ST-Elevation Myocardial Infarction in Situs Inversus Dextrocardia : A Case Report

ST-elevation myocardial infarction (STEMI) in situs inversus dextrocardia is a rare combination and poses many challenges in terms of diagnosis and management. These include the early detection of dextrocardia as well as the interpretation of the ECG. In addition, percutaneous coronary intervention could be challenging in the setting of dextrocardia because of diffi culty in cannulating the coronary arteries, selection of catheters, catheter manipulation, image acquisition and interpretation

Early cardiovascular MRI post successful reperfusion of acute myocardial infarction : An exploratory study

Post-myocardial infarction (MI) patients has varied outcome despite successful reperfusion. Our study aimed to use cardiac magnetic resonance imaging (CMR) to explore parameters that may influence outcome in successfully reperfused post-MI patients. We used left ventricular (LV) remodelling and major adverse cardiovascular event (MACE) at 6 months as a pooroutcome indicator. Consecutive patients admitted to Sarawak Heart Centre from Dec 2012 to Nov 2014 with acute anterior or inferior ST elevation MI were screened. A total of 101 patients with TIMI-3 flow were recruited. Patients underwent CMR imaging during the index admission, and another between 3 to 6 months later. LV remodelling occurred in 21.8% while microvascular obstruction (MVO) in 38.6% of patients. LV infarct size and MVO were significant in those who developed LV remodelling, while door-to-perfusion time and total-ischaemic time were not significantly different. MACE was significant in patients with larger infarcts but not significant in patients with MVO. LV infarct size was also significant in those who had reverse LV remodelling. These results suggest that early CMR measurement of infarct size and detection of MVO has the potential to predict LV improvement or deterioration at 6 months

COVID-19 Antibody Surveillance Among Healthcare Workers in A Non-COVID designated Cardiology Centre

BACKGROUND: Reports on healthcare worker antibody response to COVID-19 infection are scarce. We aim to determine theCOVID-19 antibody prevalence among healthcare workers in a cardiology centre and the relationship between case definitioncriteria with the COVID-19 antibody result. METHODS: Convenience sampling was applied. Healthcare workers in SarawakHeart Centre (SHC) cardiology, radiology, and emergency unit were recruited. A survey form on clinical symptoms and closecontact history was distributed. HEALGEN COVID-19 IgG/IgM rapid test was performed using serum/ whole blood specimen.Staff with positive COVID-19 antibody results were referred to the infectious disease specialist for assessment. RESULTS: Atotal of 310 staff were screened. 220(71%) were female, and the mean age was 36±7.7 years old. 46(14.8%) staff reported havingclinical symptoms at some stage from the end of January 2020 to the time of this surveillance. Number of staff who had a historyof overseas travel, close contact with confirmed COVID-19 patients, or had visited places with identified COVID-19 clusterswere 4(1.3%), 24(7.7%) and 24(7.7%) respectively. There were 14 staff (4.5%) with positive tests positive, 2 for IgM, and 12for IgG. All those with positive antibody were subsequently tested negative with RT-PCR test. The history of having clinicalsymptoms and exposure to COVID-19 cluster area were independently associated with a positive IgG result. CONCLUSION:The application of COVID-19 antibody serology rapid tests could determine true exposure of staff to the infection and allowus to reassess existing measures of infection control within the hospital

Clinical Outcomes and Predictors of Improved Left Ventricular Ejection Fraction in Heart Failure with Reduced Ejection Fraction due to Non-Ischemic Cardiomyopathy

Background: Left ventricular ejection fraction (LVEF) improvement is the cornerstone of LV reverse remodelling. It prognosticates heart failure with reduced ejection fraction (HFrEF). There is limited data on the clinical factors that predict LVEF improvement among non-ischemic cardiomyopathy (NICM) patients in Malaysia. Objective: To determine the 3-year outcomes and predictors of LVEF improvement in patients with (NICM) and HFrEF. Materials & Methods: We recruited patients with NICM and HFrEF (LVEF <40%) between 2016 and 2018. NICM was defined as HF with 1) normal coronary arteries or 2) any coronary artery stenosis not involving the proximal left anterior descending artery (LAD) and without transmural fibrosis in the LAD territory from cardiac magnetic resonance (CMR) imaging to account for the impaired LVEF. Clinical and imaging parameters were assessed using logistic regression statistics to determine the predictors of LVEF improvement. LVEF improvement is defined as a recovery of EF to > 40% with at least a 10-point increment from baseline. The clinical outcomes at three year were 1) change in NYHA class and 2) composite of all-cause mortality, unscheduled clinic or emergency department visits, readmission and/or ventricular arrhythmia. Results: 43 patients were recruited. The mean duration of follow-up and echocardiographic assessment interval were 46 and 23 months, respectively. The cohort had a mean age of 46±13 years, and were mostly male (72%). More patients had NYHA 1 at the end of the study (37% vs 86%). 11 patients (25%) recorded composite outcomes. 62.8% had LVEF improvement. Patients with LVEF improvement had a lower incidence of late gadolinium enhancement (51.7% vs 85.7%, odds 5.6 ,p=0.045) and midwall fibrosis on CMR (18.5% vs 62.5%, odds 7.3, p=0.003). LVEF improvement did not affect the functional NYHA recovery (92% vs 81%, p=0.28). Patients with less LVEF improvement had higher incidence of composite outcome (18.5% vs 37.5%, p=0.168). Other characteristics were not significantly different between the groups. Conclusion: Patients with NICM and LVEF improvement had lower composite outcome. Absence of late gadolinium enhancement, particularly midwall fibrosis was an independant predictor of LVEF improvement. This underscores the importance of CMR tissue characterisation to refine the prognostication of NICM patients

