Typical ECG Research Articles

A Machine Learning-Derived Electrocardiographic Algorithm for the Detection of Cardiac Amyloidosis

Background: Diagnosis of cardiac amyloidosis (CA) requires advanced imaging techniques. Typical surface ECG patterns have been described, but their diagnostic abilities are limited. Objectives: The aim was to perform a thorough electrophysiological characterization in CA patients and derive an easy-to-use tool for diagnosis. Methods: We applied electrocardiographic imaging (ECGI) to acquire electroanatomical maps in CA patients and controls. A machine learning approach was then utilized to decipher the complex data sets obtained and generate a surface ECG-based diagnostic tool. Findings: Areas of low-voltage were localized in the basal inferior regions of both ventricles and the remaining right ventricular segments in CA. The earliest epicardial breakthrough of myocardial activation was visualized on the right ventricle. Potential maps revealed an accelerated and diffuse propagation pattern. We correlated the results from ECGI with 12-lead ECG recordings. Ventricular activation correlated best with R-peak timing in leads V1 to V3. Epicardial voltage showed a strong positive correlation with R-peak amplitude in the inferior leads II, III, aVF. Respective surface ECG leads showed two characteristic patterns. Ten blinded cardiologists were asked to identify CA patients by analyzing 12-lead ECGs before and after training on the defined ECG patterns. Training led to significant improvements in the detection rate of CA with an AUC of 0.69 before and 0.97 after training. Interpretation: Using a machine learning approach, an ECG-based tool was developed from detailed electroanatomical mapping of CA patients. The ECG algorithm is simple and has proven helpful to suspect CA without the aid of advanced imaging modalities.. Funding Information: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Interests: None to declare. Ethics Approval Statement: The study was part of a registry approved by the local ethics committee (EK #796/2010) and conducted according to good clinical practice as outlined in the declaration of Helsinki. All patients gave written informed consent.

Electrocardiographic characteristics and associated outcomes in patients with Takotsubo syndrome. Insights from the RETAKO registry

Abstract Background Our aim was to describe the prevalence and prognostic significance of electrocardiographic features in patients with Takotsubo syndrome (TTS). Methods Our data come from the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO). All patients with complete electrocardiogram were included. Results 246 patients were studied, mean age was 71.3±11.5 and 215 (87.4%) were women. ST-segment elevation was seen in 143 patients (59.1%) and was present in ≥2 wall leads in 97 (39.8%). Exclusive elevation in inferior leads was infrequent (5 - 2.0%). After 48 hours, 198 patients (88.0%) developed negative T-waves in a median of 8 leads with a mean amplitude of 0.7±0.5 mV. Mean corrected QT interval was 520±72 ms and it was independently associated with the primary endpoint of all-cause death and nonfatal cardiovascular events (p=0.002) and all-cause death (p=0.008). A higher heart rate at admission was also an independent predictor of the primary endpoint (p=0.001) and of developing acute pulmonary edema (p=0.04). ST-segment elevation with reciprocal depression was an independent predictor of all-cause death (p=0.04). Absence of ST-segment deviation was a protective factor (p=0.005) for the primary endpoint. Arrhythmias were independently associated with cardiogenic shock (p<0.001). Conclusion Prolonged corrected QT interval, arrhythmia, heart rate at admission and broader repolarization alterations are associated with a poor outcome in TTS. Typical ECG at admission and after 48h. Funding Acknowledgement Type of funding source: None

Propensity score-matched comparison of short- and long-term outcomes between surgery and endoscopic submucosal dissection (ESD) for intestinal type early gastric cancer (EGC) of the middle and lower third of the stomach: a European tertiary referral center experience.

Despite the comparable results between ESD and gastrectomy reported in multiple Asiatic studies, limited data are currently present on the long-term efficacy of ESD for EGC in Western countries. The aim of this study was to compare the short- and long-term outcomes of the endoscopic submucosal dissection and surgery for non-diffuse early gastric cancer treatment in a Western cohort of patients. All patients with a diagnosis of intestinal type EGC located in the middle and lower third of the stomach from 2005 to 2015 were enrolled in the study. All patients completed a 5-year follow-up. Patients were divided according to the procedure performed (ESD/subtotal gastrectomy). The two groups were matched for age, gender, ASA score, tumor dimension, and grade of infiltration (mucosa/submucosa). After matching, 84 patients (42 per group) were included in the analysis. Peri-procedural morbidity rate was 7.1% and no difference was observed between the two groups (4.8% vs 9.5% for ESD and STG groups, respectively; p = 0.3). Similar results in terms of 5-year OS and DFS were observed for ESD and STG (77.7% vs 71.8% ; p = 0.78 and 74.9% vs 72% ; p = 0.7, respectively). At the multivariate analysis, ASA3 score was recognized as the only negative predictor factor for the 5-year OS (OR 6.2; 95% CI 2.2-16.8; p < 0.001). Regarding the DFS, both ASA3 score (OR 4.4; 95% CI 1.7-10.9; p < 0.001) and submucosal infiltration(OR 5.1; 95% CI 1.2-22.4 ; p = 0.02) were identified as independent risk factors for a worse outcome. Our results confirm the safety and feasibility ESD for EGC treatment in a Western setting. In addition, this is one of the few reports showing comparable results both in terms of short- and long-term outcomes between ESD and surgery for intestinal type ECG treatment in Western countries.

