383 ECG in biopsy-proven and clinically suspected myocarditis: morpho-functional correlates and prognostic implications

Aims A distinction exists between biopsy-proven (BP) and clinically suspected (CS) myocarditis, the latter being an exclusion diagnosis based on clinical and instrumental findings. A clear diagnostic and prognostic role of the ECG in these two groups of patients has not yet been defined. (i) To describe frequency and characteristics of ECG findings in myocarditis, and to assess any difference between CS and BP myocarditis; (2) to identify morpho-functional correlates between ECG and cardiac magnetic resonance (CMR); and (iii) to evaluate the prognostic value of ECG findings. Methods and results 162 patients were included (median age 36 years, 70% male, median follow-up 32.9 months), 36 with BP and 126 with CS myocarditis. All patients underwent CMR; for ECG-CMR correlates, the ECG nearest in time to CMR was assessed. Surrogate outcome was defined as left ventricular (LV) ejection fraction (EF) <50% and/or NYHA class >I during follow-up. In the entire cohort ECG alterations were numerous: T-wave inversion (TWI) (82%), fragmented QRS (34%), low voltages (14%), ST elevation (STE) (13%). Compared to CS myocarditis, BP myocarditis patients showed higher frequency of non-sinus rhythm (17% vs. 2%, P < 0.001), long QT (28% vs. 0%, P < 0.001), lateral TWI (36% vs. 19%, P = 0.031) and bundle branch block (19% vs. 2%, P < 0.001). BP myocarditis patients had worse clinical features at diagnosis: heart failure (64% vs. 6%, P < 0.001), arrhythmic (14% vs. 4%, P = 0.029) and fulminant presentation (14% vs. 0%, P < 0.001), and presented higher LV end-diastolic volume and lower LVEF by echocardiography and CMR (109.5 mL/m2 vs. 85.50 ml/m2, P < 0.001; 31.5% vs. 59%, P < 0.001). A correlation was observed between number of myocardial segments with oedema at CMR and low ECG voltages (P = 0.010) and between late gadolinium enhancement (LGE) mass at CMR and lateral STE (P = 0.004 and P = 0.049, respectively). Several ECG alterations correlated with the surrogate outcome: long QT (P = 0.029), lateral TWI (P = 0.006), left bundle branch block (P < 0.001), ventricular ectopic beats (P = 0.020), and atrial fibrillation (P < 0.001). Conclusions A significant difference in ECG findings between CS and BP myocarditis has been demonstrated: ECG alterations are more frequent and more severe in BP myocarditis and correlate with prognosis. Moreover, ECG alterations identified patients with pathologic morpho-functional correlates.

148 ECG abnormalities in COVID-19 pneumonia: acute pericarditis, silent cad, or both? A case report

Aims We report the case of a hypertensive 70 year-old man, who presented to the Emergency Department (ED) with fever, dry cough, malaise, dyspnoea. A nasopharyngeal swab for SARS-CoV-2 test was done, being positive. Methods and results Chest TC demonstrated ground glass bilateral pneumonia. Laboratory test showed WBC 10680/mmc, CRP 20 mg/l, TnT 0.03 ng/l, NTproBNP 147 ng/l. The liver and kidney function were within normal values. ECG was normal. He was treated with high flow oxygen (cPAP), enoxaparin, dexamethasone, doxycycline. After an initial improvement, dyspnoea got worse in 8th day, with the evidence of a new rise of inflammatory markers (PCR 95 mg/l, IL6 49 pg/ml) and the clinical new onset of cardiac rubbings on medical examination. The ECG revealed a sinus rhythm with T wave inversion everywhere. TnT remained normal. Echocardiography revealed a normal ventricular function, without segmentary alterations, absence of valvular disease. A mild pericardial effusion was evidenced, without signs of tamponade. We treated the patient with tocilizumab, after exclusion of other active infective foci. The clinical response was good, the patient was progressively weaned by oxygen and he was discharged asymptomatic. After 15 days, for ECG alterations persistence, despite no signs of ACS, a Coronary TC was done and a subcritical multivessel coronary artery disease was demonstrated: a subcritical IVA stenosis and a calcific MO. Conclusions In conclusion we report a successful treatment of COVID pneumonia likely complicated by acute pericarditis, and we observe that in these patients hypoxemia and cytochine storm possibly bring out silent vascular diseases, otherwise neglected.

