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.

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.

Flecainide toxicity with high pacemaker capture thresholds and associated takotsubo syndrome

We describe a case of a woman in her 80s with persistent atrial fibrillation (AF) despite being on flecainide who was admitted for AF with rapid ventricular response. Attempts with direct-current cardioversions were unsuccessful despite increased doses of the antiarrhythmic therapy. At atrioventricular (AV) nodal ablation, very high right ventricular capture thresholds resulted in abortion of the procedure as back-up ventricular pacing could not be assured with adequate margin for safety. Shortly following the electrophysiology (EP) study, the patient developed cardiogenic shock with new apical left ventricular regional wall motion abnormality suggestive of apical ballooning and a toxic-appearing wide QRS complex electrocardiogram (EKG). The patient was successfully treated with sodium bicarbonate infusion for presumed flecainide toxicity. The regional wall motion abnormality and EKG changes resolved along with normalisation of capture thresholds after 2 days of treatment. The patient underwent an uncomplicated successful AV nodal ablation several weeks later.

Risk Factors for Left Ventricular Dysfunction Following Surgical Management of Cardiac Fibroma

Background: Surgical resection of cardiac fibromas in children reduces hemodynamic and arrhythmia burden; however, little is known about postoperative left ventricular (LV) function. We aimed to evaluate factors associated with postoperative LV dysfunction. Methods: In this retrospective observational cohort study, imaging data were reviewed from 41 patients who had undergone surgical resection of a cardiac fibroma. Tumor volume was indexed to body surface area (tumor volume index). Right ventricular tumors were excluded from analysis of postoperative ventricular function. Postoperative regional wall motion abnormality score was defined as number of wall segments with regional wall motion abnormality, and LV dysfunction was defined as LV ejection fraction <50%. Cardiovascular magnetic resonance-derived strain was low if <5%ile by previously published normative data. Results: Of 41 patients who underwent resection at a median age of 2.1 years (range, 0.5–19), 37 fibromas were in the LV, (29 free wall and 8 septal), and 4 in the right ventricle. Preoperative median tumor volume index was 66 mL/m 2 (range, 11–376). Of 37 patients with LV tumors, younger patients had larger tumor volume index and higher grades of preoperative mitral regurgitation ( P <0.001). Larger tumor volume index correlated with higher postoperative regional wall motion abnormality score ( P <0.001). By paired pre- and post-operative cardiovascular magnetic resonance (n=14), LV end-diastolic volume increased (mean 76 versus 101 mL/m 2 , P =0.011), with decreased LV ejection fraction (mean 60% versus 55%, P =0.014), a higher prevalence of low global circumferential strain (36% versus 64%, P =0.045), and decreased cardiac index (mean 4.8 versus 3.9 L/[min·m 2 ], P =0.039). More than mild preoperative mitral regurgitation was the only independent predictor of predischarge LV dysfunction (odds ratio, 22 [95% CI, 2.8–179], P =0.008). Conclusions: Surgical resection of LV fibroma is associated with regional wall motion abnormality, increased LV volume, and reduced systolic function. Children with significant preoperative mitral regurgitation are at highest risk for LV dysfunction and warrant ongoing close surveillance.

CARDIOVASCULAR MANIFESTATIONS IN HIV POSITIVE PATIENTS IN A TERTIARY CARE HOSPITAL, CENTRAL INDIA

Background: Acquired immune deficiency syndrome (AIDS) is one of the major public health problem in india .HIV estimates report (2019)(1) of the Government, India is estimated to have around 23.49 lakh people living with HIV/AIDS (PLHIV) in 2019 . in Chhattisgarh it is 42520&HIV incidence per 1,000 uninfected population is 0.1 .with the recent advancements in therapy early mortality in HIV cases are significantly reduced but cardiovascular abnormalities are frequently seen as the disease progress and is associated with decreased quality of life. Aims and objective: To know the pattern and prevalence of various cardiovascular manifestations in HIV positive patients and its association with CD4 count, WHO stage of disease and ART Material and Methods: for the period of 1.3 years from JANUARY 2019 TO APRIL 2020studyis conducted in the Department of Medicine, PT.JNM Medical College and Dr. BRAMH, Raipur. A total of 137 HIV positive patients of age>18 years, all are on ART are included.patients included in the study underwent detailed history taking, clinical examination and investigations. Details of the history, clinical examination and investigations were noted in the proforma. The cardiovascular examination in the form of chest x-ray, ECG, 2D echocardiography and NT-ProBNP was done and their correlationswith CD4 count and WHO disease stage is studied accordingly. Electrocardiogram, chest x-ray and 2D echocardiography was done immediately following blood investigation. Result: Majority (45.25%) of the patients involved in this study were in age group of 31-45 year with the overall average mean age of 38.86 years. Male to female ratio was 3.1:1. On x-ray cardiomegaly found in 25.5% pts baseline ECG abnormalitities seen in 47.4% pts . echocardiographic abnormality seen in 56.2% pts .The commonest finding in our study is valvular abnormalities in 55 pts (40.1%) followed by diastolic dysfunction in 45 pts(32.8%). Other less common cardiac manifestations in decreasing order of frequency were reduced LVEF in 33 pts(24%), pericardial effusion in 15 pts (10.9%),left ventricular hypertrophy in 13 pts (9.4%), pulmonary arterial hypertension in 10 pts (7.2%)and regional wall motion abnormality in 9 pts (6.5%). We found A strong statistical correlation found between CD4 count and pericardial effusion in 2D-ECHO (p= 0.0410023). Also strong statistical correlation (p=0.016456) is found between the WHO stage of disease and cardiomegaly, strong statistical correlation found between WHO staging of disease and QRS abnormalities (p= 0.02551) and inverted T wave (p= 0.000528), strong statistical correlation found between WHO stage of disease and pulmonary arterial hypertension in 2D-ECHO (p=0.006832). And statistical association found between WHO stage of disease and regional wall motion abnormality (RWMA) in 2D-ECHO (p=0.002541). Conclusion: The results of the study indicate that cardiovascular abnormalities in HIV infected patients are common. Cardiac involvement and cardiovascular complications are commonly seen in HIV-infected patients and can present without any clinical manifestation. The common cardiovascular manifestation seen in our study patients is valvular leaks, regional wall motion abnormality, pericardial effusion, reduced EF etc. The incidence of cardiovascular manifestations increases as the disease progresses and CD4 count decreases. Keywords: Prevalence, Cardiovascular, Abnormalities & HIV. Study Designed: Cross Sectional Observational Study.