Dilated cardiomyopathy resulting from asymptomatic and subclinical myocarditis

The paper presents data on 10 patients with dilated cardiomyopathy (DCM) or chronic myocarditis with fatal outcomes in whom heart failure was preceded by abnormal ECG changes originally regarded as the manifestations of coronary heart disease or small myocardial infarction. The clinical course of the disease and morphological studies suggest that the ECG changes were associated with pre-existing asymptomatic viral myocarditis.     

Electrocardiographic findings and myocardial damage in acute myocarditis detected by cardiac magnetic resonance

Delayed-contrast-enhancement (DCE) magnetic resonance imaging (MRI) can identify areas of myocardial damage in patients with acute myocarditis (AM). The aim of this study was to assess the electrocardiographic findings in AM diagnosed by DCE-MRI. Eighty-one patients (72 men, 35 ± 13 years) with AM were prospectively enrolled. All of them underwent MRI and 12-lead-ECG recordings. In the admission electrocardiogram (ECG 1), as well as in that obtained 48 h later (ECG 2), the following parameters were analyzed: rhythm, PR, QRS, and QTc-intervals, intraventricular conduction, abnormal Q waves, ST segment elevation, and T wave inversion. On admission, 77 patients (95%) were in sinus rhythm, while four patients (6%) manifested severe arrhythmias. No difference between ECG 1 and ECG 2 was observed regarding abnormal Q waves, PR, QRS, and QTc-intervals. Electrocardiogram 1 was normal in 26 patients (32%, normal ECG group), and abnormal in 55 patients (68%, abnormal ECG group). ST elevation was found in 46 patients (57%), inverted T wave in seven patients (9%) and left bundle branch block (LBBB) in two patients (3%). Areas of DCE suggesting AM were found in each patient. No relationship concerning the location of the involved region (s) was found between ECG (leads with ST/T abnormalities) and MRI (areas showing DCE). The ECG in AM can either be normal or reflect abnormalities including arrhythmias, LBBB, ST segment elevation, and T wave inversion. The location of myocardial involvement deduced on the basis of ECG leads showing ST/T changes is not in close relationship with the areas of ventricular damage detected by MRI.     

The electrocardiogram in the primary care office

A 12-lead electrocardiogram (ECG) graphically displays the heart's electrical activity. It is the most common clinical tool for detection and diagnosis of heart disease, and is especially useful for detecting conditions related to abnormalities of cardiac rhythm. ECG should be considered in patients who have known cardiovascular disease or an increased risk for it. The responsibility for correctly interpreting an ECG lies with the physician, who should be able to recognize patient-dependent errors, operator-dependent errors, and artifact. Current ECG tracings should always be compared with previous tracings. Following a specific routine and methodical analysis of the data will ensure an accurate interpretation result. In the worst-case scenario, they can always be faxed or transmitted for inter-consultation with a more experienced reader.     

On-line Telemetry: Prospective Assessment of Accuracy in an All-volunteer Emergency Medical Service System

OBJECTIVE: To evaluate the need for on-line telemetry control in an all-volunteer, predominantly advanced emergency medical technician (A-EMT) ambulance system. METHODS: Emergency medical service (EMS) advanced life support (ALS) providers were asked to transmit the ECG rhythms of monitored patients over a six-month period in 1993. The ECG rhythm interpretations of volunteer EMS personnel were compared with those of the on-line medical control physician. All discordant readings were reviewed by a panel of physicians to decide whether the misdiagnosis would have resulted in treatment aberrations had transmission been unavailable. RESULTS: Patients were monitored and rhythms were transmitted in 1,825 cases. 1,642 of 1,825 rhythms were correctly interpreted by the EMS providers (90%; 95% CI 89-91%). The accuracy of the EMS providers was dependent on the patient's rhythm (chi-square, p < 0.00001), the chief complaint (chi-square, p = 0.0001), and the provider's level of training (chi-square, p = 0.02). Correct ECG rhythm interpretations were more common when the out-of-hospital interpretation was sinus rhythm (95%), ventricular fibrillation (87%), paced rhythm (94%), or agonal rhythm (96%). The EMS providers were frequently incorrect when the out-of-hospital rhythm interpretation was atrial fibrillation/flutter (71%), supraventricular tachycardia (46%), ventricular tachycardia (59%), or atrioventricular block (50%). Of the 183 discordant cases, 124 (68%) involved missing a diagnosis of, or incorrectly diagnosing, atrial fibrillation/flutter. Review of the discordant readings identified 11 cases that could have resulted in treatment errors had the rhythms not been transmitted, one of which might have resulted in an adverse outcome. CONCLUSIONS: In this all-volunteer, predominantly A-EMT ALS system, patients with a field interpretation of a sinus rhythm do not require ECG rhythm transmission. Field interpretations of atrial fibrillation/flutter, supraventricular tachycardia, ventricular tachycardia, and atrioventricular blocks are frequently incorrect and should continue to be transmitted.     

