Increased ventricular ectopy precedes Torsades de Pointes in patients with prolonged QT

OBJECTIVE

Torsades de Pointes (TdP) is a potentially lethal ventricular tachydysrhythmia. Prolonged heartrate corrected QT interval (QTc) predicts TdP; however, with poor specificity. We performed this study to identify other predictors of TdP among patients with prolonged QTc.

METHODS

We performed a retrospective case control study with 2:1 matching at an urban academic hospital. We searched our hospital electrocardiogram (ECG) database for tracings with heartrate ≤ 60, QTc ≥ 500, and QRS < 120, followed by a natural language search for electronic records with "Torsades," "polymorphic VT," or similar to identify TdP cases from 2005 to 19. We identified controls from a similar ECG database search matching for QTc, heartrate, age, and sex. We compared cardiologic and historical factors, medications, laboratory values, and ECG measurements including ectopy using univariate statistics. For those cases with saved telemetry strips that included preceding beats or TdP onset, we compared ectopy and TdP onset characteristics between the ECG and telemetry strips using mixed linear modeling.

RESULTS

Seventy-five cases including 50 with telemetry strips and 150 controls were included. Historical, pharmacologic, laboratory, and cardiologic testing results were similar between cases and controls. The proportion of telemetry tracings with premature ventricular contractions (PVC's) preceding TdP was 0.78 compared to 0.16 for case ECG's (difference 0.62(95%CI 0.44-0.75)) and 0.10 for control ECGs (difference 0.68(95%CI 0.56-0.80)). Average telemetry heartrate was 72 and QTc 549 immediately preceding TdP, similar to the ECG values.

CONCLUSIONS

Clinical factors don't differentiate patients with long QTc who develop TdP, however, an increase in PVC's in patients with prolonged QTc may usefully predict imminent TdP.

Late-onset pulmonary complications among survivors of coronavirus Disease 2019

Objectives

To assess the late-onset pulmonary complications among survivors of coronavirus disease 2019.

Methods

The cross-sectional analytical study was conducted in the department of Pulmonology, Sir Ganga Ram Hospital Lahore between October 2020 and March 2021. Total 288 patients visiting the hospital 12-week after recovery from COVID-19 enrolled using convenience sampling. After excluding patients (n=61) with a history of previous respiratory symptoms before the development of COVID-19, data from 227 patients was subjected to final analysis. Chest X-ray (CXR) was used to evaluate lung condition.

Results

Participation of middle-aged adults (54.6%) was higher than older (38.3%) and young adults (7.0%). The percentage of males was 55.5% and smokers was 29.1%. Dyspnea was the most common complication as 80.0% patients had moderate to severe dyspnea while chronic cough was 78.0% and lung fibrosis (LF) was 13.2%. The chances of LF increased with the rise in age (p-value 0.033). However, the distribution of LF was similar between males and females. The frequency of lung fibrosis in smokers was 3-time higher than among non-smokers (24.2 vs. 8.7%; p-value 0.003). The patients with LF were more dependent on O2 as compared to the patients without LF (p-value < 0.001). The frequency of tachycardia was significantly different between patients with and without LF (all p-values < 0.05).

Conclusion

LF is a common late-onset pulmonary complication of COVID-19 and is associated with old age, smoking, O2 dependency, tachycardia, and severe dyspnea.

Ivabradine for inappropriate sinus tachycardia-induced symptomatic Mobitz type I atrio-ventricular block: a case summary

Background

Inappropriate sinus tachycardia (IST) is characterized by a continuum of symptoms, and the aetiology of IST is imprecise. IST-induced autonomic dysfunction is well known, but IST-induced atrio-ventricular block is not reported to our knowledge.

Case summary

A 67-year-old female presented with a 4-day history of random intermittent difficulty in breathing, chest tightness, palpitations, and dizziness, with a recorded heart rate of 30 beats per minute (BPM) on home monitoring equipment. The initial electrocardiogram (ECG) demonstrated sinus rhythm with intermittent Mobitz type I second degree atrio-ventricular (AV) block, with continuous cardiac monitoring demonstrating frequent episodes of Wenckebach phenomenon throughout the day, with a sinus rate of 100-120 BPM. Echocardiogram showed no significant structural abnormalities. The patient was on bisoprolol, and hence, it was suspected Wenckebach may be due to that and so stopped. However, there was no tangible effect on rhythm 48 hours after stopping bisoprolol, leading to a suspicion of IST-induced Mobitz type I second degree AV block; and so decided to introduce ivabradine 2.5 mg twice daily. After 24 hours of Ivabradine, the patient remained in sinus rhythm with no documented episodes of Wenckebach phenomenon on cardiac monitor, a finding subsequently confirmed by 24-hour Holter monitoring. During a recent follow-up visit in clinic, the patient remained symptom-free, with an ECG demonstrating sinus rhythm at a physiological rate.