Study of the relation of Anti-Ro and Anti-La Antibodies with cardiac arrhythmia and other ECG abnormalities in Systemic Lupus Erythematosus

Introduction: Arrhythmias and conductive system disorders are among the cardiovascular aggravations brought about by Systemic lupus erythematosus. Anti-Ro/SSA and LA antibodies are often recognized in connective tissue disease patients as well as in apparently healthy people. Aim of the work: Assess the role of Anti-Ro and Anti-La antibodies as hazard factors for arrhythmia in grown-up SLE patients.Patients and Methods: Cross_ sectional clinical investigation. A sum of 70 SLE cases going to the outpatient and inpatient divisions of rheumatology, Sohag University Hospitals; remembered for investigations. All members will be exposed to the accompanying: Full history, General and local assessment, Routine examinations: complete blood picture, erythrocyte sedimentation rate, liver capacities, kidney capacities, ANA IF, Anti Ro and Anti La appraisal by Immunoblot measure and ElectrocardiogramResults: 13 (41.9%) of our patients who had positive anti_ RO and LA had strange ECG findings, while 18 (58.1%) of them had typical ECG, just oral/nasal ulcers and Anti _RO/LA were an independent risk factor for abnormal ECG. Disease duration was nonsignificant and positive corresponded with disease activity by SLEDAI score Conclusion: This study exhibited that the grown-up heart may represent a goal for the anti_ Ro⁄SSA antibodies 'arrhythmogenicity. Notwithstanding, the particular rhythm changes happened appear to be, correlated with age, as shown by the way that while ventricular repolarization variations from the norm (specifically QTc prolongation) are the transcendent finding in the adults, the inclusion of conduction system is limited to the fetal heart only.

Arrhythmic events in Brugada syndrome patients induced by fever.

IntroductionThe Brugada syndrome is associated with arrhythmic events, which may even lead to sudden cardiac death (SCD) as it causes arrhythmic events. A typical Brugada syndrome ECG type I can be triggered at fever situations. The aim of this pooled meta‐analysis is to further explore the baseline characteristics and the association of fever to BrS‐related arrhythmic events.MethodsWe compiled data from a search of databases (PubMed, Web of Science, Cochrane Library, and Google Scholar). We included 17 studies including 14 case reports and a total of 53 patients.ResultsOur population including 53 patients showed a male predominance of 92% with a mean age of 40.6 ± 17.7 years. 58% of patients had a family history of SCD or BrS. Genetic screening was performed in 14 patients (26%) and revealed a SCN5A mutation in 21% of the patients. ICD implantation was initiated in six patients. 75% (n = 39) of patients did not have symptoms before the fever event. Symptoms at fever included life‐threatening arrhythmia such as ventricular fibrillation (VF) or ventricular tachycardia (VT; 17%), syncope (13%), and cardiac arrest or aborted SCD (13%). One patient developed electrical storm which led to not aborted SCD.ConclusionFever is a great risk factor for arrhythmia events in BrS patients. Patients with known fever triggered Brugada syndrome should be surveilled closely during fever and be started on antipyretic therapy as soon as possible.

