Kounis syndrome secondary to nimesulide ingestion: a case report

Background Kounis syndrome, also known as "allergic myocardial infarction," is a rare co-occurrence of acute coronary syndrome (ACS) in the setting of hypersensitivity reaction to any agent. Non-steroidal anti-inflammatory drugs (NSAIDs) like are often implicated in causing allergic reactions. Here, we present a case of anterior wall myocardial infarction (AWMI) occurred following angioedema secondary to intake of Nimesulide, not described earlier in literature. Case presentation A 45-year-old female developed generalized pruritic, erythematous maculopapular rash, facial puffiness, oral ulcers and hoarseness of voice within few hours following consumption of Nimesulide for fever and body-ache. Due to development of hypotension, electrocardiogram (ECG) was done, which revealed ST elevation in V2–V6, with marked elevation of troponin (TnI) and creatine kinase (CK-MB). He had no chest pain or shortness of breath. Echocardiography showed regional wall motion (RWMA) abnormality in left anterior descending artery (LAD) territory with an ejection fraction of 25%. Coronary angiography showed a complete thrombotic cutoff of LAD, for which Tirofiban infusion was started to decrease thrombus burden. Repeat angiography on next day showed 80% lesion in proximal LAD for which she underwent revascularization with a drug-eluting stent. The patient later showed improvement in cardiac function at 8 months of follow-up. Conclusions The occurrence of ACS requiring percutaneous coronary intervention (PCI) in the setting of allergic reactions is rarely reported in the literature. One should be aware of the rare possibility of Kounis syndrome in the setting of hypersensitivity reaction when accompanying features of symptoms suggestive of coronary artery disease co-exists. When indicated, ECG monitoring and cardiac biomarkers in patients with allergic responses help to identify this rare and treatable condition.

Global Myocardial Work in Coronary Artery Disease Patients Without Regional Wall Motion Abnormality: Correlation With Gensini Score

PurposeThis study aimed to investigate global myocardial work (GMW), derived from non-invasive left ventricular (LV) pressure-strain loops (PSLs) in coronary artery disease (CAD) patients without regional wall motion abnormality (RWMA), and explored the relationship between GMW and severity of CAD using Gensini score (GS) . Methods120 patients prepared for coronary angiography (CAG) who had left ventricular ejection fraction≥55%, no resting RWMA in two-dimensional echocardiography were enrolled. Global longitudinal strain (GLS), GMW parameters (including global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW) and global myocardial work efficiency (GWE)) were quantified. The severity of coronary lesions was evaluated by GS system based on CAG findings. We divided CAG-confirmed CAD patients into three subgroups according to the tertiles of GS: low 0<GS 16, mid 16<GS 38, and high GS>38. ResultsCAD patients showed a significantly reduced GLS and GWE, but an increased GWW. GLS, GWE, GWI and GCW were significantly decreased in the high-GS group while GWW was increased. GLS, GWE, GWI and GCW was negatively correlated with the GS, GWW was positively correlated with GS. Multivariate regression analysis showed that GWE was the independent factor of predicting coronary stenosis. ROC analysis demonstrated that GWE was the most powerful predictor of high-GS and was superior to GLS. GWE under 91% had the optimal sensitivity and specificity for identifying high-GS. ConclusionThe proposed GWE, which outperformed the GLS, showed the optimal performance and could be considered as a potential predictive indicator to detect severe coronary disease in non-RWMA CAD patients.

Exacerbation of Cardiovascular Complications in case of Covid-19 Patients and their Treatments