Discussion

Mobitz type I second degree AV block is usually due to reversible conduction block at the level of the AV node whereby malfunctioning AV nodal cells tend to progressively fatigue until they fail to conduct an impulse. Under conditions of increased vagal tone and autonomic dysfunction, Wenckebach occurrence will be increased. Thus, selective impulse conduction within the sinoatrial (SA) node by ivabradine to reduce beat conduction to the AV node in patients with IST/dysautonomia-induced Mobitz type I AV will reduce the occurrence of Wenckebach.

Resolution of Sinus Tachycardia Secondary to Hyperthyroidism With Ivabradine

Currently, ivabradine is not approved for the treatment of sinus tachycardia secondary to hyperthyroidism. We aimed to increase the recognition of ivabradine as an effective alternative to, or combination with, beta-blockers in controlling sinus tachycardia secondary to hyperthyroidism. Elevated thyroid hormone levels enhance cardiac performance through a positive chronotropic effect, resulting in an increased heart rate (HR), an effect brought on by increasing the I_f funny current at sinoatrial node (SAN). Ivabradine is a novel, dose-dependent selective inhibitor of I_f channels. By decreasing SAN pacemaker activity, ivabradine allows for selective reduction of HR with a resultant increase in ventricular filling time. This mechanism sets ivabradine apart from the typical rate-reducing medications, namely beta-blockers and calcium channel blockers, which simultaneously decrease HR and myocardial contractility. We describe a case of hyperthyroidism-induced sinus tachycardia, resistant to maximal doses of beta-blocker, which was successfully managed by ivabradine. After excluding other causes of tachycardia, such as anemia, hypovolemic states, structural heart disease, drug abuse, and infection, ivabradine was given off-label for symptomatic relief of hyperthyroidism-induced sinus tachycardia. Within 24 h, HR steadily decreased to the low 80s. Our patient had a unique presentation in which he presented with hyperthyroidism-induced sinus tachycardia with no relief after administration of maximal dose of beta-blocker. Ivabradine was then given, with resolution of sinus tachycardia within 24 h.

Hemodynamic Changes Associated With Transcervical Laryngeal Injection of Botulinum Toxin

PURPOSE

Laryngeal dystonia is a chronic neurologic disorder characterized by intention-induced spasms of the vocal folds driven by aberrant central motor processing. The use of in-office transcervical botulinum toxin injection for the treatment of laryngeal disorders, such as laryngeal dystonia, has been deemed safe and efficacious. There is, however, no available data outlining the hemodynamic changes experienced by patients undergoing this frequently performed procedure.

METHODS

One hundred and one patients diagnosed with laryngeal dystonia were enrolled in this prospective study. These patients underwent transcervical laryngeal botulinum toxin injection to address their dysphonia. Vital signs where acquired prior to, and at the time of injection. Alterations in these parameters were then evaluated for statistical significance.

RESULTS

Statistically significant increases in mean heart rate (5.8 ± 10.8 bpm, P < 0.0001), systolic blood pressure and diastolic blood pressure (7.0 ± 9.5 mm Hg, P < 0.0001; 8.7 ± 14.7 mm Hg, P < 0.0001) were discovered. No statistically significant difference in oxygen saturation was noted and no patients in the study faced major adverse outcomes.

CONCLUSIONS

Though these findings may not have related to clinically significant complication, our study demonstrates the importance of understanding potential stressors in a procedure routinely performed by laryngologists. This may result in more careful patient selection, alterations in procedure, and improved safety by acting in a timely fashion if alarming changes in hemodynamic parameters are noted.

Clinical risk prediction score for post-operative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease

BACKGROUND

Accelerated junctional rhythm (AJR) and Junctional ectopic tachycardia (JET) are common post-operative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intra-operative treatment may improve outcomes, but patient selection remains a challenge.

OBJECTIVES

Our objective was to describe contemporary outcomes of post-operative AJR/JET and develop a risk-prediction score to identify patients at highest risk.

METHODS

Retrospective cohort study of children 0-18 years undergoing cardiac surgery (2011-2018). AJR was defined as usual complex tachycardia with ≥1:1 ventricular-atrial association and junctional rate >25^th percentile of sinus rate for age but < 170 bpm while JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression.

RESULTS

From 6364 surgeries, AJR occurred in 215 (3.4%) and JET in 59 (0.9%). Age, heterotaxy syndrome, aortic cross-clamp time, ventricular septal defect closure and atrio-ventricular canal repair were independent predictors of AJR/JET on multivariate analysis and included in the risk prediction score. The model accurately predicted the risk of AJR/JET with a C-index of 0.72 [95% CI 0.70, 0.75]. Post-operative AJR and JET was associated with prolonged ICU and hospital length of stay, but not with early mortality.

CONCLUSION

We describe a novel risk prediction score to estimate the risk of post-operative AJR/JET permitting early identification of at-risk patients who may benefit from prophylactic treatment.

Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report

BACKGROUND

Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital.

CASE PRESENTATION

The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient's symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient's condition.

