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Background: Fever is a common clinical manifestation of COVID-19 infection. Fever has also been associated with unmasking Brugada pattern ECG in patients and may result in life-threatening arrhythmia. Little is known regarding COVID-19 associated Brugada pattern ECG. There is paucity of data and guidance in how to manage these patients. Method(s): To identify all published case reports, the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was followed. A literature search was conducted using PubMed, EMBASE, and Scopus through September 2021. A systematic review was performed to identify the incidence, clinical characteristics, and management outcomes of COVID-19 patients with a Brugada pattern ECG. Result(s): A total of 18 cases were collected. The mean age was 47.1 years and 11.1% were women. No patient had prior confirmed diagnosis of Brugada syndrome. The most common presenting clinical symptoms were fever (83.3%), chest pain (38.8%), shortness of breath (38.8%), and syncope (16.6%). All 18 patients presented with type 1 Brugada pattern ECG. Four patients (22.2%) underwent left heart catheterization, and none demonstrated the presence of obstructive coronary disease. The most common reported therapies included antipyretics (55.5%), hydroxychloroquine (27.7%), and antibiotics (16.6%). One patient (5.5%) died during hospitalization. Three patients (16.6%) who presented with syncope received either an implantable cardioverter defibrillator or wearable cardioverter defibrillator at discharge. At follow up, thirteen patients (72.2%) had resolution of type 1 Brugada pattern ECG. Conclusion(s): COVID-19 associated Brugada pattern ECG is rare. Most patients may see resolution of the ECG pattern once their symptoms have improved. Increased awareness and timely use of antipyretics is warranted in this population.
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Background: Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players. Method(s): We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves;(b) reduction in T-wave amplitude by 50% in contiguous leads;(c) ST-segment depression;(d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads;(e) tall T-waves >=1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes. Result(s): Athletes were aged 22+/-5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3+/-4 days. The post COVID ECG was performed 14+/-16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID- 19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae;pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8+/-8 days v 2+/-4 days;p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3). Conclusion(s): 3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.
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Objective: To analyze the clinical characteristics of fatal cardiac adverse events associated with chloroquine, which was recommended for the antiviral treatment of novel coronavirus pneumonia, and provide reference for clinical safe drug use. Method(s): The fatal cardiac adverse events associated with chloroquine were searched from the World Health Organization global database of individual case safety reports (VigiBase). The clinical characteristics of the individual cases with well-documented reports (VigiGrade completeness score >=0.80 or with detailed original reports) were analyzed. The adverse events were coded using the systematic organ classification (SOC) and preferred term (PT) of Medical Dictionary for Regulatory Activities (MedDRA) version 22.1 of International Conference on Harmonization (ICH). Result(s): Up to 23 February 2020, a total of 45 reports of fatal heart injuries related to chloroquine were reported in VigiBase, which were from 16 countries. Of them, 30 reports were fully informative. Among the 30 reports,20 cases developed fatal cardiac adverse events after a single large dose of chloroquine. Of them, 17 cases' fatal cardiac adverse events were caused by overdose of chloroquine (15 cases were suicide or suspected suicide, and 2 children took chloroquine by mistake);3 cases' fatal cardiac adverse events were caused in clinical treatment;18 cases showed arrhythmia and cardiac arrest;6 cases showed prolonged QRS wave or QT interval;6 cases were with hypokalemia, including 4 severe ones. Among the 30 reports, 10 cases developed fatal cardiac adverse events after multiple administration of chloroquine, of which 4 cases were treated with chloroquine for 23 days to 2 months and died of heart failure, cardiac arrest or myocardial infarction;6 cases were treated with chloroquine for 20 months to 29 years and all of them had cardiomyopathy, which were confirmed by endomyocardial biopsy to be caused by chloroquine in 3 cases. Conclusion(s): Cardiac toxicity was the primary cause of fatal adverse events caused by chloroquine;the main manifestation of single large dose of chloroquine was arrhythmia and the manifestation of multiple administration was cardiomyopathy.Copyright © 2020 by the Chinese Medical Association.