The 2019 Corona virus Outbreak (COVID-19) is a scientific, medical and social challenge. The complexity of Severe Acute Respiratory Syndrome Corona virus 2 (SARSCoV2) focuses on the clinical course of unpredictable illnesses that can develop rapidly and cause serious complications leading to death. Systemic inflammation and lung problems can ensue, causing considerable morbidity and mortality. Acute coronary syndrome (ACS), arrhythmias, myocarditis, acute myocardial damage, heart failure, and other problems affect the cardiovascular system. Existing data about cardiovascular complications had been collected from the case study performed in China, Wuhan, and New York COVID-19 patients. In the case report of China, 16.7% out of 138 patients showed arrhythmias where heart failure was identified as a problem in 23% of patients in a retrospective study from Wuhan and 52% of non-survivors in China. On the other hand case studies on 18 COVID-19 patients with ST-elevation myocardial infarction (STEMI) on electrocardiogram (ECG) from New York were investigated; 6 patients (33%) reported chest pain, 14 patients (78%) reported ST-segment elevation, 6 patients (35%) reported regional wall motion abnormality on TTE, and 8 patients (44%) reported a clinical diagnosis of myocardial infarction and a total of 9 patients individuals (50%) had coronary angiography, with 6 patients (67%) of them showing obstructive disease. The cardiovascular consequences of COVID-19 infection are examined in this brief paper. The virus attaches to ACE2 (Angiotensin converting enzyme 2), allowing it to enter. COVID-19 therapy is currently being studied in conjunction with cardiovascular drugs. Therefore, emergency phy

Myocardial deformation techniques as potential tools to detect arrhythmogenic cardiomyopathy in early stages of the disease

Introduction Arrhythmogenic Cardiomyopathy (ACM) is a life-threatening entity which predispose to malignant arrhythmias and sudden cardiac death even in early stages of the disease. Deformation techniques obtained by echocardiography are promising tools which can identify subtle pathologic changes in the myocardial wall. Our aim is to investigate how myocardial deformation parameters may be affected throughout ACM spectrum. Methods A cohort of ACM 45 subjects, was characterized using advanced transthoracic echocardiography and divided into groups according to left ventricle ejection fraction (LVEF). Twenty-three healthy volunteers were also included as control group (CG). We analyzed regional wall motion abnormalities and left ventricular myocardial deformation parameters by 2D Speckle Tracking, such as global longitudinal strain (GLS), mechanical dispersion (MD) [standard deviation (SD) and range (delta)]. Results 23 (51,1%) of the ACM cohort were men, with a mean age of 43,13±16,55 years. Next-generation sequencing identified a potential pathogenic mutation in 37 (82,2%) of the patients. Those ACM subjects with low LVEF (ACM-L) presented lower GLS values when compared to those with normal LVEF (ACM-N) (−16,17±2,68% vs. ACM-N −19,39±2,97%; p&lt;0.001) with no significant differences in MD parameters. ACM-N showed no differences in GLS regarding to CG, but significant differences were found when analyzing MD values, with pathological dispersion times in the ACM-N group (ACM-N DMSD 50,50±20,39ms vs. CG 37,35±17,15ms; p=0,016; ACM-N DMDelta 167,4583±75,07ms vs CG 125±49,13ms; p=0,033). Conclusions MD may be an additive tool for identifying ACM patients in early stages of the disease when LVEF is still preserved. FUNDunding Acknowledgement Type of funding sources: None.

Prognostic value of ABCDE stress echocardiography

Background Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B-lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, EKG-based heart rate reserve. Aim: to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicenter, international, effectiveness study. Methods From July 2016 to November 2020, we enrolled 3,574 all-comers (age 65±11 years, 2,070 males, 58%; ejection fraction 60±10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent ABCDE-SE. The employed stress modality was exercise (n=952, with semi-supine bike, n=887, or treadmill, n=65 with adenosine for step D) or pharmacological stress (n=2,622, with vasodilator, n=2,151; or dobutamine, n=471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only end-point. Results Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D and 37% for E step. During a median follow-up of 21 months, 73 deaths occurred. At univariable analysis, predictors of all-cause mortality were step B (hazard ratio, HR: 2.621, 95% Confidence Intervals, CI: 1.654–4.152, p&lt;0.001), step D (HR: 2.578, 95% CI: 1.624–4.093, p&lt;0.001), and step E (HR: 2.955, 95% CI: 1.848–4.725, p&lt;0.001), but not step A (HR: 1.333, 95% CI: 0.731–2.430, p=0.349) and step C (HR1.581, 95% CI: 0.997–2.506, p=0.051). At multivariable analysis, ABCDE-SE was an independent predictor of mortality with score 3 (HR: 3.472, 95% CI: 1.483–8.135, p=0.004), 4 (HR: 4.045, 95% CI: 1.595–10.259, p=0.003) and 5 (HR: 5.678, 95% CI: 2.106–15.313, p=0.001) (Figure). Annual mortality rate ranged from 0.4% person/year for score 0 up to 2.4% person/year for score 5. Conclusion ABCDE-SE allows an effective risk stratification of patient global vulnerability. FUNDunding Acknowledgement Type of funding sources: None. Survival curves based on ABCDE score