Arm-ECG Wireless Sensor System for Wearable Long-Term Surveillance of Heart Arrhythmias

This article presents the devising, development, prototyping and assessment of a wearable arm-ECG sensor system (WAMECG1) for long-term non-invasive heart rhythm monitoring, and functionalities for acquiring, storing, visualizing and transmitting high-quality far-field electrocardiographic signals. The system integrates the main building blocks present in a typical ECG monitoring device such as the skin surface electrodes, front-end amplifiers, analog and digital signal conditioning filters, flash memory and wireless communication capability. These are integrated into a comfortable, easy to wear, and ergonomically designed arm-band ECG sensor system which can acquire a bipolar ECG signal from the upper arm of the user over a period of 72 h. The small-amplitude bipolar arm-ECG signal is sensed by a reusable, long-lasting, Ag–AgCl based dry electrode pair, then digitized using a programmable sampling rate in the range of 125 to 500 Hz and transmitted via Wi-Fi. The prototype comparative performance assessment results showed a cross-correlation value of 99.7% and an error of less than 0.75% when compared to a reference high-resolution medical-grade ECG system. Also, the quality of the recorded far-field bipolar arm-ECG signal was validated in a pilot trial with volunteer subjects from within the research team, by wearing the prototype device while: (a) resting in a chair; and (b) doing minor physical activities. The R-peak detection average sensibilities were 99.66% and 94.64%, while the positive predictive values achieved 99.1% and 92.68%, respectively. Without using any additional algorithm for signal enhancement, the average signal-to-noise ratio (SNR) values were 21.71 and 18.25 for physical activity conditions (a) and (b) respectively. Therefore, the performance assessment results suggest that the wearable arm-band prototype device is a suitable, self-contained, unobtrusive platform for comfortable cardiac electrical activity and heart rhythm logging and monitoring.

Электрокардиографическая диагностика сердечно-сосудистой патологии у спортсменов детских юношеских школ

Objective: to evaluate the data of cardiac screening to identify cardiac pathology and determine sports participation among in athletes of Youth Sports Schools in five districts of St. Petersburg. Materials and methods: 9847 young athletes (average age 13.8 ± 4.9 years, 6127 men) were included in the study during 8 months. Clinical protocol uncluded the collection of complaints, anamnesis, family anamnesis, physical examination, ECG in 12 leads. If necessary, Holter monitoring, echocardiography, and an exercise test were performed. Results: typical ECG changes were registered in 60.4% of athletes, borderline in 0.05% and pathological in 3.69%. All athletes with pathological changes were excluded from the training and competitive process for the period of in-depth medical examination. In the end, two athletes were not allowed to continue participation in sport (2 with stressful ventricular arrhythmias). There was not any lethal outcomes for the entire period of the study. Conclusions: cardiological screening using the routine ECG method remains the main tool for identifying a possible pathological substrate and assessing the risk of sudden cardiac death. Early detection of cardiac arrhythmias and conduction disturbances allow to take measures to prevent sudden cardiac death.

P3597Occurence of type 2 myocardial infarction in patients with coronary artery disease

Abstract Background Type 2 myocardial infarction (T2MI) is an emerging entity defined by a myocardial oxygen supply and demand mismatch, in the absence of coronary thrombosis. The prevalence of T2MI is high in patients admitted for an acute MI, but is unknown in patients with coronary artery disease (CAD). Purpose We aimed to address the comparative prevalence and characteristics of T2 and Type 1 MI in CAD patients. Patients We conducted a single-center retrospective study among 33 669 consecutive patients admitted from January 2014 to December 2016 in a university hospital emergency or intensive care unit (ICU). Patients admitted for acute MI, diagnosed by troponin elevation associated with symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes) and with history of CAD were included. They were systematically adjudicated as T1MI or T2MI according to 4th MI universal definition. Result Among the 619 patients included, 254 (41%) had T2MI and 365 (59%) had T1MI. T2MI patients were characterized by an older age (median age [IQR]: 82 [71–87] vs 72 [62–81] y, respectively, p&lt;0.001) and more frequent comorbidities than T1MI patients. In contrast, T2MI patients had similar rates of cardioprotective chronic treatments than T1MI. Only 41% of T2MI patients admitted in ICU underwent a coronary angiography, of whom most (56%) had three-vessels disease. Percutaneous coronary intervention was much less performed in T2MI than in T1MI (28% vs 67%, respectively p&lt;0.001). Median (IQR) time from first CAD diagnosis to index MI was similar for both groups (83 [27–151] months vs 94 [30–179] for T1MI, respectively p=0.22). In-hospital mortality were 2 fold higher in T2MI than in T1MI (15.0% vs 6.6%, respectively, p&lt;0.001). Moreover, in the first year following CAD diagnosis, T2MI had similar rate of occurrence than T1MI (17% vs 14%, respectively p=0.389). Conclusion This large real-life study in CAD patients with a recurrence of MI highlights the high frequency of T2MI. Furthermore, almost 1 out of 5 patients had an acute MI, either T1 or T2MI, within the first year after CAD diagnosis. These findings may have implications for prevention and management strategies of T2MI. Acknowledgement/Funding University Hospital Center Dijon Bourgogne, Agence Régionale de Santé Bourgogne Franche Comté, France

