640 Cannabis abuse and syncope

Abstract Aims Cannabis (marijuana) is the most consumed drug worldwide, counting roughly 200 million users in 2019 (4% of the global population). Once illegal in most of the world countries, cannabis is now legal for medical and recreational use in several states. During the last 20 years, we have observed a growing decriminalization wave parallel with an increase number of consumers: it is therefore mandatory not only for the cardiologists but for every physician to be aware of marijuana potential cardiovascular adverse health effects. With this paper, we present a case report of cannabis induced 16 s implantable loop recorder (ILR) recorded asystole from hypervagotonia in a 24-year-old heavy marijuana consumer. We focus on the infrequently reported association between syncope and chronic marijuana use and we try to explain the underlying mechanisms against the background of the current literature. Methods and results A 24-year-old presented to the emergency department sent by her cardiologist because of a recent finding of a 16 s asystole on the ILR she implanted 7 months before for recurrent syncopes. She openly declared that she is a heavy marijuana user (at least 5 cannabis-cigarette per day, not mixed up with tobacco, for no less than 12 years). She had a history of at least two spontaneous atypical syncopal episodes and a multitude of pre-syncopal episodes. Before being hospitalized, she underwent several diagnostic tests excluding a neurological etiology and, upon outpatient regimen, she begun a cardiology evaluation which lead to the ILR implantation. While watching TV at late night, the second prodrome-less syncopal episode occurred and a 16-s asystole was found on the ILR. During hospitalization, the patient was closely monitored and we evaluated basic autonomic function tests, carotid sinus massage, echocardiography, exercise stress test, and 24 h telemetry. Following the results of the exams, we considered a heart conduction system anomaly unlikely. Finally, the patient underwent a toxicological and a psychiatric evaluation, where she strongly expressed not wanting to abandon cannabis abuse. After a collective discussion with the heart team, syncope unit, electrophysiologists, and toxicologist, we decided to implant a dual chamber pacemaker with a rate response algorithm due to the high risk of trauma of the syncopal episodes. Conclusions Cannabis cardiovascular effects are not well known; among these we find ischaemic episodes, tachyarrhythmias, symptomatic sinus bradycardia, sinus arrest, and ventricular asystole. In the light of the poor literature, we believe that cannabis may produce opposite adverse effects depending on the duration of the habit. Acute administration increases sympathetic tone and reduces parasympathetic tone; conversely, with chronic intake an opposite effect is observed: repetitive dosing decreases sympathetic activity and increases parasympathetic activity. Physicians should be aware of the effects that cannabis produces upon the cardiovascular system: this could avoid expensive, prolonged hospitalizations, and needless diagnostic tests.

Download Full-text

838Premature Cardiac Conduction Disease in families, potential role for Implantable Loop Recorder in screening? A Case Series

EP Europace ◽

10.1093/europace/euaa162.046 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

Z Sharif ◽

L M Murphy ◽

K A H Al-Harbi ◽

C B Brennan ◽

H C Connaughton ◽

...

Keyword(s):

Diagnostic Yield ◽

Stress Test ◽

Case Series ◽

Exercise Stress Test ◽

Cardiac Risk ◽

Exercise Stress ◽

Cardiac Conduction ◽

Polymorphic Ventricular Tachycardia ◽

Target Heart Rate ◽

Loop Recorder

Abstract OnBehalf Cardiac Risk in the Young (CRY) Ireland Background Cardiac conduction disease (CCD) is a potentially fatal entity. The spectrum ranges from benign clinical course to potentially precipitating sudden cardiac death. Permanent pacemaker (PPM) may benefit affected individuals but the genetic basis of CCD may be underestimated. No prior study has investigated the utility of screening relatives of victims of Sudden Arrhythmic Death Syndrome (SADS) with implantable loop recorders (ILR). Methods We describe 7 families referred to our inherited cardiac conditions service with a family history of SADS, in whom we identified premature CCD. ILR was utilized in screening the majority of families. Results Of 63 individuals screened, 31 (49%) had ILR insertion with 7 (11%) requiring PPM implant. 2/31 had normal baseline tests, and were identified post ILR implant. Other CCD not yet meeting clinical significance was detected in 10/31 (32%) individuals. These findings (documented 11 to 330 days post implant) included pauses of 3-5.8 seconds (n = 7), nocturnal bradycardia < 34 bpm (n = 2) and non-sustained polymorphic ventricular tachycardia. Of families undergoing mutation analysis, conventional genetic panels have been negative to date. Conclusions Inherited premature CCD with variable penetrance may be an under-recognized cause of SADS. To date 12/31 (39%) of individuals with ILR have findings suggesting inherited CCD. As inheritance pattern suggests autosomal dominant transmission, longer follow up may identify more affected individuals. Clinicians involved in SADS family evaluations should consider adding ILR implantation to routine assessment to improve diagnostic yield. We suggest a larger prospective study of consecutive families whose initial investigations following a SADS death have not identified a cause. Summary of Findings Screening Abnormality Family 1 Family 2 Family 3 Family 4 Family 5 Family 6 Family 7 Bradycardia Yes Yes Yes Yes Yes Yes Yes PR >200 Yes No No No No No No <90% PTHR EST No No No No No No No Arrhythmia on EST Yes No No No No Yes No Pauses > 3s Holter/Telemetry Yes No Yes No Yes No Yes High grade AV block Holter Yes Yes No No No No No ILR: significant to date Yes Yes No No No No - ILR: findings to monitor Yes No Yes Yes No Yes - Provocation Testing No Negative No No No No No Genetics Negative Negative Awaited Awaited Awaited Awaited Negative PTHR predicted target heart rate, EST: exercise stress test

