scholarly journals 409 Not all ST elevation are myocardial infarction: a lesson learned from ‘spiked helmet sign’

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Guido Del Monaco ◽  
Sara Bombace ◽  
Antonio Taormina
Keyword(s):  
Mechanical Ventilation ◽  
Life Support ◽  
Bowel Perforation ◽  
Critical Conditions ◽  
Qtc Interval ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
First Case ◽  
St Segment ◽  
Abdominal Disease

Abstract Aims ST segment elevation is an electrocardiogram (ECG) finding first of all suggestive of acute coronary syndrome (ACS). However, there are other causes of ST segment elevation that seem to not have any relationship with coronary artery disease (CAD). One of these is the so-called ‘Spiked Helmet Sign’ (SHS), an ECG pattern characterized by upslope of ST segment before R wave onset that is reported to be found in critical illness and is associated with negative outcomes. Methods and results A 14-years-old boy came comatose (Glasgow Coma Scale = 4) to the Emergency Room after being run over by a car. He was immediately intubated and mechanically ventilated. Baseline ECG was reported to be normal, showing an incomplete right bundle branch block and a slightly prolonged QTc interval. CT-scan showed subarachnoid haemorrhage and multiple skull fractures requiring decompressive craniectomy. During hospitalization the patient developed marked hypotension complicated by rise of inflammation indexes and 12 lead ECG revealed new-onset of diffuse ST-segment elevation with spike-and-dome appearance mainly in lateral precordial leads, while lead II and V2 didn’t show any ST-segment alteration. Transthoracic echocardiogram was reported to be normal. Due to critical conditions and low likelihood of CAD, angiography wasn’t performed. The clinical course was worsened by occurrence of hyperkalaemia, acute kidney injury, and multiple episodes of ventricular tachycardia evolving in pulselessness electrical activity which required advanced life support. The patient subsequently died due to multi-organ failure, without the possibility of escalation therapy due to his status. SHS is an emerging ECG sign that is reported to be associated with critical conditions (mechanical ventilation, sepsis, bowel perforation) and in the majority of cases it is not related to CAD. It usually occurs in inferior leads (especially in case of abdominal disease) and in precordial leads (pneumothorax, aortic dissection, mechanical ventilation). Our patient had features consistent with previous cases reported in literature and, even if he experienced several episodes of cardiac arrest and blood exams revealed elevated values of cardiac troponin, the typical ECG pattern and the normal echocardiogram suggest SHS instead of ACS, avoiding unnecessary percutaneous coronary intervention. As reported in literature, even if in our case the appearance of this sign was associated with poor prognosis. Conclusions SHS mainly occurs in critically ill patients and is associated with death and poor outcomes. The potential pathophysiological mechanisms are still unclear. It is important to promptly recognize this pattern and differentiate between other causes of ST-segment elevation to select the appropriate therapy according to the setting. This is the first case-report among Italian hospitals of SHS.

scholarly journals Electrocardiographic Findings in Takotsubo Cardiomyopathy: ECG Evolution and Its Difference from the ECG of Acute Coronary Syndrome

2014 ◽  
Vol 8 ◽  
pp. CMC.S14086 ◽  
Author(s):  
June Namgung
Keyword(s):  
Acute Coronary Syndrome ◽  
Takotsubo Cardiomyopathy ◽  
Apical Ballooning ◽  
Left Ventricular ◽  
Qtc Interval ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
T Wave ◽  
Wave Inversion ◽  
St Segment

Background Electrocardiogram (ECG) manifestations of takotsubo cardiomyopathy (TC) produce ST-segment elevation or T-wave inversion, mimicking acute coronary syndrome (ACS). We describe the ECG manifestation of TC, including ECG evolution, and its different points from ACS. Methods We studied 37 consecutive patients (age 67 ± 15 years, range 23-89, M:F = 12:25) from March 2004 to November 2012 with a diagnosis of TC who were proven to have apical ballooning on echocardiography or left ventricular angiography and normal coronary artery. We analyzed their standard 12-lead ECGs, including rate, PR interval, QRS duration, corrected QT (QTc) interval, ECG evolutions, and arrhythmia events. Results Two common ECG findings in TC were ST-segment elevation (n = 13, 35%) and T inversion (n = 24, 65%), mostly in the precordial leads. After ST-segment resolution, in a few days (3.5 days), diffuse and often deep T-wave inversion developed. Eight patients (22%) had transient Q-waves lasting a few days in precordial leads. No reciprocal ST-segment depression was noted. T-wave inversion continued for several months. QT prolongation (>440 milliseconds) was observed in 37 patients (97%). There were no significant life-threatening arrhythmias except atrial fibrillation (n = 6, 16%). Conclusion There are distinct differences between the ECGs of TC and ACS. These differences will help to differentiate TC from ACS.