P6389Infection and type 2 myocardial infarction: a large observational study from emergency department

Abstract Background Troponin elevation is frequent in patients with acute infection (AI) admitted to emergency unit (EU). Acute infection (AI) has been suggested as a common trigger in type 2 myocardial infarction (T2MI), corresponding to a myocardial oxygen supply-demand mismatch without atherothrombosis. We aim to characterize risk factors of T2MI occurrence and in-hospital mortality among patients admitted to an EU with AI and elevated troponin. Methods Among the medical records of all the patients admitted from January 2014 to December 2016 in a university hospital EU (n=82 543), patients with a diagnosis of AI and elevated troponin Ic (≥0.10μg/L) (n=714) were systematically adjudicated as T2MI in the presence of symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes). Results Among the 714 patients included (aged 85, 50% male), 185 (26%) were classified as T2MI, of whom infection site was pulmonary tract (n=111), urinary tract (n=27), skin (n=15), digestive tract (n=9) or other or indefinite site (n=23). By multivariate analysis, a history of chronic obstructive pulmonary disease (COPD) (OR (95% CI): 0.53 (0.30–0.96)), high temperature (OR: 0.86 (0.74–0.99) per °C) and elevated creatinine (0R 0.998 (0.996–1.000) per μmol/L) were associated with a lower risk of T2MI, whereas age, site of infection, C-reactive protein and troponin rates were not predictors of T2MI. Death rate was similar among patients with or without T2MI (21 vs 23%, p=0.6). In contrast, age, troponine, creatinine or C-reactive protein elevations were independent co-variates associated with mortality. Conclusions Our large real-life study shows that in patients admitted to an EU with AI and troponin elevation, T2MI is a common feature, in the absence of temperature elevation, renal insufficiency or history of COPD. In such patients, inflammatory and cardiac biomarkers levels were independently associated with early mortality.

P852Frequency and prognosis of type 2 myocardial infarction vs non ischemic myocardial injury: large observational study from an emergency department

Abstract Background Type 2 Myocardial Infarction (T2MI), due to myocardial oxygen supply-demand mismatch in the absence of atherothrombosis and non-ischemic myocardial injury (NIMI), corresponding to troponin elevation without overt ischemia, are emerging concepts which are suspected to be common in patients hospitalized. However, their respective frequencies, risk profiles and short term prognosis in current routine clinical practice of emergency unit remains to be investigated. Methods Among the medical records of all the patients admitted from January 2014 to December 2016 in a university hospital emergency unit (n=82 543), patients with elevated troponin Ic (≥0.10μg/L) (n=4568) were systematically adjudicated as T2MI in the presence of symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes), or as NIMI without such signs. Patients with missing biological data on admission (n=112) or T1MI diagnosis (n=2467) were excluded. Results Among the 1989 patients included, 539 (27%) were classified as T2MI and 1450 (73%) as NIMI. When compared with patients with NIMI, T2MI had higher troponin levels (0.27 (0.14–0.71) vs 0.22 (0.13–0.54) μg/L, p=0.008, respectively). NIMI and T2MI had similar risk factors (age (84 (74–90) vs 84 (75–91) y, p=0.3), male sex (43 vs 48%, p=0.07), hypertension (67 vs 71%, p=0.133), diabetes (25 vs 25%, p=0.9), prior CAD (24 vs 26%, p=0.342), systemic inflammatory response syndrome (SIRS, 47 vs 49%, p=0.3), and systolic blood pressure (SBP) (130 (111–153) vs 132 (112–153) mmHg, p=0.545). Biological data on admission were also similar (hyperglycemia (glucose ≥11 mmol/L), 14 vs 13%, p=0.37, creatinine (96 (72–148) vs 94 (72–141) μmole/L, p=0.598), anemia (Hemoglobin rate ≤10g/dL, 13 vs 14%, p=0.5), C-reactive protein elevation (CRP ≥3 mg/L, 88 vs 89%, p=0.7)). Moreover, in-hospital mortality was high and similar for both groups (15 vs 18%, p=0.2). In multivariate analysis, age, troponin rate, SIRS, anemia, SBP, hyperglycemia, creatinine and CRP elevation were independent factors associated with hospital mortality, but not T2MI (vs NIMI) (OR: 0.88 (0.66–1.17)). Older age and hyperglycemia were specific covariates associated with increased risk of mortality in T2MI, but not in NIMI. Conclusions This large real-life study of non-T1MI inpatients with elevated troponins from emergency department shows that myocardial injury without necrosis and T2MI share the same risk factors, characterized by a high rate of infections and anemia and a high risk of hospital mortality. Acknowledgement/Funding University Hospital Center Dijon Bourgogne, France