Download Full-text

CHARACTERISTICS OF RESTING ECG AMONG SABAH PROFESSIONAL MALE FOOTBALLERS

Malaysian Journal of Movement Health & Exercise ◽

10.15282/mohe.v10i1.499 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Mohamad Azwan Aziz ◽

Redzal Abu Hanifah

Keyword(s):

Blood Pressure ◽

Sinus Bradycardia ◽

Stress Test ◽

Sports Participation ◽

Exercise Stress Test ◽

Left Ventricular ◽

Exercise Stress ◽

Cardiac Pathology ◽

Wave Inversion ◽

Electrocardiogram Ecg

The purpose of this study is to describe the resting electrocardiogram (ECG) seen among 176 professional male footballers from Sabah Football Association Club during preparticipation evaluation. Data were analysed retrospectively from 2017 to 2019. Majority of the players were Sabah natives (n=153, 87%) while the remaining were Malay footballers (n=23, 13%). Mean age of the players was 19.9 ± 3.1, mean body mass index was 22.6 kg/m2 ± 7, mean resting heart rate was 53.6 beats per minute ± 9.4, mean systolic blood pressure was 122.3 mmHg ± 12, and mean diastolic blood pressure was 65.1 mmHg ± 8.8. Using the International Criteria for ECG Interpretation in Athletes 2017 consensus guidelines, 8.5% (n=15) had abnormal ECG while 2.8% (n=5) had borderline ECG. The most common ECG changes seen in the normal findings were sinus bradycardia (n=123, 69.9%), early repolarization (n=115, 65.3%) and left ventricular hypertrophy (n=83,47.2%). Abnormal ECGs were abnormal t wave inversion (n=7,4.0%) and pre-excitation syndrome (n=5,2.9%). All footballers with abnormal ECG findings were subjected to further evaluation by a cardiologist using echocardiography assessment and exercise stress test. They passed the cardiology assessment; thus, they were deemed fit to play. ECG is a valuable tool for pre-participation health screening prior to exercise or sports participation, as it is vital for a physician to identify any abnormal ECG to minimise the risk of sudden cardiac death during exercise due to cardiac pathology.

Download Full-text

Supplemental Arm Pumping Puts Adenosine Testing on Par With Exercise Stress Test

Internal Medicine News ◽

10.1016/s1097-8690(06)74459-6 ◽

2006 ◽

Vol 39 (21) ◽

pp. 43

Author(s):

PATRICE WENDLING

Keyword(s):

Stress Test ◽

Exercise Stress Test ◽

Exercise Stress

Download Full-text

Brugada syndrome: Eligibility for subcutaneous implantable cardioverter-defibrillator after exercise stress test

Revista Portuguesa de Cardiologia (English Edition) ◽

10.1016/j.repce.2020.05.021 ◽

2021 ◽

Vol 40 (1) ◽

pp. 33-38

Author(s):

Pedro von Hafe ◽

Bebiana Faria ◽

Geraldo Dias ◽

Filipa Cardoso ◽

Maria José Alves ◽

...

Keyword(s):

Implantable Cardioverter Defibrillator ◽

Brugada Syndrome ◽

Stress Test ◽

Exercise Stress Test ◽

Exercise Stress ◽

Cardioverter Defibrillator

Download Full-text

Prognostic value of peak stress cardiac power in patients with normal ejection fraction undergoing exercise stress echocardiography

European Heart Journal ◽

10.1093/eurheartj/ehaa941 ◽

2020 ◽

Author(s):

Vidhu Anand ◽

Garvan C Kane ◽

Christopher G Scott ◽

Sorin V Pislaru ◽

Rosalyn O Adigun ◽

...