Efficacy and Safety of Evolocumab in Reducing Low Density Lipoprotein Cholesterol Levels in Chinese Patients with Non-ST-segment Elevation Acute Coronary Syndrome

2020 ◽  
Vol 18 ◽  
Author(s):  
Xiaohan Xu ◽  
Meng Chai ◽  
Yujing Cheng ◽  
Pingan Peng ◽  
Xiaoli Liu ◽  
...  
Keyword(s):  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Statin Treatment ◽  
Chinese Patients ◽  
Lipid Lowering ◽  
Control Group ◽  
Lipid Lowering Therapy ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment

Aims: To explore early intensive lipid-lowering therapy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Background: Lowering low-density lipoprotein cholesterol (LDL-C) levels can reduce cardiovascular morbidity and mortality in patients with atherosclerotic cardiovascular disease. Due to many reasons, the need for early intensive lipid-lowering therapy is far from being met in Chinese NSTE-ACS patients at high-risk of recurrent ischaemic events. Objective: To evaluate the feasibility, safety and efficacy of starting evolocumab in hospital to lower LDL-C levels in Chinese patients with NSTE-ACS. Methods: In this prospective cohort study initiated by researchers, 334 consecutive patients with NSTE-ACS who had sub-standard LDL-C levels (LDL-C ≥2.3 mmol/L after regular oral statin treatment for at least 4 weeks; or LDL-C ≥3.2 mmol/L without regular oral statin treatment) were included. Patients who agreed to treatment with evolocumab (140 mg subcutaneously every 2 weeks, initiated in hospital and used for 12 weeks after discharge) were enrolled in the evolocumab group (n=96) and others in the control group (n=238). All enrolled patients received regular statin treatment (atorvastatin 20 mg/day or rosuvastatin 10 mg/day; doses unchanged throughout the study).The primary endpoint was the change in LDL-C levels from baseline to week 12. Results: Most patients (67.1%) had not received regular statin treatment before. In the evolocumab group, LDL-C levels decreased significantly at week 4 and remained stable at week 8 and 12 (all p<0.001). At week 12, the LDL-C percentage change from baseline in the evolocumab group was -79.2±12.7% (from an average of 3.7 to 0.7 mmol/L), while in the control group it was -37.4±15.4% (from an average of 3.3 to 2.0 mmol/L). The mean difference between these 2 groups was -41.8% (95% CI -45.0 to -38.5%; p<0.001). At week 12, the proportions of patients with LDL-C levels <1.8 mmol/L and 1.4 mmol/L in the evolocumab group were significantly higher than in the control group (96.8 vs 36.1%; 90.6 vs 7.1%; both p<0.001). The incidence of adverse events and cardiovascular events was similar in both groups. Conclusions: In this prospective cohort study we evaluated the early initiation of evolocumab in NSTE-ACS patients in China. Evolocumab combined with statins significantly lowered LDL-C levels and increased the probability of achieving recommended LDL-C levels, with satisfactory safety and well tolerance.

Prognostic Significance of Relative Hyperglycemia after Percutaneous Coronary Intervention in Patients with and without Recognized Diabetes

2020 ◽  
Vol 19 (1) ◽  
pp. 91-101 ◽  
Author(s):  
Qi Zhao ◽  
Ting-Yu Zhang ◽  
Yu-Jing Cheng ◽  
Yue Ma ◽  
Ying-Kai Xu ◽  
...  
Keyword(s):  
Prognostic Significance ◽  
Coronary Intervention ◽  
Major Adverse Cardiovascular Events ◽  
St Segment Elevation ◽  
Glycemic Level ◽  
Prognostic Effect ◽  
Coronary Syndrome ◽  
St Segment ◽  
Diabetic Population ◽  
Shape Curve

Background: The research on the association between the relative glycemic level postpercutaneous coronary intervention (PCI) and adverse prognosis in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients is relatively inadequate. Objective: The study aimed to identify whether the glycemic level post-PCI predicts adverse prognosis in NSTE-ACS patients. Methods: Patients (n=2465) admitted with NSTE-ACS who underwent PCI were enrolled. The relative glycemic level post-procedure was calculated as blood glucose level post-PCI divided by HbA1c level, which was named post-procedural glycemic index (PGI). The primary observational outcome of this study was major adverse cardiovascular events (MACE) [defined as a composite of all-cause death, non-fatal myocardial infarction (MI) and any revascularization]. Results: The association between PGI and MACE rate is presented as a U-shape curve. Higher PGIs [hazard ratio (HR): 1.669 (95% confidence interval (CI): 1.244-2.238) for the third quartile (Q3) and 2.076 (1.566-2.753) for the fourth quartile (Q4), p<0.001], adjusted for confounding factors, were considered to be one of the independent predictors of MACE. The association between the PGI and the risk of MACE was more prominent in the non-diabetic population [HR (95%CI) of 2.356 (1.456-3.812) for Q3 and 3.628 (2.265-5.812) for Q4, p<0.001]. There were no significant differences in MACE risk between PGI groups in the diabetic population. Conclusion: Higher PGI was a significant and independent predictor of MACE in NSTE-ACS patients treated with PCI. The prognostic effect of the PGI is more remarkable in subsets without pre-existing diabetes than in the overall population. The predictive value of PGI was not identified in the subgroup with diabetes.