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Background: Several studies described occurrence of myocarditis after SARS-CoV-2 vaccination in pediatric patients. Weaimed to characterize the clinical course of myocarditis following SARS-CoV2 vaccination including follow-up data within the prospective German registry for suspected myocarditis in children and adolescents "MYKKE." Method: Patients younger than 18 years with suspected myocarditis and onset of symptoms within 21 days followingSARS-CoV2 vaccination were enrolled within the MYKKE registry. The suspect of myocarditis is valid in patients with clinical symptoms and diagnostic findings typically seen in myocarditis. Clinical data are monitored at initial admission and duringshort-term and long-term follow-up. Result(s): Between July 2021 and August 2022, a total of 48 patients with a median age of 16.2 years (IQR: 15.2-16.8)were enrolled by 13 centers, 88% male. Onset of symptoms occurred at a median of 3 days (IQR: 2-7) after vaccine administration, most frequently after the second dose (52%). Most common symptoms at initial admission were anginapectoris (81%), fatigue (56%), dyspnea (24%) and documented arrhythmias (17%). Initial ECG abnormalities included ST-elevation (48%) and T-wave inversion (23%). Elevated Tropon in was observed in 32 patients (67%) and in 19 cases (40%)NT-proBNP was above the normal range with a median level of 171 pg/mL (IQR: 32-501). 11 (23%) patients presentedwith mildly reduced systolic function at initial echocardiography or cardiac MRI. In 40 patients cardiac MRI and/orendomyocardial biopsy was performed (83%) and diagnosis of myocarditis could be verified in 27 cases (68%). Thirty-nine patients underwent short-term follow-up with a median of 2.8 months (IQR: 1.9-3.9) after discharge. 19 patients (49%)presented with either clinical symptoms (n = 9) and/or diagnostic abnormalities (n = 16) at follow-up. 12 patients (38%)still had medical treatment. Except for one patient with malign arrhythmias (ventricular tachycardia), no major cardiac adverse events were observed during initial admission and follow-up. Conclusion(s): Our data confirm that SARS-CoV-2 vaccine-related myocarditis is characterized by a mild disease course. However, after short-term follow-up a considerable number of patients still presented with symptoms and/or diagnostic abnormalities. Data on long-term follow-up are awaited.
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Introduction: For detecting myocardial injury in severe and critical COVID-19, the electrocardiogram (ECG) is neither sensitive nor specific;but in a resource-poor environment, it remains relevant. Changes in the ECG can be a potential marker of severe and critical COVID-19 to be used for predicting not only disease severity but also the prognosis for recovery. Method(s): The admitting and interval ECGs of 1,333 COVID-19 patients were reviewed in a two-year, single-center, retrospective cohort study. Each was evaluated for 29 pre-defined ECG patterns under the categories of rhythm, rate, McGinn-White and RV overload patterns, axis and QRS abnormalities, ischemia/infarct patterns, and AV blocks before univariate and multivariate regression analyses for correlation with disease severity;need for advanced ventilatory support;and in-hospital mortality. Result(s): Of the 29 ECG patterns, 18 showed a significant association with the dependent variables on univariate analysis. Multivariate analysis revealed that atrial fibrillation, HR >100 bpm, low QRS voltage, QTc >500msec, diffuse nonspecific T-wave changes, and 'any AMI' ECG patterns correlate with disease severity;need for advanced ventilatory support and in-hospital mortality. S1Q3 and S1Q3T3 increased the odds of critical disease and need for high oxygen requirement by 2.5-3 fold. Fractionated QRS increased odds of advanced ventilatory support. Conclusion(s): The ECG can be useful for predicting the severity and outcome of more than moderate COVID-19. Their use can facilitate rapid triage, predict disease trajectory, and prompt a decision to intensify therapy early in the disease to make a positive impact on clinical outcomes.
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Objectives: The study aims to determine the association between electrocardiographic abnormalities and in-hospital mortality of patients with Coronavirus Disease 2019 (COVID-19) infection admitted in a tertiary hospital in the Philippines. Material(s) and Method(s): We conducted a retrospective study of confirmed COVID-19-infected patients. Demographic, clinical characteristics, and clinical outcomes were extracted from the medical records. Electrocardiographic analysis was derived from the 12-lead electrocardiogram (ECG) recorded upon admission. The frequencies and distributions of various clinical characteristics were described, and the ECG abnormalities associated with in-hospital mortality were investigated. Result(s): A total of 163 patients were included in the study, most were female (52.7%) with a median age of 55 years old. Sinus rhythm (40%), nonspecific ST and T wave changes (35%), and sinus tachycardia (22%) were the frequently reported ECG findings. The presence of any ECG abnormality was detected in 78.5% of patients and it was significantly associated with in-hospital mortality (p = 0.038). The analysis revealed a statistically significant association between in-hospital mortality and having atrial fibrillation or flutter (p = 0.002), supraventricular tachycardia (SVT) (p = 0.011), ventricular tachycardia (p = 0.011), third-degree atrioventricular block (AVB) (p = 0.011), T wave inversion (p = 0.005) and right ventricular hypertrophy (RVH) (p = 0.011). Conclusion(s): The presence of any ECG abnormality in patients with COVID-19 infection was associated with in-hospital mortality. ECG abnormalities that were associated with mortality were atrial fibrillation or flutter, SVT, ventricular tachycardia, third-degree AVB, T wave inversion, and RVH. Supporting Documents Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection TARRANZA, Jannah Lee [1];RAMIREZ, Marcellus Francis [1,2];YAMAMOTO, Milagros [1] 1 Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines 2 Division of Electrophysiology, Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines.
