The role of 12-lead electrocardiogram in the risk stratification of non-ST elevation acute coronary syndrome and the correlation with coronary angiography - The CINCHONa study - A prospective cohort study in Northern India.

Background: Clinical guidelines recommend risk stratification of non-ST elevation acute coronary syndrome (NST-ACS) using the GRACE risk score. However, the GRACE risk score is not followed widely in clinical practice due to various reasons. Our primary objectives of this study were to correlate the presenting electrocardiogram (ECG) of NST-ACS with coronary angiography (CAG) findings and to identify specific ECG changes that are suggestive of severe coronary artery disease (CAD) thus helping to triage all patients with NST-ACS. Materials and Methods: This prospective observational study was undertaken on patients diagnosed with NST-ACS in a medical college hospital, in Northern India over one and a ½ years. The admission ECG of the patients was compared with CAG findings to find out the correlation between the two with respect to severity of CAD. Categorical and quantitative variables were compared using the Chi-square test and independent t-test, respectively. Odds ratio (OR) were calculated using the univariate logistic regression analysis. Results: On comparing the two groups with normal and abnormal ECG, we found that smokers had significantly higher odds of having an abnormal ECG (OR 3.31; 95% confidence interval [CI] [1.29-8.50]). Patients with an abnormal ECG had significantly lower left ventricular ejection fraction compared to those with normal ECG (52.01 ± 10.56 vs. 55.96 ± 6.13%, P = 0.045). The patients with severe CAD on CAG had significantly higher odds of abnormal ECG (OR 3.68, 95% CI [1.2311.04]). Of the specific ECG abnormalities, ST depression and T-wave inversion in same or different leads were significantly associated with severity of CAD (OR 0.13, 95% CI [0.04-0.43], P = 0.001 and OR 0.13, 95% CI [0.03-0.46], P = 0.002, respectively). Conclusion: The identification of ECG changes suggestive of high-risk CAD can dictate to transfer such patients without delay to a percutaneous coronary intervention capable hospital for urgent CAG with intent to revascularization, thus helping in risk stratification of NST-ACS at the community level.

Résumé Contexte: Les directives cliniques recommandent la stratification du risque de syndrome coronarien aigu sans élévation du segment ST (SCA-NST) à l'aide du GRACE cote de risque. Cependant, le score de risque GRACE n'est pas largement suivi dans la pratique clinique pour diverses raisons. Nos objectifs premiers de cette étude étaient de corréler l'électrocardiogramme (ECG) de présentation du NST-ACS avec les résultats de l'angiographie coronarienne (CAG) et de identifier les modifications spécifiques de l'ECG qui suggèrent une maladie coronarienne (CAD) sévère, aidant ainsi au triage de tous les patients atteints de NST-ACS. Matériels et Méthodes: Cette étude observationnelle prospective a été entreprise sur des patients diagnostiqués avec un NST-ACS dans une faculté de médecine. hôpital, dans le nord de l'Inde pendant un an et demi. L'ECG d'admission des patients a été comparé aux résultats du CAG pour déterminer la corrélation entre les deux par rapport à la sévérité de la coronaropathie. Les variables catégorielles et quantitatives ont été comparées à l'aide du test du Chi-carré et test t indépendant, respectivement. Les rapports de cotes (OR) ont été calculés à l'aide de l'analyse de régression logistique univariée. Résultats: En comparant les deux groupes avec un ECG normal et anormal, nous avons constaté que les fumeurs avaient une probabilité significativement plus élevée d'avoir un ECG anormal (OR 3,31 ; Intervalle de confiance à 95 % [IC] [1,29­8,50]). Les patients avec un ECG anormal avaient une fraction d'éjection ventriculaire gauche significativement inférieure à à ceux ayant un ECG normal (52,01 ± 10,56 vs 55,96 ± 6,13 %, P = 0,045). Les patients atteints de coronaropathie sévère sur CAG avaient des taux significativement plus élevés risque d'ECG anormal (OR 3,68, IC à 95 % [1,2311,04]). Parmi les anomalies spécifiques de l'ECG, le sous-décalage du segment ST et l'inversion de l'onde T dans le même ou différentes dérivations étaient significativement associées à la sévérité de la coronaropathie (OR 0,13, IC 95 % [0,04­0,43], P = 0,001 et OR 0,13, IC 95 % [0,03­0,46], P = 0,002, respectivement). Conclusion: L'identification des modifications de l'ECG suggérant une coronaropathie à haut risque peut dicter le transfert de ces patients sans délai vers un hôpital capable d'intervention coronarienne percutanée pour CAG urgent avec intention de revascularisation, contribuant ainsi au risque stratification du NST-ACS au niveau communautaire. Mots-clés: Syndrome coronarien aigu, coronarographie, électrocardiogramme, score de risque GRACE, coronarien aigu sans sus-décalage du segment ST syndrome.