Smartphone electrocardiogram for detecting atrial fibrillation after a cerebral ischaemic event: a multicentre randomized controlled trial

Aims: Atrial fibrillation (AF) is a preventable cause of ischaemic stroke but it is often undiagnosed and undertreated. The utility of smartphone electrocardiogram (ECG) for the detection of AF after ischaemic stroke is unknown. The aim of this study is to determine the diagnostic yield of 30-day smartphone ECG recording compared with 24-h Holter monitoring for detecting AF ≥30 s. Methods and results: In this multicentre, open-label study, we randomly assigned 203 participants to undergo one additional 24-h Holter monitoring (control group, n = 98) vs. 30-day smartphone ECG monitoring (intervention group, n = 105) using KardiaMobile (AliveCor®, Mountain View, CA, USA). Major inclusion criteria included age ≥55 years old, without known AF, and ischaemic stroke or transient ischaemic attack (TIA) within the preceding 12 months. Baseline characteristics were similar between the two groups. The index event was ischaemic stroke in 88.5% in the intervention group and 88.8% in the control group (P = 0.852). AF lasting ≥30 s was detected in 10 of 105 patients in the intervention group and 2 of 98 patients in the control group (9.5% vs. 2.0%; absolute difference 7.5%; P = 0.024). The number needed to screen to detect one AF was 13. After the 30-day smartphone monitoring, there was a significantly higher proportion of patients on oral anticoagulation therapy at 3 months compared with baseline in the intervention group (9.5% vs. 0%, P = 0.002). Conclusions: Among patients ≥55 years of age with a recent cryptogenic stroke or TIA, 30-day smartphone ECG recording significantly improved the detection of AF when compared with the standard repeat 24-h Holter monitoring. Keywords: Anticoagulation; Atrial fibrillation; Cryptogenic stroke; Digital health; Smartphone electrocardiogram.

Characterizing and Prognosticating Heart Failure with Improved Ejection Fraction Using NT-proBNP, Growth Differentiation Factor 15 and Global Longitudinal Strain

Background: Heart failure with improved ejection fraction (HFiEF) is a novel heart failure (HF) subgroup. There are sparse data on using NT-proBNP, growth differentiation factor 15 (GDF15) and global longitudinal strain (GLS) to characterize and prognosticate HFiEF patients. Objectives: (1) To determine the level and correlation between NT-proBNP, GDF-15 and GLS in HFiEF patients. (2) To examine the correlation of each marker with NYHA, MAGGIC prognostic score, HF etiologies, comorbidities status, degree of LVEF/ LV end-diastolic diameter change from baseline and diastolic dysfunction. (3) To look for association of each marker with follow-up LVEF change and 1-year composite mortality or HF events outcome. Materials & Methods: This was a cross-sectional observational study in Sarawak Heart Centre HF clinic. 53 HfiEF patients who had NT-proBNP and GDF15 tests performed were selected. This cohort had no HF events in the past 6 months during the blood tests. Clinical characteristics, echocardiography parameters, and 1-year composite clinical outcome were analyzed retrospectively. Results: The mean age of the cohort was 52 years old and 81% were male. The cohort was highly comorbid (hypertension 71%; diabetes 45.3%; AF 17.3%). Most of the patients (87%) were asymptomatic by NYHA (I) and low rate of composite outcome was observed, 5.7%. The mean NT-proBNP, GDF-15, GLS were 357 pg/ml, 1572 pg/ml, and -12.1% respectively. There were significant moderate correlation between GDF15 with NT-proBNP (r=0.414) and NT-proBNP with GLS (r=-0.351). Higher NT-proBNP and GDF15 levels were associated with poorer MAGGIC prognostic scores (r=0.549, 0.41 respectively). NT-proBNP was the only marker associated with a higher degree of LVEF improvement compare to baseline echocardiography. NT-proBNP was also related to severe diastolic echo parameters. Hypertension and diabetes were strongly associated with higher elevated GDF15 levels. The lower mean GLS level was significantly associated with the presence of composite outcome (-6.45% vs -12.47%, p=0.0). Patients with NT-proBNP levels below the median cutoff had favourable follow-up LVEF improvement (+9.73%, p=0.035). Conclusion: In our HFiEF study cohort, NT-proBNP best correlate and prognosticate future LV remodelling. GDF15 was closely related to systemic illnesses such as diabetes. The role of GLS in our HFiEF cohort remains uncertain