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Cardiovascular inclusion has been accounted for in patients with serious intense respiratory condition Covid 2 contamination, which might be reflected by electrocardiographic changes. Cardiovascular injury is additionally connected with humanity, need for intensive care, and seriousness of illness in patients due to Coronavirus. Some case features cardiovascular contribution as an intricacy related with Coronavirus, even without indications and indications of interstitial pneumonia. Two Coronavirus incidents in our report displayed diverse ECG indications by means of the sickness caused decay. The main case introduced brief SI QIII TIII sound structure followed by changeable almost whole atrioventricular square, and the second exhibited ST-section height joined by choroidal ventricular tachycardiac. The hidden systems of these ECGs irregularities in the serious phase of Coronavirus might be ascribed to hypoxia and incendiary harm brought about by the infection. Since the scourge of Coronavirus pulled in the consideration, hearsays were encompassing ECG variations in the contaminated people. We pointed toward indicative dissimilar noticed ECG discoveries and talking about their experimental importance. This deliberate audit recommends that recognizing ECG designs that may be connected with Coronavirus is fundamental. Given that doctors don't perceive these examples, they may mistakenly hazard the existences of their patients. Moreover, significant medication instigated ECG changes give attention to the medical care laborers on the dangers of potential treatments. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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The vaccination used for the prevention of COVID-19 could unmask patients with hidden Brugada syndrome even without febrile episodes. We described a case of unmasking or Brugada syndrome in a female patient after vaccination for COVID-19. A possible relationship with sudden death events requires further study. In people with known Brugada syndrome or in their relatives, we recommend serial electrocardiographic monitoring after the administration of the vaccination dose. Copyright © 2022 Heart, Vessels and Transplantation.
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Background. The COVID-19 pandemic has spread globally and millions of infections have occurred. As cases mount, atypical manifestations of COVID-19 and post-infectious complications such as multisystem inflammatory syndrome in children (MIS-C) become more likely. MIS-C is a life threatening post-infectious complication of COVID-19. There is a paucity of data of MIS-C in the Dominican Republic (DR). We seek to understand the clinical manifestations of MISC-C in the DR. Methods. This is a retrospective review of cases admitted to a pediatric hospital in the Dominican Republic from March 2020 to December 2021. Patients with clinical findings and a diagnosis of MIS-C were included. Echocardiographic (Echo) and electrocardiographic (ECG) changes were reviewed. Results. A total of 16 patients were included in our study, of which 68.75 were male. Ages were 12.5% < 1 years old, 12.5% between 1-4, 62.5% 5-12 and 12.5% over 12. Fever and rash were the most common clinical findings (Figure 1), while 69% had a new abnormality on echo and 50% had new ECG abnormalities. Echocardiographic findings are listed in Figure 2. Clinical findings in patients admitted with MIS-C Echo findings ECG findings Conclusion. The clinical manifestation of MIS-C are primarily fever, conjunctivitis, rash and hypotension. Because these findings can be non-specific, a high level of suspicion is needed. With over two thirds of patients with MIS-C showing echocardiographic changes and more than 50% showing ECG changes, these two tests can add significant diagnostic value in the right clinical setting. Clinicians should consider early echocardiography and ECG in patients with possible or suspected MIS-C.