Seven day continuous ambulatory electrocardiographic telemetric study with pocket electrocardiographic recording device for detecting hydroxychloroquine induced arrhythmias.

Objective: The use of hydroxychloroquine (HCQ) for COVID-19 treatment and prophylaxis raised issues concerning its cardiac safety owing to the possibility of QT prolongation and arrhythmias. There was no study on long-term electrocardiographic telemetry monitoring of patients taking HCQ. We planned a continuous electrocardiographic Holter telemetry of these patients for 7 days. Material and Methods: Health care workers taking HCQ as pre exposure prophylaxis and patients on HCQ were monitored using seven day Holter electrocardiographic telemetry with continuous beat to beat analysis. Telemetry can instantly convey any arrhythmic event or significant QT prolongation to the medical faculty. Results: Twenty-five participants with a mean age of 42.4 ± 14.1 years were included in the study; 40% were females. Twenty percent of participants needed to stop HCQ. Four patients developed QT prolongation >500 ms and needed to stop HCQ, one patient had accelerated idioventricular rhythm and stopped treatment, and one had short episodes of atrial fibrillation. No malignant arrhythmia or ventricular arrhythmia, or torsade de pointis were noted. No episode of significant conduction disturbance and arrhythmic death was noted. Baseline mean QTc was 423.96 ± 32.18 ms, mean QTc corrected at 24 h was 438.93 ± 37.95, mean QTc was 451.879 ± 37.99 at 48 h, and change in baseline mean QTc to max QTc was 30.74 ± 21.75 ms at 48 h. All those who developed QTc prolongation >500 ms were greater than 50 years of age. Conclusion: Ambulatory telemetry ECG monitoring detects early QT prolongation, and stopping drugs prevents malignant arrhythmias. HCQ seems to have less risk of QT prolongation in young, healthy individuals.

Comparative study of acute coronary syndrome in postmenopausal women and age-matched men: A prospective cohort study in Southern India.

Background: Acute coronary syndrome (ACS) differs in women and men with respect to risk factors, clinical presentation, complications and outcome. The major reason for the differences has been the effect of estrogen which protects women from coronary artery disease (CAD) till menopause. Women develop CAD one decade later than men. Hence, we compared the profile of ACS in postmenopausal women with age-matched men to see, does the difference still exist. Materials and Methods: Comparative prospective study of 50 postmenopausal women as study group and fifty age-matched men as a control group diagnosed with ACS, who were admitted in a medical college hospital from December 2013 to September 2015. Chi-square test and Student's t-test have been used to find the significant association of study parameters between women and men. Results: Chest pain was the main complaint in the majority of the women (76%) and men (88%). Radiation of chest pain (60%) and sweating (72%) were significantly present in men compared to women (24% and 26%, respectively), whereas breathlessness was significantly present in women (40%) compared to men (16%). Women had later presentation to the hospital after symptom onset compared to men. Women had a higher respiratory rate (22.02 cycles/min) compared to men (20 cycles/min) and more crepitations compared to men. Men had more ventricular tachycardia (14%) and intracerebral hemorrhage (4%), whereas women had all other complications more than or same as men and higher in-hospital mortality (14%) compared to men (8%). Conclusion: Postmenopausal women with ACS had more atypical presentation of symptoms, later presentation to hospital, more tachypnea, more crepitations, more complications, and higher in-hospital mortality compared to men of the same age group. The difference in the profile of ACS continues to exist even after menopause and age matching.