P1812Speckle tracking echocardiography for early detection of left ventricular systolic dysfunction in patients with Chagas disease

Abstract Introduction Longitudinal strain by speckle tracking echocardiography (STE) imaging is a reliable tool for quantitative measurement of myocardial contractility. Assessment of left ventricular (LV) systolic function has a central role in the evaluation of patients with Chagas disease, particularly for identification of subtle changes that could predict disease progression. Purpose We aimed to detect early LV dysfunction using LV global longitudinal strain (GLS) in patients with Chagas disease and its relationship to other echocardiographic and laboratory parameters. Methods Eight-hundred and fifty patients with Chagas disease (mean age of 60±12 years, 70% female) who live in remote areas in Brazil were enrolled. Clinical evaluation, ECG, N-terminal pro-brain natriuretic peptide (NT-ProBNP), and echocardiogram were performed. LV GLS was assessed offline on the four-, three- and two-chamber views. Patients were divided into tertiles according to the LV strain. Data were analyzed using One-way ANOVA. Results The ECG was normal in 19%, whereas typical ECG abnormalities related to Chagas cardiomyopathy were found in 58% of the patients. Overall mean LV ejection fraction (LVEF) was 59±11%, and LV GLS was - 14.1±4.4%. Apical aneurysm was detected in 34 patients (4%).The prevalence of LV systolic dysfunction, defined as LVEF &lt;54% and GLS ≤ |16|%, was 19% and 66%, respectively. Abnormal GLS was observed in 408 (48%) patients despite a normal LVEF. Stratified according to tertiles of LV GLS, patients in the first tertile (strain &lt;|10.7|%), had a significantly decreased in LVEF (Fig 1, A), increased E/e' ratio (Fig 2,B), left atrial volume (Fig 1,C), and NT-proBNP levels (Fig 1,D), indicating severity of LV dysfunction (n=215). Similarly, the patients in the third tertile (strain &gt;|17|%), had normal standard echo parameters and NT-proBNP levels (n=210). However, patients in the second tertile (|10.7|% to |17|%; n=425), the strain was abnormal while other parameters were normal, showing LV impairment that was not evidenced by conventional exams. Conclusions LV longitudinal strain assessed by STE in a general population of Chagas disease provided diagnostic information beyond conventionally measured LVEF. Early detection of ventricular impairment may help to identify Chagas disease patients at risk for development of heart failure.

Unmasking Brugada Syndrome with Oral Flecainide Provocation. A Case Series of Three Patients

The present case series discuss three patients who had brugada type 2/ type 3 like ECG pattern that was converted to type 1 pattern with oral flecanide challenge test. Brugada syndrome is associated with a high incidence of sudden cardiac death, typical ECG pattern being ST-segment elevation in the right precordial leads with T wave inversion. Pharmacological provocation should only be performed when the baseline ECG is not diagnostic of Brugada Syndrome. PR prolongation in the baseline ECG is also a contraindication because of the risk of inducing AV block. Drug challenge is performed under strict monitoring of BP and 12-lead ECG and facilities for cardio version and resuscitation are available. Atypical RBBB pattern/type 2/3 Brugada pattern on ECG in patients of syncope or family history of sudden cardiac arrest is commonly encountered by a cardiologist. This can be performed to provoke type 1 brugada pattern on ECG. Diagnosed cases of Brugada may be treated with ICD with proper indication if needed and thus prevent sudden cardiac death.

Case Study on Fraud in Export Credit Insurance for Export Financing Against Account Receivables

The Korean government introduced Export Credit Guarantee (‘ECG’) and Export Credit Insurance (‘ECI’) programs to support national exports. A typical ECG and ECI not only covers the risks of non-payment by importers, but also enables export financing for an exporter. Although, these programs provide various benefits, they can however be misused by fraudulent exporters. Such fraud not only contravenes the intended purpose of the programs, but also harms honest exporters by increasing insurance premiums.