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Background and Aim: Multisystem Inflammatory Syndrome in Children (MIS-C) associate with Coronavirus disease-19 is a life-threatening clinical condition in which cardiovascular system is frequently affected. Shock, cardiac arrhythmias, myocarditis, reduced left ventricular ejection fraction (LVEF), pericardial effu-sion, and coronary artery dilatation are amongst the most common cardiac complications. In this study, we aim to assess myocardial status in patient with cardiac involvement in MIS-C. Method(s): Over a 14-month period, we retrospectively collected clinical, biological, echocardiographic data in children who were admitted to our hospital with a diagnosis of MIS-C and cardiac involvement. WHO criteria for clinical case definition of MIS-C were adopted. Elevation in brain-natriuretic-peptide and troponin-I, electrocardiographic abnormalities, echocardio-graphic evidence of pericarditis, myocarditis, reduced LVEF, valvular disease, and coronary artery dilatation were including cri-teria. LV indexed end-diastolic (EDVi), end-systolic (ESVi), stroke volumes were measured with Cardiac Magnetic Resonance (CMR). T2 mapping, Cine-RM and late gadolinium enhance-ment studies were performed. Result(s): 14 children were identified and included in the study, 71% of which were male. Median age at disease onset was 7 years old (IQR 5 to 9 years). All patients underwent cardiological evaluation in the first 48 hours of hospital staying. LVEF was lt;45% in 28.6% and lt;35% in 14.3% of patients. Myocarditis was detected in 78.6%, pericarditis in 28.6%, valvular damage in 35.7%, coronary abnormalities in 42.9%. All patients underwent CMR after on average 4 months (median: 3.87, IQR 2 to 4) from disease onset, after full clinical and biological recovery. ESVi and stroke volumes resulted within normal range in 100%. CMR abnormalities were observed in 21%. Particularly, left ventricular EDVi resulted elevated in 7%, delayed washout in T2 was described in 7%, and increased T2 mapping in 7%. Conclusion(s): Despite complete clinical and biological resolution, increased EDVi, delayed washout in T2 and increased T2 mapping at follow-up CMR in patient with cardiac involvement due to MIS-C may be signs of myocardial remodeling.
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Background: Cardiac injury associated with multi-system inflammatory syndrome in children (MIS-C) has been extensively reported but the impact of cardiac injury in children with SARSCoV-2 infection in the absence of MIS-C has not been well described. In this study we describe the cardiac involvement found in children with positive SARS-CoV-2 PCR tests and evaluate the association of cardiac injury with severe outcome in this population. Methods: A retrospective chart review of all patients ages 0-21 presenting to the emergency department or admitted at our institution during and just beyond the peak of the COVID-19 pandemic at our institution was performed. We excluded patients with MIS-C, cardiomyopathy, or complex congenital heart disease. Cardiac injury was defined as elevated high sensitivity troponin and/or N-terminal pro-brain type natriuretic peptide above 99th percentile. Severe illness was defined as need for advanced respiratory support (positive pressure or mechanical ventilation above baseline), inotropic or vasopressor support, and/or death from any cause during admission. Results: During the study period there were 103 patients with positive SARS-CoV-2 PCR, 17 of whom were excluded for MIS-C, 4 of whom were excluded for cardiomyopathy, 2 for complex congenital heart disease including one with repaired Taussig-Bing anomaly and one with double outlet right ventricle who underwent Fontan surgery. Of the 80/103 (78%) patients remaining in the analysis, 31/80 (39%) were female and the median age was 12.5 years (IWR 1.9-17.5). High-sensitivity troponin T and/or NT-proBNP were measured in 27/80 (34%) patients and abnormalities were present in 5/27 (19%), all of whom had underlying comorbidities such as lung disease, diabetes, or genetic syndromes. Severe outcome occurred in 14/27 (52%) patients and 5/5 (100%) of those with cardiac injury as compared to 9/22 (41%) patients without cardiac injury (p<0.05). Advanced respiratory support was more common in those with cardiac injury as compared to those without, occurring in 5/5 (100%) patients with cardiac injury and in 8/22 (36%) patients without cardiac injury (p<0.05). Electrocardiographic abnormalities were identified in 14/38 (37%) studies and no left ventricular dysfunction was identified on echocardiography. Conclusion: During the initial peak of the pandemic at our institution, cardiac injury was present in 19% of those for whom high-sensitivity troponin and/or NT-proBNP were measured. Presence of cardiac injury was associated with greater risk of severe outcomes including advanced respiratory support. Larger studies to determine the true incidence of cardiac injury in children with COVID-19 would be useful to guide recommendations for standard workup and management.