Takotsubo syndrome as an overlooked and elusive cause of a single episode of dyspnea in young women: a case report

Background Dyspnea is a common symptom in patients presenting to the emergency department. It has a variety of causes that range from non-urgent to life-threatening. One episode of dyspnea in a healthy young person is easy to overlook. However, if the symptoms occur after physically or emotionally stressful events, careful evaluation needs to be undertaken because it may be associated with Takotsubo syndrome, which is rarely expected but can be fatal. Herein, we report the case of Takotsubo syndrome in a healthy young woman who arrived at the emergency department after experiencing a short single episode of dyspnea following a minor surgery. Case presentation A 23-year old woman with no underlying chronic disease underwent closed reduction surgery for a nasal bone fracture under general anesthesia (with sevoflurane as the anesthetic). Approximately 5 h later, she presented to the emergency department with dyspnea, which improved soon upon arrival at the emergency department. There were no other symptoms. The dyspnea occurred about 5 h after being discharged on observation, with an uneventful postoperative course. Her electrocardiogram and chest X-ray findings were unremarkable. On testing, troponin I and creatine kinase myocardial band levels were elevated at 6.122 ng/mL and 11.2 µg/L (reference ranges: 0.000–0.046 ng/mL and 0.0–5.0 µg/L), respectively. Bedside echocardiography revealed an ejection fraction of 25%, with mid-ventricular and apical akinesia and basal hyperkinesia. The pulmonary and coronary angiographic computed tomographic scans were unremarkable. Hence, apical Takotsubo syndrome was suspected. A follow-up echocardiogram taken 5 days after admission showed full recovery with a normalized ejection fraction (60%) and no regional wall motion abnormality. The patient was discharged on the sixth day with no other complications. Conclusion When atypical symptoms, such as transient dyspnea, manifest, it becomes necessary to suspect and diagnose Takotsubo syndrome to ensure timely and appropriate medical management, especially when a preceding stressful event, such as minor surgery has occurred. It might be helpful to perform bedside point-of-care echocardiography to check for regional wall motion abnormalities that are typically associated with Takotsubo syndrome.

A Novel Diagnostic Score Integrating Atrial Dimensions to Differentiate between the Athlete’s Heart and Arrhythmogenic Right Ventricular Cardiomyopathy

Objective: The 2010 Task Force Criteria (TFC) have not been tested to differentiate ARVC from the athlete’s heart. Moreover, some criteria are not available (myocardial biopsy, genetic testing, morphology of ventricular tachycardia) or subject to interobserver variability (right ventricular regional wall motion abnormalities) in clinical practice. We hypothesized that atrial dimensions are useful and robust to differentiate between both entities and proposed a new diagnostic score based upon readily available parameters including echocardiographic atrial dimensions. Methods: In this observational study, 21 patients with definite ARVC were matched for age, gender and body mass index to 42 athletes. Based on ROC analysis, the following parameters were included in the score: indexed right/left atrial volumes ratio (RAVI/LAVI ratio), NT-proBNP, RVOT measurements (PLAX and PSAX BSA-corrected), tricuspid annular motion (TAM), precordial TWI and depolarization abnormalities according to TFC. Results: ARVC patients had a higher RAVI/LAVI ratio (1.76 ± 1.5 vs. 0.87 ± 0.2, p < 0.001), lower right ventricular function (fac: 29 ± 10.1 vs. 42.2 ± 5%, p < 0.001; TAM: 19.8 ± 5.4 vs. 23.8 ± 3.8 mm, p = 0.001) and higher serum NT-proBNP levels (345 ± 612 vs. 48 ± 57 ng/L, p < 0.001). Our score showed a good performance, which is comparable to the 2010 TFC using those parameters, which are available in routine clinical practice (AUC93%, p < 0.001 (95%CI 0.874–0.995) vs. AUC97%, p < 0.001 (95%CI 0.93–1.00). A score of 6/12 points yielded a specificity of 91% and an improved sensitivity of 67% for ARVC diagnosis as compared to a sensitivity of 41% for the abovementioned readily available 2010 TFC. Conclusions: ARVC patients present with significantly larger RA compared to athletes, resulting in a greater RAVI/LAVI ratio. Our novel diagnostic score includes readily available clinical parameters and has a high diagnostic accuracy to differentiate between ARVC and the athlete’s heart.