J-waves in acute COVID-19: A novel disease characteristic and predictor of mortality?

Background J-waves represent a common finding in routine ECGs (5–6%) and are closely linked to ventricular tachycardias. While arrhythmias and non-specific ECG alterations are a frequent finding in COVID-19, an analysis of J-wave incidence in acute COVID-19 is lacking. Methods A total of 386 patients consecutively, hospitalized due to acute COVID-19 pneumonia were included in this retrospective analysis. Admission ECGs were analyzed, screened for J-waves and correlated to clinical characteristics and 28-day mortality. Results J-waves were present in 12.2% of patients. Factors associated with the presence of J-waves were old age, female sex, a history of stroke and/or heart failure, high CRP levels as well as a high BMI. Mortality rates were significantly higher in patients with J-waves in the admission ECG compared to the non-J-wave cohort (J-wave: 14.9% vs. non-J-wave 3.8%, p = 0.001). After adjusting for confounders using a multivariable cox regression model, the incidence of J-waves was an independent predictor of mortality at 28-days (OR 2.76 95% CI: 1.15–6.63; p = 0.023). J-waves disappeared or declined in 36.4% of COVID-19 survivors with available ECGs for 6–8 months follow-up. Conclusion J-waves are frequently and often transiently found in the admission ECG of patients hospitalized with acute COVID-19. Furthermore, they seem to be an independent predictor of 28-day mortality.

Lithium-induced ECG modifications: navigating from acute coronary syndrome to Brugada syndrome

Lithium is frequently used in the treatment of bipolar disorders and is known to induce ECG alterations. This case study describes various patterns of lithium-induced ECG modifications in a patient with acute-on-chronic lithium intoxication. Clinicians should be familiar with this problem as it can have life-threatening consequences and lead to important changes in patient’s management. Our patient was admitted for acute delirium with an ECG showing atrial fibrillation with wide QRS and ST-segment elevation. These modifications were first mistaken for an acute myocardial infarction and a diagnosis of Brugada syndrome was finally reached. Treatment after the acute phase implied changes in the therapeutic modality and required frequent monitoring.

Does obesity have an effect on the ECG in children?

This review summarizes current data on influences of childhood obesity on the 12-lead electrocardiogram (ECG). Studies on obese adults showed a higher risk of cardiovascular complications and also, partly pathological, ECG alterations. Data on ECG alterations in obese children is rare. In current studies, no pathological findings were found. All alterations, which mimic the later pathological phenomena in obese adults, were within normal ranges. Studies reported significantly longer P-wave time and P-wave dispersion (Pd) in obese children [Üner A, Doğan M, Epcacan Z, Epçaçan S. The effect of childhood obesity on cardiac functions. J Pediatr Endocr Met 2014;27:261–71.], no correlation of heart rate, P-wave, or QT dispersions (QTd) [Akyüz A, Alpsoy S, Akkoyun DC, Nalbantoǧlu B, Tülübaș F, et al. Effect of overweight on P-wave and QT dispersions in childhood. Turk Kardiyol Dern Ars 2013;41:515–21.], significantly higher QTd in obese children [Yildirim S, Binnetoglu FK, Battal F, Aylanc H, Nazan Kaymaz N, et al. Relation between QT variables and left ventricular geometry in athletes and obese children. Acta Med Port 2016;29:95–100.], no significant association between obesity and QTc interval (QTc), but longer PR intervals, wider QRS duration and left axis shifting of frontal P-wave, QRS and T-wave axes [Sun G, Li Y, Zho X, Guuo X, Zhang X, et al. Association between obesity and ECG variables in children and adolescents: a cross-sectional study. Exp Ther Med 2013;6:1455–62.], significant prolongation of QTc, T peak-to-end, and QTd in the obese children [Paech C, Liebold A, Gebauer RA, Wagner F, Vogel M, et al. Relative QT interval prolongation and electrical inhomogeneity of cardiac repolarization in childhood obesity. Prog Pediatr Cardiol 2017;47:64–7.], slight shift to the left in the QRS axis (with no changes in the P axis), increased amplitudes of the left-sided leads in obese children, and no correlation of the heart rate with the weight [Paech C, Anhalt M, Gebauer RA, Wagner F, Vogel M, et al. New normal limits for pediatric ECG in childhood obesity? Influence of childhood obesity on the ECG. Prog Pediatr Cardiol 2018;48:119–23.]. Altogether, the study results are inconsistent. Clearly, pathological phenomena in the ECG of obese children were not reported: only preliminary stages like QTc prolongation within the norm were found. The pathological alterations seen in adult obese patients are not (yet) seen in childhood. The slight changes reported in childhood obesity are likely to manifest later and to develop into pathological phenomena in obese adults and, therefore, might increase the risk of cardiovascular events like arrhythmia and sudden cardiac death in adulthood.