Hymenoptera heartaches -cardiac manifestation with hymenoptera stings,a retrospective study from a tertiary care hospital in South India

IntroductionHymenoptera stings usually have a multitude of presentations from very subtle to life-threatening conditions. Various cardiac manifestations including Kounis syndrome often get missed due to lack of suspicion. The aim of the study was to describe the clinical profile of the cardiac etiologies associated with hymenoptera stings and review literature with focus on diagnosis and treatment strategies.MethodologyA retrospective chart analysis was performed including all adult patients who had a hymenoptera sting during a two-year window (October 2018 – October 2020). Of these, patients with cardiac features were enrolled. A structured case record form was used to capture information like basic demography, clinical profile, and outcomes.ResultsThirteen cases presented with hymenoptera stings of which six cases had cardiac presentation and were considered. The most common presentations were breathlessness and generalised itching with only one patient complaining of chest pain. All patients(with available data) had ECG changes suggestive of ischemia and associated raised troponin levels with 2D echo changes. The diagnoses considered included Kounis syndrome, hypersensitivity myocarditis, and Takotsubo cardiomyopathy. Patients were managed conservatively with one patient undergoing a coronary angiography. All patients were stable at discharge.ConclusionCardiac manifestations with hymenoptera stings although rare may complicate diagnosis and treatment.It should be borne in mind during assessment and standardised guidelines should be developed for ED treatment such as the one recommended in this study. Keywords:Hymenoptera, Kounis syndrome, Acute Coronary Syndrome, emergency medicine.     

Comparative analysis of the effectiveness and tolerance of chrysanol and myochrysine in patients with rheumatoid arthritis (preliminary report)

Fifty patients with a significant rheumatoid arthritis (RA) were treated with gold salts for 6 months to 4 years. Patients with highly active conditions (stages II-III) and with erosive arthritis (stages IIb-IV) prevailed. Extraarticular manifestations were recognized in 76% of the patients. The efficacy of chrisanol given in a dose of 1.5 ml of a 5% solution was compared to that of myocrisin in a dose of 50 mg, i. e. 25 mg metallic gold once a week. The efficacy of the drugs was evaluated from their effects on the disease activity (clinical manifestations of the articular syndrome, ESR, morphological signs of rheumatoid synovitis) and progression (the rate of the development of erosive arthritis in hand and foot joints, the time course of serum RF content, and systemic disease manifestations). These characteristics were examined with the aid of modern ultrasonic and radionuclide research methods. The evaluations were made by the treatment onset and by months 3, 6, 12 and 18 of the treatment. Analysis of the data obtained attests to a high clinical efficacy of both the drugs exhibiting basic activity which is confirmed by a decrease in the degree of the morphological manifestations of synovitis and extraarticular signs of RA, particularly of myocarditis. A method for following up outpatients to prevent grave complications of chrysotherapy is offered.     