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Background and aims: To evaluate the safety, pharmacokinetics (PK) and antiviral activity of ALG-010133, a STOPS molecule designed to reduce hepatitis B S-antigen (HBsAg) in chronic hepatitis B (CHB) patients. Method: This was a 3-part, multicenter, double-blind, randomized, placebo-controlled study. In Parts 1 and 2, single and multiple subcutaneous (SC) doses of ALG-010133were generallywell tolerated in healthy volunteers (Gane et al, EASL 2021). Part 3 evaluatedweekly SC doses of ALG-010133 or placebo × 12 weeks in virologically suppressed Hepatitis B e-antigen (HBeAg) negative CHB subjects (N = 10/cohort;8 active:2 placebo). Reported here are preliminary blinded Part 3 safety, PK, and antiviral data;unblinded data will be presented at the conference. Results: 31 CHB subjects completed dosing and follow-up in Cohorts 1 (120 mg;N = 10), 2. (200 mg;N = 10), and 3 (400 mg;N = 11). Most subjects were male (61%) and 48% were white, with mean age 48 years, mean BMI 26.1 kg/m2 and baseline HBsAg across cohorts of 3.6 to 3.7 log10 IU/ ml. Therewas 1 unrelated serious treatment emergent adverse event (TEAE) (hospitalization for orchitis) and 1 unrelated TEAE (COVID-19 infection) resulting in premature study drug discontinuation. All TEAEs were Grade 1 or 2 in severity, except for 1 Grade 3 TEAE of injection site erythema (severity based only on surface area criteria of ≥100 cm2;required no treatment and resolved despite continued study drug dosing) and the aforementioned TEAE of orchitis (Grade 3). There was no dose relationship to severity or frequency for any TEAE. The most common (≥3 subjects) TEAEs were injection site erythema (n = 5), increased ALT (n = 4), injection site bruising (n = 4), increased AST (n = 3), and injection site pruritus (n = 3);none were assessed as clinically concerning. Although treatment-emergent ALT and AST elevations (n = 13) were observed, all were Grade 1 (<2.5x upper limit of normal [ULN]) or 2 (≥2.5 to <5x ULN) and none led to premature study drug discontinuation or were associated with symptoms or evidence of liver dysfunction. There were no other clinically significant lab abnormalities. No clinically significant physical examinations, vital signs, or ECG abnormalities were reported. Plasma ALG-010133 exposures increased more than dose proportionally between the 120 to 400 mg dose levels, with moderate variability and minimal accumulation. Compared to baseline, the magnitude of HBsAg decline at Week 12 was <0.1 log10 IU/ml for placebo and across all ALG-010133 dose levels, including the projected efficacious dose level of 400 mg (estimated to maintain total liver exposures >3x EC90 for HBsAg inhibition). Conclusion: ALG-010133 was safe and well tolerated with predictable PK properties when given to CHB subjects as multiple SC doses of up to 400 mg. No meaningful HBsAg reduction was observed across all cohorts. Further clinical development of ALG-010133 has been discontinued.
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The proceedings contain 226 papers. The topics discussed include: mitral valve abnormalities in decedents of sudden cardiac death due to hypertrophic cardiomyopathy and idiopathic left ventricular hypertrophy;prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players;clinical outcomes and myocardial recovery in energetics, perfusion and contractile function after valve replacement surgery in severe aortic stenosis patients with diabetes comorbidity;brain phenotype of takotsubo syndrome;improving the diagnostic accuracy of apical hypertrophic cardiomyopathy;investigating a novel role for nesprin-1 and the linc complex in cardiomyocyte mechanotransduction;transcatheter aortic valve implantation in patients with right bundle branch block: should prophylactic pacing be undertaken?;and disease penetrance in asymptomatic carriers of familial cardiomyopathy variants.
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Introduction: Paediatric multisystem inflammatory syndrome (PIMS) began to present in April 2020 midway through the covid-19 pandemic. Occurring 2-4 weeks after initial covid-19 infection, patients presented with persistent fever, evidence of inflammation and single or multiorgan dysfunction1. The Yorkshire and Humber congenital heart disease network is made up of the Leeds congenital heart unit and 18 peripheral hospitals2.With limited local paediatric cardiology availability, the vast majority of children presenting with PIMS required transfer to Leeds. This presentation aims to describe the cohort of children that were seen within the network as well as to identify any markers of significant cardiac involvement which could beusedto reduce the frequency of unnecessary inter hospital transfers. Methods: This was a retrospective case notes review of all patients treated within the Yorkshire and Humber network with symptoms of PIMS between 1st May and 30th November 2020. Patients were classified as to whether or not they had significant cardiac involvement (defined as at least one of: inotrope requirement, ejection fraction <50%, pericardial effusion, coronary artery changes and significant ECG abnormalities). Cardiac markers were analysed at presentation and throughout the hospital admission including plasma NT pro-BNP, LDH, CRP, d-dimer and troponin. Statistical tests (Fisher's exact test for categorical variables, ttest for continuous variables) were used to identify which factors were indicative of significant cardiac involvement (SCI). Results: 22 patients met the inclusion criteria (Table 1). 14/22 patients (63.6%) were judged to have SCI. Markers that were found to be indicative of SCI included CRP and plasma NT pro-BNP (Table 2). Furthermore, when using a threshold of 2000ng/L, plasma NT pro-BNP was found to be 71% sensitive and 80% specific for SCI. In addition, when combined with a CRP threshold of 100mg/L, there was a positive predictive value of 85% and negative predictive value of 75%. Conclusions: PIMS is an important new syndrome affecting paediatric patients across the Yorkshire and Humber region. A significant proportion of the affected patients have cardiac involvement and require management in a specialist centre. Early identification of these patients using serological markers facilitates rapid treatment preventing long term sequelae whilst also reducing unnecessary interhospital transfers.