RésuméContexte: Le syndrome coronarien aigu (SCA) diffère chez les femmes et les hommes en ce qui concerne les facteurs de risque, la présentation clinique, les complications et les résultats. La principale raison des différences a été l'effet de l'œstrogène qui protège les femmes de la maladie coronarienne (CAD) jusqu'à la ménopause. Les femmes développent CAD une décennie plus tard que les hommes. Par conséquent, nous avons comparé le profil du SCA chez les femmes ménopausées avec des hommes du même âge pour voir si la différence existe toujours. Matériels et méthodes: Étude prospective comparative de 50 femmes ménopausées en tant que groupe d'étude et de cinquante hommes du même âge en tant que groupe témoin ayant reçu un diagnostic de SCA, qui ont été admises dans un hôpital universitaire de médecine de décembre 2013 à septembre 2015. Test du chi carré et test de Student. -test ont été utilisés pour trouver l'association significative des paramètres d'étude entre les femmes et les hommes. Résultats: La douleur thoracique était la principale plainte chez la majorité des femmes (76 %) et des hommes (88 %). L'irradiation de la douleur thoracique (60 %) et la transpiration (72 %) étaient significativement présentes chez les hommes par rapport aux femmes (24 % et 26 %, respectivement), tandis que l'essoufflement était significativement présent chez les femmes (40 %) par rapport aux hommes (16 %) . Les femmes se sont présentées plus tard à l'hôpital après l'apparition des symptômes par rapport aux hommes. Les femmes avaient une fréquence respiratoire plus élevée (22,02 cycles/min) par rapport aux hommes (20 cycles/min) et plus de crépitations par rapport aux hommes. Les hommes présentaient plus de tachycardie ventriculaire (14 %) et d'hémorragie intracérébrale (4 %), tandis que les femmes présentaient toutes les autres complications plus ou autant que les hommes et une mortalité hospitalière plus élevée (14 %) que les hommes (8 %). Conclusion: Les femmes ménopausées atteintes de SCA présentaient une présentation plus atypique des symptômes, une présentation plus tardive à l'hôpital, plus de tachypnée, plus de crépitations, plus de complications et une mortalité hospitalière plus élevée que les hommes du même groupe d'âge. La différence dans le profil du SCA continue d'exister même après la ménopause et l'appariement de l'âge. Mots-clés: Syndrome coronarien aigu, infarctus aigu du myocarde, hommes, ménopause, angor instable, femmes.

Acute Left Ventricular Systolic Dysfunction Following Device Closure of Ruptured Sinus of Valsalva Aneurysm.

Acute cardiorespiratory distress following device closure of ruptured sinus of Valsava (RSOV) aneurysm can have a battery of differentials. We report a case of acute left ventricular dysfunction with aspiration that caused cardiorespiratory distress immediately following RSOV device closure. Supportive medical therapy led to complete recovery. (Level of Difficulty: Intermediate.).

Heart Failure in Tetralogy of Fallot due to Associated Hypertrophic Obstructive Cardiomyopathy: A Lesson to Learn.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Heart failure (HF) in a case of uncomplicated TOF is uncommon but can occur under special circumstances. TOF associated with hypertrophic obstructive cardiomyopathy (HOCM) is a very rare combination of anomalies, and very few cases have been reported in the literature. Here, we report the case of a 2-month-old male infant who presented to us with central cyanosis and features of HF. He was worked up and found to have TOF with HOCM and advised surgical correction. Hence, we propose that HOCM is also one factor which can precipitate HF in a patient of TOF along with the classical causes mentioned in the literature. Furthermore, the left ventricular outflow tract obstruction of HOCM in a patient of TOF has an inverse relation with the degree of cyanosis.