Keyword(s):

Ejection Fraction ◽

Stress Echocardiography ◽

Stress Test ◽

Peak Stress ◽

Left Ventricular ◽

Exercise Stress ◽

Cardiac Power ◽

Exercise Stress Echocardiography ◽

Lv Mass

Abstract Aims Cardiac power is a measure of cardiac performance that incorporates both pressure and flow components. Prior studies have shown that cardiac power predicts outcomes in patients with reduced left ventricular (LV) ejection fraction (EF). We sought to evaluate the prognostic significance of peak exercise cardiac power and power reserve in patients with normal EF. Methods and results We performed a retrospective analysis in 24 885 patients (age 59 ± 13 years, 45% females) with EF ≥50% and no significant valve disease or right ventricular dysfunction, undergoing exercise stress echocardiography between 2004 and 2018. Cardiac power and power reserve (developed power with stress) were normalized to LV mass and expressed in W/100 g of LV myocardium. Endpoints at follow-up were all-cause mortality and diagnosis of heart failure (HF). Patients in the higher quartiles of power/mass (rest, peak stress, and power reserve) were younger and had higher peak blood pressure and heart rate, lower LV mass, and lower prevalence of comorbidities. During follow-up [median 3.9 (0.6–8.3) years], 929 patients died. After adjusting for age, sex, metabolic equivalents (METs) achieved, ischaemia/infarction on stress test results, medication, and comorbidities, peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.5, 95% confidence interval (CI) 0.4–0.6, P < 0.001] and HF at follow-up [adjusted HR, highest vs. lowest quartile, 0.4, 95% CI (0.3, 0.5), P < 0.001]. Power reserve showed similar results. Conclusion The assessment of cardiac power during exercise stress echocardiography in patients with normal EF provides valuable prognostic information, in addition to stress test findings on inducible myocardial ischaemia and exercise capacity.

Download Full-text

Cardiac Rehabilitation and Physical Performance in Patients after Myocardial Infarction: Preliminary Research

Journal of Clinical Medicine ◽

10.3390/jcm10112253 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2253

Author(s):

Agnieszka Grochulska ◽

Sebastian Glowinski ◽

Aleksandra Bryndal

Keyword(s):

Myocardial Infarction ◽

Cardiac Rehabilitation ◽

Physical Performance ◽

Stress Test ◽

Maximal Oxygen Consumption ◽

Exercise Stress Test ◽

Health Condition ◽

Exercise Stress ◽

Test Time ◽

Before And After

(1) Background: Cardiovascular diseases, in particular, myocardial infarction (MI), are the main threats to human health in modern times. Cardiac rehabilitation (CR), and especially increased physical activity, significantly prevent the consequences of MI. The aim of this study was to assess physical performance in patients after MI before and after CR. (2) Methods: 126 patients after MI were examined. They were admitted to the cardiac rehabilitation ward twice: in the 3rd month after MI, and then in the 6th month after the last rehabilitation session. CR lasted 20 treatment days (4 weeks with 5 treatment days and 2 days’ break). The exercise stress test on the treadmill and a 6-minute walk test (6MWT) were used to assess physical performance. Patients were assigned to an appropriate rehabilitation model due to their health condition. (3) Results: In the studied group, the exercise stress test time and the metabolic equivalent of task (MET), the maximal oxygen consumption (VO2max), and 6MWT score increased significantly (p = 0.0001) at two time-points of observation. (4) Conclusion: CR significantly improves physical performance in patients after MI.

Download Full-text

P1398 Echocardiographic continuous monitoring of exercise stress test using probe fixation device

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.831 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

K Wdowiak-Okrojek ◽

P Wejner-Mik ◽

Z Bednarkiewicz ◽

P Lipiec ◽

J D Kasprzak

Keyword(s):