Frequency and prognosis of type 2 myocardial infarction vs non ischemic myocardial injury: Large observational study from an emergency department

Type 2 Myocardial Infarction (T2MI), due to myocardial oxygen supply-demand mismatch in the absence of atherothrombosis and of non-ischemic myocardial injury (NIMI), i.e. troponin elevation without overt ischemia are new emerging physiopathological entities. We aimed to investigate frequencies and characteristics of T2MI and NIMI in current routine clinical practice of emergency unit. Among patients admitted from 2014 to 2016 in a university hospital emergency unit ( N = 82,543), patients with elevated troponin Ic (≥ 0.10μg/L) ( N = 4568) were adjudicated as T2MI if symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes), or as NIMI without such signs. Patients with missing admission biological data ( N = 112) or T1MI ( N = 2467) were excluded. Among the 1989 patients included, 539 (27%) were diagnosed as T2MI and 1450 (73%) as NIMI. When compared with NIMI, T2MI had higher troponin levels (0.27 (0.14–0.71) vs 0.22 (0.13–0.54) μg/L, P = 0.008, respectively). Risk factors were similar for both groups (age (84(74–90) vs 84(75–91) y, P = 0.3), male sex (43 vs 48%, P = 0.07), hypertension (67 vs 71%, P = 0.133), diabetes (25 vs 25%, P = 0.9), prior CAD (24 vs 26%, P = 0.342), systemic inflammatory response syndrome (SIRS) (47 vs 49%, P = 0.3), and systolic blood pressure (SBP) (130 (111–153) vs 132 (112–153) mmHg, P = 0.545). Biological data on admission were also similar (hyperglycemia (glucose ≥ 11mmol/L), 14 vs 13%, P = 0.37, creatinine (96 (72–148) vs 94 (72–141) μmole/L, P = 0.598), anemia (Hemoglobin ≤ 10g/dL, 13 vs 14%, P = 0.5), C-reactive protein elevation (CRP ≥ 3mg/L, 88 vs 89%, P = 0.7)). Moreover, in-hospital mortality was high and similar for both groups (15 vs 18%, P = 0.2), even when adjusted for confounding. This large real-life study shows that NIMI and T2MI are common and share the same risk factors, characterized by a high rate of infections and anemia and a high risk of hospital mortality.

Infection and type 2 myocardial infarction: A large observational study from emergency department

Troponin elevation is frequent in patients with acute infection (AI) admitted to emergency unit (EU). Acute infection has been suggested as a common trigger in type 2 myocardial infarction (T2MI), corresponding to a myocardial oxygen supply-demand mismatch without atherothrombosis. We aim to characterize risk factors of T2MI occurrence and in-hospital mortality in patients admitted to an EU with AI and elevated troponin. Among the medical records of all the patients admitted from 2014 to 2016 in a university hospital EU ( N = 82,543), patients with a diagnosis of AI and elevated troponin Ic (≥ 0.10μg/L)( N = 714) were systematically adjudicated as T2MI in the presence of symptoms of myocardial ischemia (typical chest pain and/or ECG changes). Among the 714 patients included (aged 85, 50% male), 185 (26%) were classified as T2MI, of whom infection site was pulmonary tract ( N = 111), urinary tract ( N = 27), skin ( N = 15), digestive tract ( N = 9) or other or indefinite site ( N = 23). By multivariate analysis, a history of chronic obstructive pulmonary disease (COPD) (OR (95% CI): 0.53 (0.30–0.96)), high temperature (OR: 0.86 (0.74–0.99) per °C) and elevated creatinine (0R 0.998 (0.996–1.000) per μmol/L) were associated with a lower risk of T2MI, whereas age, site of infection, C-reactive protein and troponin rates were not predictors of T2MI. Death rate was similar among patients with or without T2MI (21 vs 23%, P = 0.6). In contrast, age, troponine, creatinine or C-reactive protein elevations were independent predictors of mortality. Our large real-life study shows that in patients admitted to an EU with AI and troponin elevation, T2MI is a common feature, especially in the absence of temperature elevation, renal insufficiency or history of COPD, but is not an independent factor of in-hospital mortality.