Cor triatriatum with supramitral ring: "cor tetratriatum", associated with Raghib syndrome with Eisenmenger syndrome: multimodality imaging approach in this exceedingly rare case report.

BACKGROUND: Cor triatriatum and supramitral ring are congenital anomalies which result in formation of three chambers of atria. To the best of our knowledge, simultaneous presence of both entities in the same patient resulting in the formation of four chambers of atria has not been described in the literature. Here, we report a case of simultaneous presence of cor triatriatum and supramitral ring associated with Raghib syndrome and Eisenmenger syndrome. CASE PRESENTATION: We report the case of a middle-aged gentleman, who presented to us with features of atrial septal defect with Eisenmenger syndrome. Multimodality imaging confirmed the simultaneous presence of supramital ring and cor triatriatum resulting in "cor tetratriatum" along with Raghib syndrome. Presence of Eisenmenger syndrome compelled us to offer medical therapy for the patient. CONCLUSION: This is the first case report describing the simultaneous presence of supramitral ring and cor triatriatum resulting in a new entity-"cor tetratriatum".

Transient Complete Heart Block Following Femoral Arterial Sheath Removal: An Extreme Case of Vasovagal Reflex Syndrome.

How to cite this article: Kodliwadmath A, Walia R, Ola R, Sharma P. Transient Complete Heart Block Following Femoral Arterial Sheath Removal: An Extreme Case of Vasovagal Reflex Syndrome. Indian J Crit Care Med 2021;25(7):825-827.

Apparently normal epicardial coronaries in a patient with inferior wall myocardial infarction on the background of mild coronavirus disease-2019: take a second look!

The coronary angiographic (CAG) findings of ST elevation myocardial infarction (STEMI) in patients of coronavirus disease 2019 (COVID-19) range from increased coronary artery thrombus burden to normal coronaries due to STEMI mimics. Here we report the case of a 45-year-old gentleman who presented with evolved inferior wall myocardial infarction with ongoing angina along with mild COVID-19. CAG showed normal epicardial coronaries except for distal right posterior descending coronary artery (RPDA) 100% occlusion on careful examination. He was treated for the myocardial infarction with medical management along with treatment of COVID-19. The importance of our case is to highlight the possibility of distal total occlusion of small coronary branches which may be missed if not carefully looked for as a normal CAG in COVID-19 patient will require only supportive therapy, while the finding of distal 100% occlusion of RPDA deemed us to prescribe optimal medical therapy as per acute myocardial infarction protocol along with treatment for COVID-19.

Left ventricular tamponade- pathophysiology determines the therapeutic approach: a case series.

BACKGROUND: Left ventricular (LV) tamponade is rare. LV tamponade can occur in cases of a loculated pericardial effusion overlying the LV and in cases of circumferential pericardial effusions in patients with severe pulmonary arterial hypertension (PAH). Both causes of LV tamponade share the common feature of not presenting with the classical features of cardiac tamponade. However, the therapeutic approach of the two is different. CASE SUMMARY: Here, we report two cases of LV tamponade. The first patient was a case of post-mitral valve replacement who presented with loculated posterior pericardial effusion with LV tamponade. Due to the loculated and posterior nature of the effusion, his pericardial fluid was drained from the axilla by echocardiographic and fluoroscopic guidance. The second patient presented with features of severe PAH with a circumferential pericardial effusion and LV tamponade. Due to the circumferential nature of the effusion, the pericardiocentesis was performed from the subxiphoid route. DISCUSSION: The pathophysiology of LV tamponade must be determined accurately before performing pericardiocentesis. Left ventricular tamponade in patients with severe PAH and non-loculated circumferential effusion can be drained from the subxiphoid route, while LV tamponade due to loculated effusion overlying LV must be drained by echocardiographic and fluoroscopic guidance from the axilla.

