Takotsubo Cardiomyopathy as a Complication/ Sequelae of Prolonged Refractory Seizure: A Case Report from Nepal

Takotsubo cardiomyopathy(TC) is a reversible, yet underdiagnosed cause of mortality and morbidity in the intensive care units. It occurs secondary to sudden catecholamine surge precipitated by any form of emotional or pathological stress. Association between central nervous system disorders and Takotsubo cardiomyopathy is being increasingly reported. Epilepsy is the second most common CNS disorder to trigger TC, SAH being the first. We report a case of TC in an elderly man with prolonged, recurrent seizure episodes refractory to the commonly used antiepileptic drugs (AEDs), who developed unexplained tachycardia, hypotension and elevated cardiac enzymes.

The evaluation of cTnT/CK-MB ratio is as a predictor of change in cardiac function after myocardial infarction

Objective: Cardiac enzymes that are released during acute myocardial infarction (AMI) are of prognostic importance. This study aimed to investigate the relationship between cardiac troponin T (cTnT) and creatine kinase myocardial band (CK-MB) release during AMI and 6-month post-AMI left ventricular (LV) function, as assessed by magnetic resonance imaging. Methods: This prospective cohort observational study included 131 adult patients (113 males, 18 females, mean age 53.8 (8.6) years) who had been diagnosed with a new ST-segment elevation AMI (STEMI) in the emergency department. Cardiac enzymes were assessed by serial measurements. Blood samples obtained at 12 h post-AMI were included in the analysis. The reference value for CK-MB was 2–25 U/L, while for troponin it was - 0.1 ng/mL. Values above the reference limit were accepted as positive. Patients underwent cardiovascular magnetic resonance at 2 weeks and 6 months post-AMI. LV stroke volume was quantified as LV EDV – LV ESV, and ejection fraction (EF) was determined with the following equation: EF = [(LV EDV – LV ESV)/LV EDV] × 100. Adverse remodeling was defined based on the threshold values that are commonly accepted for changes in the LV end-diastolic volume (∆LV-EDV, &qt;10%) and LV end-systolic volume (∆LV-ESV, &qt;12%). Results: All of the patients were cTnT- and CK-MB-positive at 12 h. There was no found significant difference between both groups regarding the risk factors of coronary artery disease (including diabetes mellitus, hypertension, hyperlipidemia and smoking). Adverse cardiac remodeling was observed in 32.1% (n = 42) of the patients. cTnT/CK-MB was determined to be an independent predictor of the ΔLV-EDV (β ( SE = 0.55 ( 0.08, p<0.001), ΔLV-ESV (β ( SE = 1.12 ( 0.28, p<0.001), and adverse remodeling (OR = 1.13, p<0.001). The cTnT/CK-MB ratio was able to predict adverse remodeling with 85.7% sensitivity and 74.2% specificity (area under the ROC curve (AUC) = 0.856, p<0.001). The cTnT levels were able to predict adverse remodeling with 73.8% sensitivity and 78.7% specificity (AUC = 0.796, p<0.001). CK-MB did not significantly predict adverse remodeling (AUC = 0.516, (p=0.758). Conclusion: The cTnT/CK-MB ratio was superior to its components in predicting changes in LV function after STEMI. The cTnT/CK-MB ratio can be used in clinical practice for risk stratification and treatment optimization.

Acute Myocarditis Due to Scorpion Sting in a 9-year-old Girl

A 9-year-old girl with signs and symptoms of acute toxic myocarditis and cardiogenic shock with elevated cardiac enzymes was admitted to the Critical Care Unit (CCU) of our hospital with an ejection fraction of 25%. The patient was managed with supportive care and the administration of polyvalent antivenom and inotropes, and after 8 days, she was discharged without any complication with normal ejection fraction. Toxic myocarditis can be a result of scorpion envenomation. After two months of follow-up, the patient recovered completely and medications were discontinued.

Abstract P257: Refractory Hypertension Partially Improved With Anxiolytics

Background: Resistant hypertension is a BP that is not controlled by three or more anti-hypertensive medications of different classes, including diuretics. Refractory hypertension is an evolving term reflecting a BP that is not controlled with five agents or more of different anti-hypertensive classes, including diuretics. Patient with refractory HTn has to have secondary hypertension workup. Case: A 45-year-old lady with a known past medical history of obesity, HTN, and DM-II. She was admitted as she had generalized fatiguability and vague chest pain. The ECG, and the TTE showed hypertensive heart disease. She had normal cardiac enzymes. Initial BP was recorded to be 185/127 mmHg. Consequently, she was commenced on anti-HTN medications. Her BP was difficult to control with the maximum doses of six anti-HTH medications (amlodipine, valsartan, hydralazine, indapamide, labetalol, spironolactone)(Fig 1). Decision-making: All the secondary causes of HTN were excluded; normal renin-aldosterone ratio, normal US doppler for the renal arteries, normal sleep study, normal CT chest and abdomen looking for masses, normal dotatate scan, and negative pheochromocytoma work-up. Because she had social stress, she was commenced on anxiolytics (alprazolam). Subsequently, the BP reading improved by around 10-20 SBP; however, her average reading continued to be around 160/90 mmHg. Conclusion: Refractory hypertension is a management dilemma, especially when the causes of secondary hypertension are excluded. Benzodiazepines can be a reasonable option in certain situations where the refractory hypertension is believed to be stress-induced.