Interdisciplinary safety precautions protocol for electroconvulsive therapy (ECT) in a patient with treatment-resistant major depression and Brugada ECG

IntroductionBrugada syndrome (BrS) is a rare cause of sudden cardiac death in young, otherwise healthy individuals with a structurally normal heart. The diagnosis of BrS is made by typical ECG changes (so-called “coved” type 1-ECG) that may be transient and can be unmasked by sodium-channel-blocking medications. Once the pathognomonic ECG pattern is identified, potentially aggravating drugs have to be discontinued. Since many drugs in psychiatric indications have the potential to induce Brugada-like ECG changes, therapy in such patients is challenging and a rapid worsening of depressive or psychotic symptoms can be the consequence. The limited remaining psychopharmacological treatment options may lead to the consideration of electroconvulsive therapy (ECT). MethodsIn a patient with treatment-resistant major depression and high risk of suicide, a Brugada type 1-ECG has been recorded during routine control under antidepressant pharmacotherapy. We report on the successful treatment using ECT after establishing an interdisciplinary safety precautions protocol for patients with suspected BrS, involving cardiologists, anesthesiologists and psychiatrists. ResultsSpecific considerations of the safety precautions protocol include choice of anesthetic agents, advanced cardiac monitoring, specific emergency prearrangements and the ECT procedure itself. The type of muscle relaxant chosen and the autonomic response on the seizure stimulation were considered most important to avoid ECT-related adverse events. ConclusionECT might be a promising option in the treatment of severe depressive episodes in patients presenting with a Brugada ECG, if an interdisciplinary risk assessment and safety precautions are carefully considered.

Apical Hypertrophic Cardiomyopathy in an asymptomatic male

Apical Hypertrophic cardiomyopathy is a rare variant of HCM and has a prevalence of around ~ 15 % among HCM patients. As compared to other variants, it has a relatively benign prognosis. Predominantly prevalent in the Japanese population; it is characterized by localized hypertrophy of the LV apex as compared to other segments. It is usually silent in early stages and is manifested at an adult stage with typical ECG changes of giant T wave inversions in the precordial leads. Transthoracic echocardiography remains the mainstay of non – invasive diagnosis. We report a case of an asymptomatic elderly male who presented with the classical deep T wave inversion in ECG for which echocardiography revealed the apical variant of hypertrophic cardiomyopathy.

Infection and type 2 myocardial infarction: A large observational study from emergency department.

Troponin elevation is frequent in patients with acute infection (AI) admitted to emergency unit (EU). Acute infection (AI) has been suggested as a common trigger in type 2 myocardial infarction (T2MI), corresponding to a myocardial oxygen supply-demand mismatch without atherothrombosis. We aim to characterize risk factors of T2MI occurrence and in-hospital mortality among patients admitted to an EU with AI and elevated troponin. Among the medical records of all the patients admitted from January 2014 to December 2016 in a university hospital EU ( n = 82,543), patients with a diagnosis of AI and elevated troponin Ic (≥ 0.10 μg/L)( n = 714) were systematically adjudicated as T2MI in the presence of symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes). Among the 714 patients included (aged 85, 50% male), 185 (26%) were classified as T2MI, of whom infection site was pulmonary tract ( n = 111), urinary tract ( n = 27), skin ( n = 15), digestive tract ( n = 9) or other or indefinite site ( n = 23). By multivariate analysis, a history of chronic obstructive pulmonary disease (COPD) [OR (95% CI): 0.53 (0.30–0.96)], high temperature [OR: 0.86 (0.74-0.99) per °C] and elevated creatinine (0R 0.998 (0.996–1.000) per μmol/L) were associated with a lower risk of T2MI, whereas age, site of infection, C-reactive protein and troponin rates were not predictors of T2MI. Death rate was similar among patients with or without T2MI (21 vs. 23%, P = 0.6). In contrast, age, troponine, creatinine or C-reactive protein elevations were independent co-variates associated with mortality. Our large real-life study shows that in patients admitted to an EU with AI and troponin elevation, T2MI is a common feature, in the absence of temperature elevation, renal insufficiency or history of COPD. In such patients, inflammatory and cardiac biomarkers levels were independently associated with early mortality.

Frequency and prognosis of type 2 myocardial infarction vs. non-ischemic myocardial injury: Large observational study from an emergency department.