P794 Treadmill exercise stress echocardiography in children; our experience.

Background Exercise stress echocardiography (ESE) is routinely used in adults but its role in children (C) is less established Purpose To assess the feasibility and clinical value of ESE in outpatient children Methods We enrolled 309 consecutive C (mean age = 14,1 ± 2,6 years, range 6-17 yrs) who underwent treadmill ESE between 2002 and 2019: One group (Group I) of 258 C including: 237 with exercise related symptoms (chest pain and/or dyspnea and/ or lypotimia-syncope), 15 with resting ECG alterations, 6 with positive ECG stress test and other group of C (Group II) including: 10 asymptomatic for screening requested by parents, 11 with symptoms unrelated to exercise, 12 with antecedents of sudden death in the family, and 17 with known pathology - 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, 1 each with Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, aortic switch operation. Regional wall motion abnormalities (RWMA) by 2-D and continuous wave Doppler (transvalvular or transaortic or intraventricular (IVG) gradients were assessed in all. Results The success rate was 309/309 (100%). Only one complication (allowing asthma diagnosis by serendipity) occurred: a severe asthmatic crisis in one girl studied because of chest pain with exercise (with ESE negativity), Stress-induced RWMA occurred in 2 pts (one with HCM, the other with normal coronary arteries). A significant orthostatic exercise induced IVG (> 30 mmHg) was present in 101 of the 258 C (39%) studied due to symptoms, ECG alterations or positive stress ECG. In group II the C with induced IVG attained greater heart rate (HR) 184 ± 12 vs 174 ± 16 (p < 0,001); greater blood pressure (BP) 150 ± 19 mmHg vs 136 ± 23 mmHg (p < 0,001). The OR to the reproduced symptoms that motivated the exam during the SE comparing the 101 C with IVG with the 158 without IVG was 8,22 (4,83-13,99) p < 0,001 (95% CI). Conclusions Treadmill ESE is feasible and safe in young people. RWMA are of limited usefulness in our outpatient C group. Doppler often documents significant exercise induced IVG, occult at rest that associate with symptoms. Abstract P794 Figure. ESE Induced IVG in a C with chest pain

Electrocardiographic alterations and raised procalcitonin levels during anaphylactic shock

Anaphylaxis represents a systemic disease occurring after the exposure to an allergen. Drugs for the treatment of anaphylactic reactions (ie, corticosteroids and adrenalin) could induce autonomic alterations, such as tachycardia, hyperthermia, tachypnoea and leucocytosis. We describe the case of a 52-year-old woman presenting with a severe allergic reaction after the ingestion of amoxicillin-clavulanate. The occurrence of ECG alterations, laboratory abnormalities and procalcitonin (PCT) elevation will be discussed with particular emphasis on the possible misleading role of PCT during anaphylactic shock.

Interpretation of electrocardiogram in an ultra-marathon athlete: a case report

The electrocardiogram (ECG) of athletes, especially in those that are endurance-trained, frequently shows some alterations; however, abnormalities of athlete’s ECG may be an expression of an underlying heart disease, which carries a risk of sudden death during sport. It is important that ECG abnormalities are correctly distinguished. We report a case of an ultramarathon athlete who arrived in Emergency Department, after a 100-kilometer race, showing ECG alterations that required further investigations to rule out a cardiac disease. ECG trace showed anterior repolarization abnormalities with ST-segment elevation in V1 to V3 leads. He was admitted to the Cardiology Department and underwent a coronary study that was normal. A cardiac magnetic resonance was also performed. The final diagnosis was athlete’s heart.