对急性呼吸系统感染患儿血清CK-MB增高的再认识

目的　探讨急性呼吸系统感染患儿血清CK MB增高而无心肌炎临床症状和心电图改变的原因。方法　对急性呼吸系感染患儿于病程的 1～ 5天内采静脉血同时测定CK MB(采用免疫抑制法 )和CTnⅠ (采用夹心ELISA法 ) ,并动态观察病人临床症状、心电图改变以判断是否合并心肌炎。结果　 13 0例急性呼吸系感染患儿中血清CK MB增高 5 8例 ,血清CTnⅠ增高 3例 ,其阳性率为 10 0 % ,经卡方检验P <0 .0 5 ,差异有显著性。 12 7例临床无心肌炎的病例中 ,血清CK MB增高 5 5例 ,正常 72例 ,12 7例患儿中血清CK MB增高组、CK MB正常组与正常儿童对照组三组间CTnⅠ值经方差分析P >0 .0 5 ,差异无显著性。结论　应用免疫法测定的血清CK MB值不能作为判断呼吸系感染时有无心肌损伤的“金指标” ,应改用质量法测定血清CK MB ,或测定血清CTnⅠ来补充。     

Influenza myocarditis and pericarditis

The true incidence of influenza myocarditis in the general population is unknown, because of the variable clinical presentation and the absence of a established noninvasive diagnostic test that can confirm the diagnosis. Influenza is, however, one of the frequently implicated viruses caused myocarditis as well as Coxsackie B, adenovirus, echovirus and cytomegalovirus. The clinical manifestations of viral myocarditis vary greatly from asymptomatic electrocardiographic changes to fulminant heart failure with fatal arrhythmias. We should recognize that subtle cardiac symptoms and signs in many subclinical cases may be overshadowed by systemic manifestations of the underlying influenza infection. Although specific therapy consisted of anti-viral agents, intravenous gamma-globulin treatment or mechanical ventricular supports may be available for influenza myocarditis, it has not been established that the myocarditic process itself will be favorably affected.     

The pediatric electrocardiogram part II: Dysrhythmias

The following article in this series will describe common arrhythmias seen in the pediatric population. Their definitions and clinical presentations along with electrocardiogram (ECG) examples will be presented. In addition, ECG changes seen in acute toxic ingestions commonly seen in children will be described, even if such ingestions do not produce arrhythmias per se. Disturbances of rhythm seen frequently in patients with unrepaired and corrected congenital heart disease will be more fully discussed in the third article of this series. Numerous classification schemes for arrhythmias exist; in this article arrhythmias will be grouped based upon their major ECG manifestations.     

老年心血管疾病伴焦虑抑郁障碍患者心电图对比分析

目的探讨老年心血管疾病伴焦虑抑郁障碍患者心电图改变的临床特征。方法对283例老年心血管疾病伴焦虑抑郁障碍患者（A组）和267例老年心血管疾病不伴焦虑抑郁障碍患者（B组）的心电图资料进行对比分析。结果老年心血管疾病患者心电图均以房性心律失常、室性早搏、窦性心律失常、各种传导阻滞、缺血性ST—T异常改变为主,尤其以房性心律失常最多见。A组窦性心动过速、室性早搏检出率显著高于B组（χ2=12．45、11．40,P〈0．01）。结论老年心血管疾病患者心电图主要以心律失常及缺血性ST—T异常改变为主,当心电图上以窦性心动过速、室性早搏为主要表现时,应加强其心理方面的重视,并结合临床表现予以有针对性的干预。     

Ventricular extrasystole as manifestation of viral myocarditis and myopericarditis in young patients

AIM: To investigate relationship between frequent and complicated ventricular extrasystole (VE) in young patients and previous viral myocarditis (VM); to study VE long-term prognosis. MATERIAL AND METHODS: We examined 75 patients with mild and moderate myocarditis which developed after acute respiratory infections and other viral diseases (Coxsackie infection was serologically confirmed in 49%; flu, paraflu and adenoviral infection--in 8%). Acute myocarditis was diagnosed basing on the data of ECG, activity of cardiospecific enzymes and isoenzymes, x-ray, echocardiography, Holter ECG monitoring, exercise tests. The patients were followed up from 3 to 26 years (mean 14.6 years). RESULTS: Bigeminal polymorphic extrasystoles and bigemia sites persisted for the whole periods of observation. They could disappear at resting ECG but were registered at 24-h ECG monitoring in all the cases. Echocardiography detected fibrous alterations of the pericardium with its thickening in 89% cases. Exercise tolerance test at the end of the study recorded normal physical performance in 89.3% patients. This suggests a favorable disease outcome. Low physical performance, moderate dilation of the left ventricle and ejection fraction lowering to 48% requiring medication were observed only in 4 patients who were capable to work. CONCLUSION: Frequent and complicated VE after viral myocarditis were present at resting ECG for many years in 42.3% patients. Holter 24-h ECG monitoring registered VE in all the examinees. 89% patients had fibrous lesions of the pericardium showing that viral myocarditis in most cases runs as myopericarditis, in some cases being subclinical.     