Acute adrenal insufficiency as a mysterious cause of shock following percutaneous coronary intervention: a cardiologist's nightmare.

The differential diagnosis of shock following percutaneous coronary intervention (PCI) is vast. Access site complications and bleeding can cause hypovolemic shock. Peri-procedural myocardial infarction, abrupt closure, stent thrombosis, coronary dissection and coronary perforation have a stormy presentation. Vasovagal shock is manifested by bradycardia and hypotension and quickly responds to atropine. Anaphylactic shock secondary to contrast administration can be stormy but usually responds to steroids or adrenaline. Septicemia due to unsterile techniques can cause a less dramatic shock. Acute adrenal insufficiency causing shock following PCI has not been described to the best of our knowledge. We report the case of a 54-year-old woman who underwent successful multivessel PCI. She had refractory unexplained shock following the PCI with no much response from inotropic or intra-aortic balloon pump. After ruling out all possible causes of shock and clinical suspicion of adrenal insufficiency, she was treated with steroids resulting in dramatic improvement in her hemodynamics.

Congenitally corrected transposition of great vessels with infundibular pulmonary stenosis with ventricular septal defect, presenting with atypical atrioventricular nodal reentrant tachycardia: a rare association.

Congenitally corrected transposition of great vessels (CCTGV) is a rare congenital heart disease (CHD) accounting for <1% of CHDs. CCTGV with infundibular pulmonary stenosis (PS) with ventricular septal defect (VSD) is part of Fallot's physiology. It is known to be associated with bradyarrhythmias like atrioventricular (AV) blocks, and acquired complete AV block occurs at a rate of 2% per year. Patients can have left-sided accessory pathways, which may cause atrioventricular reentrant tachycardia (AVRT). Tachyarrhythmias like atrioventricular nodal reentrant tachycardia (AVNRT) are very rare in such patients. A 30-year-old woman, a known case of CCTGV with PS with VSD, not corrected surgically and not on any drugs, presented with the syndrome of paroxysmal supraventricular tachycardia without hemodynamic compromise. Electrocardiogram showed atypical AVNRT. She was pharmacologically cardioverted to normal sinus rhythm with adenosine. CTGV with PS with VSD known to be associated with AV blocks, and preexcitation can sometimes present with atypical AVNRT.

Dysplastic pulmonary valve stenosis associated with unilateral absent first metacarpal: A rare association.

CONTEXT: Dysplastic pulmonary valve stenosis is a less common variety of valvular pulmonary stenosis. It is known to be part of Noonan syndrome. Bony hand anomalies in patients of pulmonary stenosis are very rare. CASE REPORT: A 50-year-old lady, with no significant past history, presented with slowly progressive breathlessness and fatigue, and had progressed from NYHA class 1 to 2 over 2 years. She had unilateral absent first metacarpal and diagnosed on workup to have dysplastic pulmonary valve stenosis and was treated with balloon valvuloplasty. CONCLUSION: Dysplastic pulmonary valve stenosis can rarely be associated with bony hand anomalies like absent first metacarpal.

Phenytoin-induced Stevens-Johnson syndrome with myocarditis: a rare case report.

Stevens-Johnson syndrome (SJS) is an acute life-threatening mucocutaneous reaction caused by excessive necrosis and detachment of the epidermis. It is commonly drug induced and phenytoin is a common precipitant. Phenytoin, an antiepileptic drug, is also known to cause myocarditis. Phenytoin causing both myocarditis and SJS in the same patient is very rare and can lead to increased morbidity and mortality. Here, we describe the case of a 43-year-old male who developed SJS and myocarditis secondary to phenytoin. In spite of aggressive resuscitative efforts, the patient could not be revived. Thus, a combination of myocarditis with SJS increases the mortality and should be considered in patients with SJS secondary to phenytoin and associated shock.