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Introduction: Many antiviral agents such as hydroxychloroquine have been studied to treat COVID-19, without being broadly accepted. Multiple side effects have been described, with QTc interval prolongation being one of the most worrisome. Literature on electrocardiographic alterations in COVID-19 is scarce. There aren't large samples of paediatric patients receiving hydroxychloroquine beyond Covid-19 to establish its relationship with electrocardiographic abnormalities. This study aims to describe QTc prolongation in relation to hydroxychloroquine and its association with other antivirals: lopinavir/ritonavir, remdesivir and azithromycin. Methods: COVID-19 cases were detected by Polymerase Chain Reaction from nasopharyngeal aspirate and matched at a 1:2 ratio according to age and sex with controls not exposed to study drugs nor infected by COVID-19. Electrocardiograms, collected S62 Cardiology in the Young: Volume 32 Supplement 1 prospectively, were evaluated manually by the same person. QT intervals were calculated in 3 different beats and corrected with the Bazett formula. Electrocardiographic cut-off points were determined: before treatment, within 72 hours of the start and after more than 72 hours. Data were compared by using oneway ANOVA. Results: 11 out of 48 paediatric patients admitted due to COVID- 19 from March to July 2020, received antiviral therapy (22.9%) based on clinical evidence at the time;median age 9 years (IQR 10.5), 54.5% were male. Among the main underlying pathologies, congenital heart diseases (36.4%) and malignant haematological diseases (27.3%) stood out;5 had received treatments potentially causing QTc prolongation. 10 patients (90.9%) received hydroxychloroquine, mostly in association with azithromycin (80%). 3 patients received lopinavir/ritonavir and one remdesivir. The mean of the baseline QTc interval was 418.5ms (407.4-429.6, 95%CI), before 72 hours was 424.6ms (398.1-451.2). A prolongation occurred after 72 hours: 439.7ms (408.5-470.9) but was not significant (p=0.253). 2 patients had long QTc interval before starting the treatment, and 4 after 72 hours. No patient presented arrhythmias. Conclusions: A small proportion of patients received antiviral drugs. All had underlying diseases and a great proportion were taking drugs with an effect on QTc interval;this could contribute to QTc prolong. QTc prolongation occurred after 72 hours under treatment. Although only one patient had a QTc interval longer than 500ms (treatment was stopped afterwards) and none presented arrhythmias, QTc monitoring is advised.
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Cardiovascular manifestations and electrocardiographic abnormalities have been reported among some prevalent infections in tropical regions, which lead to a great amount of morbidity and mortality. The major infectious diseases include chikungunya, dengue fever, H1N1 influenza, and coronavirus disease-19 (COVID-19) in the viral category, leptospirosis, salmonellosis, scrub typhus and tuberculosis in the bacterial category, and malaria in the protozoan parasite category. All these infirmities constitute a foremost infection burden worldwide and have been linked to the various cardiac rhythm aberrancies. So we aimed to identify and compile different studies on these infections and associated acute electrocardiographic (ECG) changes. The search was made in online international libraries like PubMed, Google Scholar, and EMBASE, and 38 most relevant articles, including original research, systematic reviews, and unique case reports were selected. All of them were evaluated thoroughly and information regarding ECG was collected. Myocarditis is the predominant underlying pathology for rhythm disturbance and can be affected either due to the direct pathogenic effect or the abnormal immune system activation. ECG variabilities in some infections like chikungunya, scrub typhus, and leptospirosis are associated with longer hospital stay and poor outcome. Tropical infective diseases are associated with prominent acute cardiac rhythm abnormalities due to myocarditis, which can be identified preliminarily by ECG changes.