Brain-derived neurotrophic factor is associated with coronary macrophage infiltrates in patients with acute coronary syndrome

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R.A Montone ◽  
M Camilli ◽  
M Russo ◽  
M Del Buono ◽  
F Gurguglione ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Neurotrophic Factor ◽  
Serum Levels ◽  
Brain Derived Neurotrophic Factor ◽  
C Reactive Protein ◽  
St Segment Elevation ◽  
Protein Levels ◽  
Reactive Protein ◽  
Coronary Syndrome ◽  
St Segment

Abstract Background Brain-derived neurotrophic factor (BDNF) is a neurotrophine that plays a key role in the regulation of both central and peripheral nervous system. Moreover, BDNF is secreted in multiple tissues and exerts systemic, autocrine, and paracrine effects in the cardiovascular system. Of importance, BDNF expression was enhanced in macrophages and smooth muscle cells in atherosclerotic coronary arteries and may be involved in thrombus formation. Thus, BDNF has been suggested as an important link between inflammation and thrombosis, potentially involved in the pathogenesis of acute coronary syndrome (ACS). Purpose In our study we aimed at assessing serum levels of BDNF in patients with ACS, evaluating differences according to clinical presentation [ST-segment elevation myocardial infarction (STEMI) vs. Non-ST-segment elevation ACS (NSTE-ACS)]. Moreover, we assessed the presence of optical coherence (OCT)-defined macrophage infiltrates (MØI) in the culprit vessel of ACS patients and evaluated their relationship with BDNF levels. Methods ACS patients were prospectively selected. Blood samples were collected at admission and serum levels of BDNF were subsequently assessed. Presence of OCT-defined MØI along the culprit vessel was assessed. Results 166 ACS patients were enrolled [mean age 65.3±11.9 years, 125 (75.3%) male, 109 STEMI, 57 NSTE-ACS]. Serum levels of BDNF were higher among STEMI patients compared with NSTE-ACS [median (IQR) 2.48 pg/mL (1.54–3.34) vs. 2.12 pg/mL (1.34–2.47), p=0.007], while C-reactive protein levels did not differ between the two groups. OCT assessment was performed in 53 patients and MØI were detected in 27 patients. Of importance, patients with MØI in the culprit vessel had higher levels of BDNF compared with patients without MØI [median (IQR) 2.23 pg/mL (1.38–2.53) vs. 1.41 pg/mL (0.93–2.07), p=0.023], while C-reactive protein levels did not differ between the two groups. Of note, at multivariate regression analysis BDNF levels were independent predictor of MØI [OR: 2.20; 95% CI (1.02–4.74), p=0.043]. Conclusions Serum levels of BDNF may reliable identify the presence of local macrophage inflammatory infiltrates in patients with ACS. Moreover, BDNF levels are higher in patients with STEMI compared with NSTE-ACS. Taken together, these data suggest that BDNF may represent an interesting link between local inflammatory activation and enhanced thrombosis in ACS. BDNF serum levels Funding Acknowledgement Type of funding source: None

scholarly journals Effect of PCSK9 E670G and R46L Polymorphisms on Major Adverse Cardio-Cerebrovascular Events in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

2021 ◽  
Author(s):  
Anwar Santoso ◽  
Yulianto Yulianto ◽  
Hendra Simarmata ◽  
Abhirama Nofandra Putra ◽  
Erlin Listiyaningsih
Keyword(s):  
Myocardial Infarction ◽  
Proportional Hazards Model ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Segment Elevation Myocardial Infarction ◽  
Cerebrovascular Events ◽  
St Segment ◽  
Significant Difference

AbstractMajor adverse cardio-cerebrovascular events (MACCE) in ST-segment elevation myocardial infarction (STEMI) are still high, although there have been advances in pharmacology and interventional procedures. Proprotein convertase subtilisin/Kexin type 9 (PCSK9) is a serine protease regulating lipid metabolism associated with inflammation in acute coronary syndrome. The MACCE is possibly related to polymorphisms in PCSK9. A prospective cohort observational study was designed to confirm the association between polymorphism of E670G and R46L in the PCSK9 gene with MACCE in STEMI. The Cox proportional hazards model and Spearman correlation were utilized in the study. The Genotyping of PCSK9 and ELISA was assayed.Sixty-five of 423 STEMI patients experienced MACCE in 6 months. The E670G polymorphism in PCSK9 was associated with MACCE (hazard ratio = 45.40; 95% confidence interval: 5.30–390.30; p = 0.00). There was a significant difference of PCSK9 plasma levels in patients with previous statin consumption (310 [220–1,220] pg/mL) versus those free of any statins (280 [190–1,520] pg/mL) (p = 0.001).E670G polymorphism of PCSK9 was associated with MACCE in STEMI within a 6-month follow-up. The plasma PCSK9 level was higher in statin users.

Baseline CHA 2 DS 2 ‐VASc score and prognosis in octogenarians with non‐ST segment elevation acute coronary syndrome

2021 ◽  
Author(s):  
Pablo Díez‐Villanueva ◽  
Alberto Vera ◽  
Albert Ariza‐Solé ◽  
Francesc Formiga ◽  
Manuel Martínez‐Sellés ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Elevation Acute Coronary Syndrome
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