Prognostic Value of Leucocyte Telomere Length in Acute Myocardial Infarction

Introduction: Leucocyte telomere length (LTL) has been described as a marker of biological age, endothelial dysfunction and atherosclerosis. The association between LTL and clinical characteristics of Asian patients, and their outcomes following acute myocardial infarction (AMI) have been inconclusive. Objective: To investigate the relationship between LTL and developing AMI, the association of LTL with inpatient and 30-day mortality, and the comparison to LTL with established AMI risk scores in predicting these outcomes. Methodology: 100 patients aged 30-70 years admitted with an AMI to a tertiary referral center between May-Oct 2017 were enrolled; these were matched with 100 non-AMI ('healthy') controls for gender and age (+/- 1 year). Clinical data was obtained prospectively; inpatient and 30-day outcomes documented. LTL was reflected by a well described variable called a tis ratio (TSR). The TSR was measured at enrolment using a quantitative PCR-based methods (qPCR) and results blinded to the clinician

Ventricular tachycardia storm as predominant cardiac manifestation of lupus myocarditis

SUMMARY Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease that can affect any part of the heart, causing arrhythmias on top of other cardiac manifestations. Malignant ventricular tachyarrhythmias are rare manifestations of SLE. Our case is the first one reported in the literature of an SLE patient with multi-organ involvement who subsequently presented with ventricular tachycardia (VT) storm as a cardiac manifestation. This case also demonstrates the use of Stellate ganglion block to treat intractable VT storm when chemical and electrical cardioversions failed, while waiting for immunosuppressive drugs to take effect. Timely treatment resulted in a good outcome for our patient

Smartphone electrocardiogram for QT interval monitoring in Coronavirus Disease 2019 (COVID-19) patients treated with Hydroxychloroquine

ABSTRACT Introduction: The global pandemic of Corona Virus Disease 2019 (COVID-19) has led to the re-purposing of medications, such as hydroxychloroquine and lopinavir-ritonavir in the treatment of the earlier phase of COVID-19 before the recognized benefit of steroids and antiviral. We aim to explore the corrected QT (QTc) interval and ‘torsadogenic’ potential of hydroxychloroquine and lopinavir-ritonavir utilising a combination of smartphone electrocardiogram and 12-lead electrocardiogram monitoring. Materials and Methods: Between 16-April-2020 to 30-April2020, patients with suspected or confirmed for COVID-19 indicated for in-patient treatment with hydroxychloroquine with or without lopinavir-ritonavir to the Sarawak General Hospital were monitored with KardiaMobile smartphone electrocardiogram (AliveCor®, Mountain View, CA) or standard 12-lead electrocardiogram. The baseline and serial QTc intervals were monitored till the last dose of medications or until the normalization of the QTc interval. Results: Thirty patients were treated with hydroxychloroquine, and 20 (66.7%) patients received a combination of hydroxychloroquine and lopinavir-ritonavir therapy. The maximum QTc interval was significantly prolonged compared to baseline (434.6±28.2msec vs. 458.6±47.1msec, p=0.001). The maximum QTc interval (456.1±45.7msec vs. 464.6±45.2msec, p=0.635) and the delta QTc (32.6±38.5msec vs. 26.3±35.8msec, p=0.658) were not significantly different between patients on hydroxychloroquine or a combination of hydroxychloroquine and lopinavir-ritonavir. Five (16.7%) patients had QTc of 500msec or more. Four (13.3%) patients required discontinuation of hydroxychloroquine and 3 (10.0%) patients required discontinuation of lopinavirritonavir due to QTc prolongation. However, no torsade de pointes was observed. Conclusions: QTc monitoring using smartphone electrocardiogram was feasible in COVID-19 patients treated with hydroxychloroquine with or without lopinavir-ritonavir. The usage of hydroxychloroquine and lopinavir-ritonavir resulted in QTc prolongation, but no torsade de pointes or arrhythmogenic death was observed