Myocarditis related to drug hypersensitivity

Hypersensitivity myocarditis is an inflammatory disease of the myocardium usually related to a drug allergy. The clinical manifestations may be nonspecific, and the diagnosis is seldom suspected or established during life. We report a case that demonstrates both typical and atypical features of this disease and review the clinicopathologic correlations. This case illustrates the potential occurrence of both electrical conduction block and ventricular tachyarrhythmias, either of which may account for the mechanism of sudden death in these patients. When cardiac symptoms or electrocardiographic abnormalities (or both) occur in a setting consistent with drug allergy, hypersensitivity myocarditis should be considered. Treatment consists of discontinuation of use of the drug responsible for the reaction and, possibly, administration of corticosteroids and immunosuppressive therapy.     

Right Ventricular endomyocardial biopsy: clinicopathologic correlates in 100 consecutive patients

The first 100 consecutive patients to undergo right ventricular endomyocardial biopsy at the Mayo Clinic were divided retrospectively into five groups, depending on the prebiopsy clinical diagnosis, and the biopsies were review histologically in a single-blind format. Group 1 consisted of 34 patients with a diagnosis of unexplained congestive heart failure and a dilated heart; of these, 4 (12%) had active myocarditis by biopsy. Of the six patients in group 2 with a clinical diagnosis of myocarditis, only one (17%) had biopsy evidence of inflammation, but two (33%) had changes that, in the clinical setting, were suggestive of cardiomyopathy. Group 3 consisted of 27 patients with dysrhythmia, syncope, or cardiac arrest but without congestive heart failure; of these, 4 (15%) had active myocarditis by biopsy, and 8 (30%) had changes that, with the clinical history, were consistent with cardiomyopathy. Group 4 included 19 patients with unexplained congestive heart failure and a nondilated heart; 4 (21%) had cardiac amyloid on biopsy. Group 5 was a diverse group of 14 patients with possible cardiac involvement by a known systemic disease; myocardial disease was documented by biopsy in 7 (50%). On the basis of these findings, we recommend endomyocardial biopsy (1) in patients with dilated cardiomyopathy in whom myocarditis is suspected, (2) in patients with the clinical diagnosis of active myocarditis in whom tissue documentation is indicated before treatment with anti-inflammatory or immunosuppressive drugs, (3) in patients with clinically unexplained life-threatening dysrhythmias in whom myocarditis or cardiomyopathy may be present, and (4) in patients with apparent hypertrophic or restrictive cardiomyopathy in whom cardiac amyloid may be present.     

Myocardial depression in septic shock caused by meningococcal infection

Comparative hemodynamic measurements recorded in 19 cases of septic shock associated with Neisseria meningitidis bacteremia and in 20 shock cases associated with bacteremia due to other Gram-negative bacilli showed a significantly higher incidence of early myocardial depression in the cases with meningococcal infection. Echocardiographic, ECG, and serum enzyme (CK-MB isoenzyme) studies closely correlated with impaired myocardial contractility and development of cardiogenic shock in patients with meningococcal bacteremia. Autopsy of the heart from three patients who succumbed to shock confirmed the presence of myocarditis with intracellular Gram-negative diplococci. Our observations suggest that the onset of cardiac dysfunction precedes clinical manifestations of shock.     

酷似AMI的恙虫病感染致急性心肌炎一例

急性心肌炎是由各种原因引起的心肌急性炎症性病变。部分急性心肌炎可引起胸痛、心肌酶及心电图的动态改变,与AMI临床症状类似。恙虫病是由恙虫病立克次体引起的一种急性疫源性传染病,恙虫病感染可引起心肌弥漫间质性炎症病变。恙虫病感染致病的临床表现多样,易出现漏诊误诊。该文报道了1例酷似AMI的恙虫病感染致急性心肌炎患者的诊治过...     