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Study Objectives: COVID-19, due to the cancellation of many clinical rotations, has introduced new challenges as graduating students prepare to start residency with less direct patient care experience compared to prior years. In many schools, clinically relevant ECG interpretation is typically learned in a longitudinal fashion at the bedside and this lack of clinical experience may affect acquisition of this key skill. To bridge this gap in knowledge within the requirements of social distancing the investigators developed a novel, virtual ECG curriculum designed for MS-4 students entering residency. Our objectives include increased self-confidence with ECG interpretation, recognition of key ECG patterns and arrhythmias, and understanding pathologies related to ECG findings. Methods: Learners were MS-4 students self-selected from a single osteopathic medical school. Using Kern’s Six Steps of Curriculum Design, the investigators adapted an existing ECG curriculum that was originally developed for emergency medicine PGY-1s. The curriculum consisted of biweekly Zoom lectures over 4 weeks for a total of 8 sessions and 12 hours. Each session included additional readings, homework, weekly summaries, and an end-of-course project. Outcomes were measured according to the Kirkpatrick model. Learner reaction was assessed using a Too-Much-Too-Little (TMTL) scale from 1-5, with 3 indicating a perfect score. Knowledge acquisition was assessed using a pre- and post-course test. Although we have collected preliminary feedback for behavioral changes, we plan to formally assess for level 3 outcomes in a follow-up survey after July 1, 2021. Anonymous surveys were used for data collection, and statistical analysis was conducted using a percentages independent sample t-test. Results: The total sample size was 27 self-selected MS-4 students who met inclusion criteria. Learner reactions were overwhelmingly positive, with 100% (27) indicating they would take the course again or recommend it to a friend. Using a TMTL scale, 77% (21) of participants gave a 3 for lecture length, 58% (16) gave a 3 for time commitment (with 42% stating time commitment was too low and 0% too high), and 77% (21) gave a 3 for level of detail the course provided. The average score between the pre- (M = 56%, SD = 14) and post-tests (M = 73%, SD = 12) showed a statistically significant improvement (p<0.0001). Student’s confidence with interpreting ECGs, understanding ECG rhythms, and ability to call a “Code STEMI” all improved (2.59 to 3.59, 2.67 to 3.74, 2.56 to 3.67 respectively;p<0.0001 for all comparisons). Preliminary behavioral feedback from students following the course included the ability to identify and interpret pathology such as Wellen’s waves, hypothermia, and Wolf-Parkinson-White Syndrome during clinical rotations. Conclusion: This study demonstrated that virtual teaching is a satisfactory method for medical students to learn ECG interpretation and provides an additional mode that medical educators can use in the future. Learners drastically improved their self-confidence and knowledge with ECG interpretation following participation in a novel, virtual learning curriculum.
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Background: In young adults and adolescent males, myocarditis has been described as a rare complication of SARS-CoV-2 mRNA-vaccination. Reported findings include chest pain, elevated troponin levels, and cardiac MRI abnormalities. ECG abnormalities include ST-elevation but to our knowledge, ventricular arrhythmia has not been yet described. In the vast majority of reported cases, symptoms were relatively mild and patients recovered fully. Method: Here, we report two male adolescents (15 resp. 13 years old) admitted to our hospital with nonsustained (ns) VT and chest pain (patient no. 1) and near syncope (patient no. 2) after receiving an mRNA-SARS-CoV-2 vaccine (patient no. 1: 4 days after the second dose and patient no. 2: 15 days after days after the first dose). Further workup included family history, standard 12 lead ECG, the Holter monitoring, heart catheterization, myocardial biopsy, invasive programmed RV stimulation, and cardiac MRI. Results: Both patients did not have elevated troponin levels nor specific ECG findings. Family history was free for cardiac diseases, sudden cardiac death, or syncopal episodes. The Holter monitoring showed recurrent ns VT in one patient. Cardiac MRI and myocardial biopsy in both patients did not show evidence of myocarditis, but both patients showed severe thickening of the arterioles in myocardial biopsy. Invasive RV-stimulation did not trigger VT. Ultimately, both patients did not meet diagnostic criteria for myocarditis and β-blockers were started for ns VT. As of today, four more patients in age group 12 to 17 years were diagnosed with vaccine-associated myocarditis in our institution and one male with COVID-19 associated myocarditis. Notably, none of these patients had ventricular tachycardia or other cardiac arrhythmia. Conclusion: We observed ventricular tachycardia after SARS-CoV-2-mRNA vaccination in two adolescent males. This manifestation seems to be distinct from the well-described vaccine-associated myocarditis. Interestingly in both patients, perivascular thickening of arterioles was noted in biopsy. The mechanism and causality of ventricular arrhythmia in association with SARS-CoV-2 mRNA vaccines remain unclear and requires further observation.