In current routine clinical practice of emergency unit, frequencies and characteristics of Type 2 Myocardial Infarction (T2MI), due to myocardial oxygen supply-demand mismatch in the absence of atherothrombosis and of non-ischemic myocardial injury (NIMI), i.e. troponin elevation without overt ischemia, remains to be investigated. Among medical records of all the patients admitted from January 2014 to December 2016 in a university hospital emergency unit ( n = 82,543), patients with elevated troponin Ic (≥ 0.10 μg/L) ( n = 4568) were adjudicated as T2MI if symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes), or as NIMI without such signs. Patients with missing admission biological data ( n = 112) or T1MI ( n = 2467) were excluded. Among the 1989 patients included, 539 (27%) were diagnosed as T2MI and 1450 (73%) as NIMI. When compared with NIMI, T2MI had higher troponin levels [0.27 (0.14–0.71) vs. 0.22 (0.13–0.54) μg/L, P = 0.008, respectively]. Risk factors were similar for both groups [age 84(74–90) vs. 84(75–91) y, P = 0.3], male sex (43 vs. 48%, P = 0.07), hypertension (67 vs. 71%, P = 0.133), diabetes (25 vs. 25%, P = 0.9), prior CAD (24 vs. 26%, P = 0.342), systemic inflammatory response syndrome (SIRS) (47 vs. 49%, P = 0.3), and systolic blood pressure (SBP) (130 (111–153) vs. 132 (112-153) mmHg, P = 0.545). Biological data on admission were also similar [hyperglycemia (glucose ≥ 11 mmol/L), 14 vs. 13%, P = 0.37, creatinine [96 (72–148) vs. 94 (72–141) μmole/L, P = 0.598], anemia (Hemoglobin ≤ 10 g/dL, 13 vs. 14%, P = 0.5), C-reactive protein elevation (CRP ≥ 3 mg/L, 88 vs. 89%, P = 0.7)]. Moreover, in-hospital mortality was high and similar for both groups (15 vs. 18%, P = 0.2), even when adjusted for confounding. This large real-life study shows that NIMI and T2MI are common and share the same risk factors, characterized by a high rate of infections and anaemia and a high risk of hospital mortality.

46. A case report on primary hepatic amyloidosis

Background: We describe an unusual case of hepatic amyloidosis. Case Summary: 40 yr old female r/o Secunderabad came with complaints of generalized weakness since 4 months, B/Lpedal odema since 15 days, decreased appetite since 2 months. Pedal odema not associated with PND, ↓ urine output, SOB, abdominal distension. H/O weightloss of 10 kgs over 4 months. No HTN, DM, CVA, CAD, TB, Epilepsy. Systemic examination: Hepatomegaly, 10 cm below costal margin in MCL, moving with respiration, firm in consistency, smooth surface, sharp border Splenomegaly 2–3 cm below costal margins. Investigations: CBP-Hb%-10.5 gm%, TLC–7300/mm3, N-50%, L-45%, E-1%, M-4%, platelets-adequate. HEMOGRAM-Hb-12.5 gm%, PCV-38.4%, RBC-5.5 million/mm3, MCV-72.8 fml, MCH-22.3 pg, MCHC – 30.3, TLC-10500, N-58%, L-38% (3% showing reactive changes), M-2%, E-2%, Platelets – 2.6 lakhs, RBC normocytic normochromic, few target cells seen, WBC within normal limits. No hemoparasites no atypical cells Sr creatinine-0.6 mg%, Sr electrolytes- Na-132, K-4.7, Cl∼99. LFT with enzymes –TB–0.5 mg/dl, CB–0.2 mg/dl, UCB–0.3 mg/dl, SGPT–42 U/L, SGOT-91 U/L, Sr ALP- 1028 U/L, TP-4.3 gm/dl, Albumin–2.6 gm/dl ↓, Sr. globulin-1.7 gm/dl, PT-15.7, INR-1.36. USG Abdomen–Liver enlarged in size, normal echotexture, no focal lesions, few enlarged periportal lymphnodes largest measuring 1 cm. CECT abdomen showed hepatomegaly and splenomegaly. Liver biopsy showed amyloidosis of liver, show amorphous, eosinophilic substance within the extracellular spaces. Immunohistochemistry showed the immune profile is consistent with involvement by AL amyloidosis, lambda chain type ECG–low voltage complexes. Bonemarrow aspiration–mild prominence of plasma cells accounting for 8% of marrow cellularity There is deposition of acellular magenta coloured material within stromal fragments. Spot urine protein creatinine ratio– 5.9. CUE–albumin ++, pus cells –4-5/hpf, epithelial cells –6-7/hpf. 2DECHO–grade 1 diastolic dysfunction, mild MR, mild TR, speckled appearance of IAS and IVS thickened pericardium. Urine for immunofixation electrophoresis – both kappa and lambda type bence jones proteins present in urine Serum protein electrophoresis–low albumin, increased α1, α2, β globulins, normal γ globulin. Conclusions: Primary amyloidosis often involves liver. 27% of primary systemic amyloidosis present with hepatomegaly, while jaundice and portal hypertension are rare. Splenic involvement is common, but splenomegaly is seen in only 10% of patients. Treatment of primary amyloidosis is chemotherapy, traditionally with melphalan and prednisolone. However response rate is only 30% with treatment. The authors have none to declare.