Idioventricular rhythm induced by therapeutic hypothermia

We report the case of a 11-year-old girl with fulminant myocarditis and cardiogenic shock who received cardiopulmonary resuscitation and extracorporeal membrane oxygenation support. During the induction of hypothermia, her rhythm degenerated into idioventricular rhythm with extremely prolonged QRS duration. The hypothermia-induced bradycardia caused a drop of mixed venous oxygenation saturation and which was resolved by re-warming to normothermia. This finding suggested that hypothermia may compromise cardiac performance and physicians should be cautious about its application in patients with fulminant myocarditis.     

帕博利珠单抗相关爆发性心肌炎一例

免疫检查点抑制剂(ICIs)是近年来肿瘤治疗领域的最重要进展之一。随着ICIs适应证的不断拓展及国内原研药相继进入临床,ICIs将用于越来越多的肿瘤患者,然而ICIs的严重不良反应尚未引起临床医师的广泛关注。该文报道1例肝癌术后复发接受帕博利珠单抗治疗引起爆发性心肌炎的病例,患者主要表现为心肌酶升高,难治性心律失常,伴有肝损伤,呼吸衰竭等,虽经积极抢救最终死亡。该例提示ICIs相关免疫性心肌炎早期症状不典型,但疾病呈爆发性进展,需要临床医师早期识别,及早干预。     

Disorders of heart rhythm and conduction in dilated and hypertrophic cardiomyopathies

Idiopathic cardiomyopathies are characterized by diversity of clinical manifestations, among which heart rhythm abnormalities are the most common. The authors carried out qualitative and quantitative evaluations of heart rhythm abnormalities in patients with dilated and hypertrophic cardiomyopathies (DCMP, HCMP) and compared those abnormalities according to the data of daily ECG monitoring. Forty patients with DCMP and 30 with HCMP were examined. In 8 (25%) patients with DCMP and in 2 (6.7%) with HCMP, permanent atrial fibrillation was recorded. Among patients with sinus rhythm, supraventricular premature heart beats were found in 30 (96.8%) patients with DCMP and in 24 (85.7%) with HCMP. However, their number during 24 h exceeded 500 in 9 (29%) and in 7 (25%) patients, respectively. Supraventricular paroxysmal tachycardia (greater than or equal to 3 complexes at HR greater than or equal to 100/min) was recorded in 7 (22.6%) patients with DCMP and in 4 (14.3%) patients with HCMP. Ventricular premature heart beats were recorded in 38 (95%) patients with DCMP and in 21 (70%) patients with HCMP, polytopic in 31 (77.5% and 17 (56.7%), coupled in 227 (67.5%) and 10 (33.3%), ventricular paroxysmal tachycardia (greater than or equal to 3 complexes at HR greater than or equal to 100/min) in 22 (55%) and 5 (16.7%) patients, respectively. AV conduction abnormalities among patients with sinus rhythm were noted in DCMP and HCMP, in 12 (38.7%) and 1 (3.6%) cases, respectively. Thus, heart rhythm abnormalities are often encountered in both patients with DCMP and HCMP. However, in patients with DCMP, heart arrhythmias are graver and prognostically unfavourable.(ABSTRACT TRUNCATED AT 250 WORDS)     

Autonomic nervous system balance, variability and arrhythmia in survivors of myocardial infarction

AIM: To investigate relations between heart rhythm variability (HRV), vegetative balance and electric myocardial activity in myocardial infarction (MI) survivors. MATERIAL AND METHODS: HRV was studied by short 5-min parts of ECG and data of ECG Holter monitoring were analysed for 98 patients who had macrofocal MI 1.5 months to 5 years before. RESULTS: Manifestations of electric heart instability were polymorphic. 69.4% examinees had hyperactivity of the parasympathetic nervous system (PSNS). The influence of the sympathetic nervous system (SNS) increased with growing severity of arrhythmia. Supraventricular arrhythmia occurred more frequently in high PSNS activity, while ventricular arrhythmia occurred more often in SNS prevalence combined with low HRV. CONCLUSION: HRV analysis for MI survivors, especially in combination with Holter ECG monitoring, gives an objective assessment of various manifestations of cardiac dysfunction and therefore enables timely adequate therapy.