Acute ST-segment elevation myocardial infarction secondary to vaccine-induced immune thrombosis with thrombocytopaenia (VITT)

A 40-year-old man with no cardiac history presented with central chest pain 8 days after receiving the ChAdOx1 nCov-19 vaccine against COVID-19. Initial blood tests demonstrated a thrombocytopaenia (24×109 μg/L) and a raised d-dimer (>110 000 μg/L), and he was urgently transferred to our tertiary referral central for suspected vaccine-induced immune thrombocytopaenia and thrombosis (VITT). He developed dynamic ischaemic electrocardiographic changes with ST elevation, a troponin of 3185 ng/L, and regional wall motion abnormalities. An occlusion of his left anterior descending coronary artery was seen on CT coronary angiography. His platelet factor-4 (PF-4) antibody returned strongly positive. He was urgently treated for presumed VITT with intravenous immunoglobulin, methylprednisolone and plasma exchange, but remained thrombocytopaenic and was initiated on rituximab. Argatroban was used for anticoagulation for his myocardial infarction while he remained thrombocytopaenic. After 6 days, his platelet count improved, and his PF-4 antibody level, troponin and d-dimer fell. He was successfully discharged after 14 days.

Echocardiographic Findings and Associated Factors in HIV Infected Patients at a Tertiary Hospital in Ethiopia

Background: Non-communicable diseases including cardiovascular diseases are becoming an important part of Human Immunodeficiency Virus (HIV) care. Echocardiography is a useful non-invasive tool to assess for cardiac disease and different echocardiographic abnormalities have been seen previously. Available evidence on the echocardiographic abnormalities in Ethiopia is scarce. The aim of this study was to investigate the echocardiographic abnormalities in HIV infected patients and factors associated with the findings.Methods: A cross-sectional study was conducted on 285 patients with HIV infection including collection of clinical and echocardiographic data. Logistic regression was used to examine the association between echocardiographic abnormalities and associated factors with variables with a p-value of < 0.05 in the multivariate model considered statistically significant.Results: Diastolic dysfunction was the most common abnormality seen in 30.1% of the participants followed by regional wall motion abnormality (22.2%), left ventricular hypertrophy (10.3%), enlarged left atrium (8.1%), pulmonary hypertension (3.5%) and pericardial effusion (2.1%). Almost all patients had normal left ventricle systolic function. Diastolic dysfunction was independently associated with increasing age, elevated blood pressure and left ventricular hypertrophy while regional wall motion abnormality was associated with male gender, increasing age and abnormal fasting blood glucose. Left ventricular hypertrophy was associated with increasing age and blood pressure and the later was associated with left atrial enlargement. The level of immunosuppression did not affect echocardiography findings. Conclusions: A high prevalence of echocardiographic abnormalities was found and included diastolic dysfunction, regional wall motion abnormality, left ventricular hypertrophy and left atrial enlargement. Male gender, age above 50 years, elevated blood pressure and elevated fasting blood glucose were associated with echocardiographic abnormalities. Appropriate screening and treatment of echocardiographic abnormalities is needed.