient ST-segment elevation imitating myocardial infarction in the course of hyperkalaemia accompanying DKA. In this article we present a case of a 20-year-old male patient with type 1 diabetes mellitus, DKA and normokalaemia, who experienced severe retrosternal pain, and ECG presented ST-segment elevation imitating acute myocardial infarction of the anterior wall. On the basis of the performed cardiac tests, including laboratory testing, coronary angiography and ultrasound scan, acute coronary syndrome was ruled out. The regression of retrosternal pain and electrocardiographic changes with patient hydration and correction of metabolic disorders suggest the diagnosis of pseudopericarditis, i.e. non-infections irritation of the pericardial membranes due to the loss of fluid in the pericardial sac as a result of dehydration. The diagnosis of acute myocardial infarction based on ST-segment elevation in the ECG recording in a patient with diabetes mellitus and ketoacidosis, without concomitant hyperkalaemia, must be made very carefully, even in the presence of retrosternal pain. The possibility of pseudopericarditis associated with severe dehydration must also be considered.

An unusual case of transient ST-segment elevation during hypertensive crisis in a patient with left ventricular hypertrophy

We report the case of a 73-year-old patient with severe left ventricular hypertrophy presenting with acute ST-segment elevation mimicking acute myocardial infarction on ECG during a hypertensive crisis. Unexpectedly, emergency coronary angiography showed no evidence of coronary thrombosis or spasm. Electrocardiographic alterations gradually resolved after lowering blood pressure.

Transient ST-segment elevation during acute pancreatitis

Transient ST-segment elevation during acute pancreatitis

Transient ST-segment elevation in precordial leads by acute marginal branch occlusion during stent implantation

The isolated right ventricular infarction is a rare entity. Our case presented a selective occlusion of an acute marginal branch that supplies the right ventricular free wall with isolated ST elevation in precordial leads simulating an occlusion of the left anterior descending artery and without pseudonormalization in inferior due to the non-involvement of the main branch in the ischemic process. Our case clearly illustrates a rare differential diagnosis when a new ST segment elevation appears in earlier precordial leads in patients with symptoms of myocardial ischemia.

Abstract 15383: Clinical Features and Prognosis of Patients Who Survived Ventricular Fibrillation Due to Coronary Artery Spasm

Introduction: Coronary artery spasm can lead to lethal arrhythmia and sudden cardiac death. The aim of this study was to elucidate the clinical features and prognosis of patients who survived cardiac arrest due to coronary artery spasm. Methods: We retrospectively studied consecutive patients who survived ventricular fibrillation out of hospital cardiac arrest due to coronary artery spasm, and discharged neurologically intact. Results: Nineteen patients (18 men and 1 woman, mean age 55 ± 10 years) were enrolled. In all patients, ventricular fibrillation (VF) was documented as the initial rhythm at cardiac arrest. Transient ST-segment elevation during spontaneous attack was observed in 9 patients. Acetylcholine provocation tests were performed and resulted in positive in 15 patients. In 11 patients, cardiac arrest was the first episode of vasospastic attack. All patients were treated with vasodilators including calcium channel blockers. An implantable defibrillator (ICD) was implanted in 12 patients according to the discretion of the attending physician. During a mean follow-up interval of 42 months, 4 episodes of VF were observed in 3 patients and ST-segment elevation myocardial infarction (STEMI) was observed in 1 patient. Two episodes of VF were occurred before the diagnosis of coronary artery spasm was confirmed during the index hospitalization, and the other 2 VF were occurred after ICD implantation. All VF were treated by manual defibrillation or ICD shocks. None of patients developed cardiovascular death. There are no differences in the characteristics of the patients between those with and without recurrence of VF and STEMI. However, medications against coronary artery spasm were discontinued before the cardiac events in all episodes of VF and STEMI. The intervals between cessation of medications and cardiac events were less than 2 days in all cardiac events. Conclusions: The patients who survived cardiac arrest due to coronary artery spasm were at high risk for recurrence of severe ischemia and lethal arrhythmia. Cessation of medication, even within a few days, was closely associated with cardiac events. ICD therapy may be beneficial in patients who survived cardiac arrest due to coronary artery spasm.