TAKATSUBO CARDIOMYOPATHY AFTER CAESEREAN SECTION – A CASE REPORT.

BACKGROUND : Acute cardiac complications in peripartum period provide a diagnostic challenge. Takatsubo cardiomyopathy occurs most frequently in postmenopausal women exposed to emotionalandphysicalstress. We report a case of apical ballooning syndrome, also known as Takotsubo Cardiomyopathy (TCM) or broken-heart syndrome, in a preeclamptic patient post operatively. CASE : 44 year preeclamptic primi presented with dyspnoea three hours after sub arachnoid block for caeserean. On evaluation, trans thoracic echo revealed apical ballooning with global hypokinesia along with raised NT-Pro BNP level. ECG and cardiac enzymes werenormal. She was intubated, ventilated and treated with inotropes and anti failure medications by a multidiciplinary team.She was extubated on Postoperativeday (POD) 3 and discharged on POD 13 with stable vitals. Her echo done on third month was completely normal with adequate left ventricular function. CONCLUSION : Physical, emotional stress and oestrogen deciency in immediate post partum period may be the predisposing risk factors for TCM even if regional anaesthesia is given. Trans thoracic echo plays a vital role in differenciating TCM from other peripartumcardiac complications like pulmonary thrombo embolism, peripartum cardimyopathy or acute coronary syndrome.

Cardiac magnetic resonance in COVID-19 positive and probable cases: A report from a high volume CMR centre in Ireland

Funding Acknowledgements Type of funding sources: None. Introduction Coronavirus disease 2019 (COVID-19) infection can have multisystem involvements. The inflammation sequelae can cause myocarditis. The COVID-19 pandemic has impacted Ireland significantly. Understanding of myocardial involvement in COVID-19 is not fully elucidated but has been reported. The Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic in Ireland is a high volume CMR centre with approximately 4500 cases per year and accepting referral from all hospital in Ireland. These analyses are to describe the CMR findings in COVID-19 positive and probable cases attending the centre. Methods Consecutive 65 referrals with mention of "COVID-19" from March 2020 to December 2020 was assessed. 56 cases were included in this analysis. Cases were categorised as COVID-19 positive cases or probable (viral illness like symptoms) cases. The demography and CMR parameters were collected. Serial imaging of selected cases was included. Descriptive analyses methods were applied. Results In the period of 10 months, there was 49 COVID-19 positive cases (65.3% male; median age 49 [32 : 61] years) and 7 COVID-19 probable cases (42.9% male; median age 39 [37 : 59] years). In the COVID-19 positive cases, 25 had normal CMR, 11 has evidence of myocarditis, 1 with pericarditis, 2 with infarction/ischaemia, 3 with dilated cardiomyopathy, 2 with hypertrophic cardiomyopathy and 5 with other findings. There were 3 COVID-19 positive cases with serial imaging showing resolving myocarditis (100% female; median age 41 [30 : 47] years). 2 professional athletes with COVID-19 positive test showed no evidence of myocarditis. There are no significant differences in the age of male COVID-19 positive versus female group (p= 0.0752). Different demography and CMR parameters and tissue characterisation are described in Table 1 and Table 2. Conclusions The prevalence of myocarditis in this cohort is approximately 1 in 5 (21.4%). Within the COVID-19 positive cases, the prevalence is 22.4%. These observations may reflect selection bias for CMR referral in those with cardiac symptoms or cardiac enzymes leak.

Cross talk of serum elements, cardiac and liver enzymes in patients with HCV chronic hepatitis and hepatocellular carcinoma in Pakistani population

HCV-associated hepatic pathologies are now the frequent inducer of cardiac abnormalities because of cardio-hepatic interaction. Studies are going on to elucidate and highlight the possible factors involved in this complex interaction, but this paradigm is still unclear. Here, we aimed to explore the interrelationship among electrolytes, cardiac, and liver enzymes in HCV-associated hepatic abnormalities, including chronic hepatitis and hepatocellular carcinoma in the Pakistani population. 100 Hepatitis C virus (HCV) infected patients with liver disorders and 50 healthy individuals were recruited in the present analysis. Trace elements, ions, and enzyme concentrations were quantified via an automatic analyzer, while HCV was confirmed by enzyme-linked immunosorbent assay (ELISA). Our results demonstrated that serum Ca++, Mg++, Fe++, Cl-, and PO4- levels were significantly increased in HCV patients with hepatic pathologies, including cirrhosis and carcinoma. Cardiac enzymes, including aspartate aminotransferase (AST), creatine kinase (CK2), and lactate dehydrogenase (LDH) concentration, were also elevated in HCV patients. Furthermore, serum cholesterol and triglyceride levels significantly differed in HCV patients than in normal individuals. Impaired alkaline transaminase (ALT) and alkaline phosphatase levels in HCV patients further validate the HCV patients' hepatic pathologies. Interestingly, all these impaired factors were positively correlated with the progression of hepatic disorders. In conclusion, altered ionic concentrations, cardiac enzymes, and liver dysfunction markers suggest their significant relationship to HCV leading liver pathologies in the Pakistani population.