ABSTRACT
Background: Hydroxychloroquine (HCQ) was widely used as a potential therapy for COVID-19 infection. We studied the effects of HCQ on electrocardiogram (ECG) intervals. Method(s): We conducted a large-scale retrospective study of COVID-19 patients treated with HCQ admitted between March 1, 2020 and June 1, 2020. Extensive medical chart review was performed. Baseline and on treatment ECG intervals were manually measured by 3 electrophysiologists. The QT interval was corrected using Bazett formula (QTc). The paired t-test was used for the main analysis. Result(s): Paired ECG data from 1890 patients were analyzed. The mean age was 47.0 (+/-12.6) years with a strong male prevalence (85.6%). The commonest comorbidities were hypertension (39.6%) and diabetes mellitus (36.8%). The average duration of HCQ therapy was 6.3 (+/-2.3) days. 404 patients (21.4%) had severe COVID-19 infection and the mortality rate was 3.86%. Intensive care admission and mechanical ventilation was required in 209 (11.1%) and 166 (8.8%) patients, respectively. During therapy, heart rate (HR) decreased from 87.2 +/- 16.8 bpm to 80.6 +/- 14.7 bpm (P<0.001). The mean PR interval increased from 153.2 +/- 21.9 ms to 162.9 +/- 22.8 ms (P<0.001). The mean QRS duration increased from 92.8 +/- 12.6 ms to 97.4 +/- 13 ms (P <0.001). The average QTc increased from 427.4 +/- 25.4 ms to 438.4 +/- 29.9 ms (P<0.001). Conclusion(s): HCQ caused a modest but statistically significant prolongation in PR, QRS and QTc intervals. A reduction in HR was also noted mainly due to clinical improvement. (Figure Presented).
ABSTRACT
Objective: NA Background: Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterized on nerve conduction study (NCS) by prolonged distal latencies, slowed conduction velocities, prolonged late responses, conduction blocks, and temporal dispersion. Unmyelinated fibers typically conduct action potentials at speeds of 0.5-10 m/s;myelinated fibers conduct an order of magnitude faster, e.g. 50-70 m/s. While very slow conduction velocities < 25 m/s are typically associated with the genetic neuropathies as in the Charcot-Marie Tooth neuropathies, CIDP can manifest with slow conduction velocities. Prompt recognition of CIDP is crucial for the timely initiation of immunotherapy. Design/Methods: NA Results: This case series of three CIDP patients demonstrates very slow conduction velocities and prolonged distal latencies. An 81-year-old woman with history of multiple sclerosis and chronic myelogenous leukemia presented with inability to walk over a few months with diffuse sensory loss. NCS showed absent motor responses in the leg, partial conduction blocks in the arm, prolonged ulnar motor distal latency 7.9 ms (normal ≤3.4ms), and very slow conduction velocities < 15 m/s. A 50-year-old woman with prior history of COVID-19 presented with diffuse weakness. NCS showed ulnar motor distal latency of 23.2 ms, slowed motor conduction velocities < 30 m/s. After treatment initiation with intravenous immunoglobulin, sensory responses improved, and conduction velocities increased to > 30 m/s. A 49-year-old woman presented with 3 months of bilateral weakness and sensory symptoms two weeks after a COVID-19 vaccination. NCS showed ulnar motor distal latency of 14 ms and slowed motor conduction velocities < 30 m/s. Conclusions: Very slow conduction velocities are a feature not just of the genetic neuropathies but also of acquired demyelination as seen in CIDP, and the latter is distinguished by abnormal temporal dispersion and conduction blocks. Astute electrophysiologists should modify sweep speed and gain to increase sensitivity for delayed or dispersed responses.
ABSTRACT
Background: COVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation. Purpose: We compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol. Methods: We retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (< 90%) or need for assisted ventilation/intubation, bradycardia (heart rate < 45 bpm) and persistent hypotension (systolic blood pressure < 90 mmHg). Results: Baseline characteristics and hemodynamic variables did not differ between the two groups (all p > 0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine. Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine;p = 0.057). Conclusion: Deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.