Image Quality ◽

Physical Exercise ◽

Stress Test ◽

Exercise Stress Test ◽

Bicycle Ergometer ◽

Exercise Stress ◽

Fixation Device ◽

The Mean ◽

First Time

Abstract Background Stress echocardiography (SE) plays an important role among methods of noninvasive diagnosis of ischemic disease. Despite the advantages of physical exercise as the most physiologic stressor, it is difficult (bicycle ergometer) or impossible (treadmill) to obtain and maintain the acoustic window during the exercise. Recently, an innovative probe fixation device was introduced and a research plan was developed to assess the feasibility of external probe fixation during exercise echocardiography on a supine bicycle and upright treadmill exercise for the first time. Methods 37 subjects (36 men, mean age 39 ± 16 years, 21 healthy volunteers, 16 patients with suspected coronary artery disease) were included in this study. This preliminary testing stage included mostly men due to more problematic probe fixation in women. All subjects underwent a submaximal exercise stress test on a treadmill (17/37) or bicycle ergometer (11/37). Both sector and matrix probes were used. We assessed semi-quantitatively the quality of acquired apical views at each stage – the four-point grading system was used (0-no view, 1-suboptimal quality, 2-optimal quality, 3-very good quality), 2-3 sufficient for diagnosis. Results The mean time required for careful positioning of the probe and image optimization was 12 ± 3 min and shortened from 13,7 to 11,1 minutes (mean) in first vs second half of the cohort documenting learning curve. At baseline, 9 patients had at least one apical view of quality precluding reliable analysis. Those patients were excluded from further assessment. During stress, 17 patients maintained the optimal or very good quality of all apical views, whereas in 11 patients the quality significantly decreased during the stress test and required probe repositioning. The mean image quality score at baseline was 2,61 ± 0,48 and 2,25 ± 0,6 after exercise. Expectedly, good image quality was easier to obtain and maintain in the supine position (score 2,74 ± 0,44) points as compared with upright position (score 2,25 ± 0,57). Conclusion This preliminary, unique experience with external probe fixation device indicates that continuous acquisition and monitoring of echocardiographic images is feasible during physical exercise, and for the first time ever - also on the treadmill. This feasibility data stem from almost exclusively male patients and the estimated rate of sufficient image quality throughout the entire test is currently around 60%. We are hoping, that gaining more experience with the product could increase the success rate on exercise tests. Abstract P1398 Figure. Treadmill and ergometer stress test

Download Full-text

Implantable loop recorder: experience of a center

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.015 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

C Marques Pires ◽

P Medeiros ◽

C Oliveira ◽

I Campos ◽

M Flores ◽

...

Keyword(s):

Positive Impact ◽

Blood Pressure Monitoring ◽

Electrophysiological Study ◽

Stress Test ◽

Sinus Node ◽

Oral Anticoagulants ◽

Paroxysmal Supraventricular Tachycardia ◽

Implantable Loop Recorder ◽

Diagnostic Challenge ◽

Loop Recorder

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Symptoms like syncope and palpitations are frequent and represent a diagnostic challenge. The implantable loop recorder (LR) is an important diagnostic tool, in selected cases. AIM To describe the main implantation indications of LR and to evaluate the diagnostic findings and therapeutic interventions. METHODS A retrospective study of patients (pts) that underwent LR implantation in our hospital from 2014 to 2019. For each pt the indication for implantation, baseline characteristics, previous study, recorded tracing and interventions were evaluated. RESULTS A total of 52 pts were included, 56% women, with a mean age of 60 years old. The implantation indications were recurrent syncope/ presyncope in 47 pts (90%) and palpitations in 5 pts (10%). All pts had a baseline echocardiogram and electrocardiogram, with 90% in sinus rhythm. QRS complex and atrial-ventricular conduction was normal in 50% of the pts. Previous to LR implantation, 46 pts (89%) had performed Holter, 19 (37%) carotid sinus massage, 14 (27%) Tilt table test, 29 (56%) stress test, 11(21%) ambulatory blood pressure monitoring and 9 (17%) electrophysiological study. During the monitoring period, 27 pts (52%) had recurrence of the symptoms. In this subgroup, we observed that 67% had a rhythmic cause capable of justified the symptoms, with a median of 5 months since implantation until diagnosis. In addition, the LR was useful in ruling out a rhythmic cause for symptoms in 33% of the cases. In the 47 pts with syncope/presyncope: 6(13%) had sinus node dysfunction, 4 (9%) had atrioventricular conduction disturbance, 1(2%) had atrial fibrillation (AF) and 3 (6%) had ventricular dysrhythmias. In the 5 pts with palpitations: 1(20%) had AF ad 3 (60%) had paroxysmal supraventricular tachycardia. LR results led to cardiac device implantation in 13 pts (pacemaker-9, implantable cardioverter desfibrillator-4). In addition, 2 pts are waiting for electrophysiological study and eventual ablation and 3 pts initiated antiarrhythmic therapy, and those with new diagnosis of AF also initiated oral anticoagulants. CONCLUSION In this study, the implantation of LR was useful to clarify the cause of the symptomology in 52% of the pts. In 35% of pts with symptom-rhythm correlation it ensured timely introduction of therapeutic approach with a positive impact on life quality.

Download Full-text