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Case Report A 62-year-old Caucasian, female patient with history of celiac disease and chronic pain s/p spinal cord stimulator presented to our institution to follow up on abnormal lab findings. The patient presented to her PCP with complaints of worsening weakness, nausea, vomiting, constipation, polydipsia, and occasional palpitations. Labs resulted a severely elevated serum calcium level (17 mg/dL), increased BUN (32), and elevated Cr (1.8) indicating acute kidney injury. Full workup was initiated. Vitamin D, 25-Hydroxy level returned greater than 209 and PTH resulted in a normal range of 22. Detailed history revealed that the patient was taking 50,000 units of vitamin D3 by mouth six times/ week for six months. Fear surrounding the current COVID- 19 pandemic prompted the exorbitant intake of vitamin D supplementation in hopes of immune improvement. Bisphosphonate were contraindicated due to AKI.Volume expansion with normal saline and calcitonin successfully decreased the patient's serum calcium. Discussion The diagnostic criteria for reversible Brugada pattern, recently classified as Brugada phenocopy, includes four mandatory components. Primarily, an ECG tracing delineating type 1 or type 2 Brugada morphology. Secondarily, the presence of an underlying condition that is identifiable and reversible. Third, complete resolution of the ECG pattern upon elimination or correction of the underlying condition. Fourth, a low probability for Brugada syndrome determined by the lack of symptoms, clinical history, and family history. Our patient experienced severe hypercalcemia with palpitations that prompted an ECG. The abnormal ECG produced was read independently by two interventional cardiologists and a cardiac electrophysiologist who all concluded the ST segment and T wave deviations were consistent with Brugada pattern type 1. Importantly, the ECG was compared to one from a year prior which showed a normal rate and rhythm. There was complete resolution on repeat ECG once serum calcium was returned to reference range. The patient did not experience Brugada specific symptoms of syncope, seizures, nocturnal agonal breathing, or sudden cardiac death. No family history suggested Brugada syndrome or cardiac issues. Electronic medical record documentation tracked over the last 5 years showed no concerns for prior arrhythmias or syncope. Additionally, the patient does not fit the epidemiological profile of a male of Southeast Asian decent which is classically associated with Brugada syndrome. To our knowledge, this is the first documented presentation of Brugada phenocopy induced by severe hypercalcemia secondary to vitamin D toxicity. Conclusion Although the mechanism is not completely understood, severe hypercalcemia can cause a reversible type 1 Brugada pattern on ECG. Careful consideration of vitamin supplementation must be discussed with patients to avoid potentially fatal cardiac outcomes.
ABSTRACT
Background: To examine influence of COVID-19 pandemic on cardiovascular system in general population, ECG changes during the COVID-19 pandemic period were compared with those before the pandemic period. Methods: Incidence of newly appeared ECG abnormalities (T wave abnormalities and ST-segment depression including minor changes, and abnormal Q wave) was evaluated in subjects 40 to 74 years of age who had 12-lead ECG recording in annual health checkup offered to adult citizens of Moriguchi city, Osaka, Japan in 2019 and 2020. The incidence was compared with that of those who received ECG recording in 2018 and 2019 as the control value before the COVID-19 pandemic. Those with history of cardiovascular disease, any T wave abnormality, any ST-segment depression, abnormal Q wave, left bundle brunch block, or pace-maker rhythm at baseline ECG were excluded. Multivariate logistic regression analyses were performed adjusted for age, sex, hypertension, current smoking, diabetes, drinking habit and hypercholesterolemia. Results: There were 5,221 (mean age 63±10, men 40%) subjects who received ECG recording in 2018 and 2019 and 4,100 (mean age 63±10, men 41%) subjects who received ECG recording in 2019 and 2020. The incidence of newly appeared T wave abnormalities was 5.2 %, ST-segment depression was 2.8 % and abnormal Q wave was 1.1 % from 2018 to 2019, whereas the incidence of newly appeared T wave abnormalities was 5.8 %, ST-segment depression was 4.3 % and abnormal Q wave was 1.7 % from 2019 to 2020. The incidence of ST-segment depression (odds ratio (OR)=1.59, 95% confidence interval (CI)=1.27 to 1.98, p<0.0001) and that of abnormal Q wave (OR=1.56, 95% CI=1.09 to 2.22, p=0.0149) from 2019 to 2020 was significantly higher compared to that from 2018 to 2019. Conclusions: Increased incidence of ST-segment depression and abnormal Q wave was observed during the COVID-19 pandemic period.