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Background: Little data is known regarding the impact of the COVID-19 pandemic on cardiac services during the second year. This globally distributed survey aimed to study the impact of the pandemic on cardiovascular services, type of PPE currently used by participants and their academic achievements during pandemic. Methods: A 23-item online survey was distributed via social media among HCPs involved in cardiac services. Survey items assessed the proportion of change in various cardiac services in 2021, as compared with 2020. Results: Among 111 respondents, 54.95% were resident in Asia, while 27.02% were resident in Europe, see Figure (1). Among total respondents;57.7 % were females. 58.6% of respondents were from COVID-19 designated hospitals. Interventional cardiologists constitute 46.8% of respondents, clinical cardiologists were 22.5%, 12.6% were specialising in cardiac imaging, while 9% were electrophysiologists. 55% were consultants/attendings while 34.2% were fellows/ trainees. Proportions of return of cardiac services to pre-pandemic states are depicted in Figure (2). The highest return to pre-pandemic services were in emergency coronary catheterisation (25.2%), 21.6% of respondents noted return to pre-pandemic states in elective coronary catheterizations, and trans-thoracic echocardiograms [TTE]. Telemedicine was used by 64.9% of outpatient consultations. 94.6% of respondents were vaccinated. Respondents reported that most used PPE during their daily practice was surgical mask (69.36 %) followed by N95/FFP mask (53.15%). 30.6% reported decline in conference participation as faculty/speaker, while 21.6% reported decline in publications during the pandemic. Conclusion: In an increasingly vaccinated global cardiology workforce, cardiac services are gradually picking up to pre-pandemic rates, with the highest being noted for coronary catheterisations and trans-thoracic echocardiograms. (Figure Presented).
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Background: Following restrictions imposed by the Covid-19 pandemic, virtual care became frequently employed. The adoption and maintained utilization of virtual care in Cardiac Arrhythmia specialty compared to other parts of cardiology may be greater owing to the nature of the care being given. Objective: To assess digital health resource utilization over time in EP and non-EP providers. Methods: All patient appointments in our cardiovascular medicine clinics at our Center from March 2020 through November 2021 were analyzed. Completed appointments by EP and non-EP providers were categorized as Virtual (VV) or In-Person (IPV). Routine remote device transmissions were excluded from the analysis. The VV rate was defined as the number of VVs divided by total Visits (IPVs and VVs). Results: Over the 21-month observation period, a total of 23,052 VVs (37%) and 39,882 IPVs (63%) were completed. The monthly percentage of virtual visits ranged from 13.5% (N=454/3383) in November 2021 to 97.5% in April of 2020 (N=2123/2178). Compared to other cardiovascular subspecialties, EP had a consistently higher proportion of virtual visits that has persisted throughout the observation period (range 29%-98.4%). With regard to new visits only, in 2020 there were 395/735 (53.7%) new EP VVs vs. 1608/3523 45.6% Non-EP VVs (p<.01). This discrepancy widened in 2021 as there were 524/1353 (38.7%) of all new EP VVs vs. 1400/6181 (22.7%) of all new non-EP VVs. The same widening discrepancy was seen with return visits (RPV). RPVs in 2020 were 3155/4720 (66.8%) EP VVs vs. 9659/16516 (58.5%;p<.01). This discrepancy for RPVs also widened in 2021 as there were 2010/4662 (43.1%) of all RPV EP VVs vs. 4301/19607 (21.9%;p<.01) of all new non-EP VVs. (see attached figure). Conclusion: Cardiac electrophysiologists and arrhythmia patients have adopted and maintained virtual visits to a greater extent compared to other areas of cardiovascular medicine. This may reflect improved at home sensor use and outpatient monitors to facilitate virtual visits in EP. [Formula presented] [Formula presented]
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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.