CONCLUSION

If a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient's condition is critical, and early diagnosis will lead to a favorable outcome for the patient.

How arrhythmias weaken the ventricle: an often underestimated vicious cycle

Arrhythmia-induced cardiomyopathy (AIC) is classified as a form of dilated cardiomyopathy in which left ventricular systolic dysfunction (LVSD) is triggered by tachycardic or arrhythmic heart rates. On the one hand AIC can develop in patients without cardiac disease and on the other hand it can appear in patients with pre-existing LVSD, leading to a further reduction in left ventricular (LV) ejection fraction. A special aspect of AIC is the potential termination or partial reversibility of LVSD; thus, AIC is curatively treatable by the elimination of the underlying arrhythmia. Since arrhythmias are often seen merely as a consequence than as an underlying cause of LVSD, and due to the fact that the diagnosis of AIC can be made only after recovery of LV function, the prevalence of AIC is probably underestimated in clinical practice. Pathophysiologically, animal models have shown that continuous tachycardic pacing induces consecutive changes such as the occurrence of LVSD, increased filling pressures, LV dilatation, and decreased cardiac output. After termination of tachycardia, reversibility of the described pathologies can usually be observed. Studies in human ventricular myocardium have recently demonstrated that various cellular structural and functional mechanisms are activated even by normofrequent atrial fibrillation, which may help to explain the clinical AIC phenotype.

What acute cardiac care physicians need to know from the latest 2022 ESC Guidelines for ventricular tachycardia and sudden cardiac death

The present paper summarizes and comments on the latest 2022 ESC guidelines on ventricular tachycardia and sudden cardiac death. Most relevant recommendations for acute cardiovascular care physicians are addressed, particularly, in the fields of coronary artery disease, dilated cardiomyopathy, and inflammatory diseases. New recommendations encompass the implantation of a defibrillator (ICD) in the setting of acute myocarditis. Furthermore, the pathophysiology of the electrical storm including involved molecular pathways as well as the angry Purkinje fibre syndrome is presented and discussed.

Atrial high-rate episode burden and stroke risks for patients with device-detected subclinical atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Atrial high-rate episode (AHRE) and stroke are related; however, the magnitude of the correlations between different AHRE burdens and stroke remains unknown. We analysed studies that evaluated this relationship.

METHODS

We searched for observational controlled studies that reported the associations of different AHRE burdens with stroke in populations with cardiac implantable electronic devices (CIEDs). The primary endpoint was stroke or thrombosis during follow-up. We performed subgroup analyses according to the classification criteria and research design of the included studies.

RESULTS

Of the 5985 studies identified, 9 met the eligibility criteria and included 42,958 patients. Patients with low and high AHRE burdens had a 1.2-fold risk of stroke (no heterogeneity) and a 2.52-fold risk of stroke (moderate heterogeneity), respectively. After excluding studies analysing the atrial fibrillation history, no significant difference in progressive stroke risk was observed for patients with a low AHRE burden (without significant heterogeneity). An increased likelihood of stroke was observed for patients with a high AHRE burden (decreased heterogeneity). Four of the nine studies classified high and low AHRE burdens using the longest AHRE time. Five studies classified high and low AHRE burdens based on the median of the total AHRE time as the cutoff value. Low and high AHRE burdens were more closely related to stroke when classified by the total AHRE duration than when classified by the single longest AHRE duration.

CONCLUSIONS

For populations with CIEDs without an atrial fibrillation history, a high AHRE burden was significantly associated with stroke.

A Clinical Score for Predicting the Paroxysmal Supraventricular Tachycardia's Recurrence Risk; a Retrospective Cross-sectional Study

Introduction

Identifying prognostic variables associated with the probability of recurrent paroxysmal supraventricular tachycardia (PSVT) would aid decision-making regarding disposition of the patients. This study aims to develop a clinical scoring system to predict PSVT recurrence after adenosine administration in the emergency department (ED).

Methods

This retrospective cross-sectional study was conducted on patients who were referred to the emergency department of Ramathibodi Hospital, a university-affiliated super-tertiary care hospital in Bangkok, Thailand, with diagnosis of PSVT during a 10-year period from 01 January 2010 until 31 December 2020. The cases were divided into recurrent and non-recurrent PSVT based on the response to standard treatment and the independent predictors of recurrence were studied using multivariable logistic regression analysis.

Results

264 patients were diagnosed with PSVT and successfully converted by adenosine. 24 (9.1%) had recurrent PSVT, and 240 (90.9%) had no recurrent PSVT in the same ED visit. The risk of PSVT recurrence in ED corresponded with the history of hypertension (p = 0.059), valvular heart disease (p = 0.052), heart rate ≥ 100 (p = 0.012), and systolic blood pressure < 100 after electrocardiogram (ECG) converted to sinus rhythm (p = 0.022) and total dose of adenosine (p = 0.002). We developed a clinical prediction score of PSVT recurrence with an accuracy of 79.5%. A score of 0 (low risk), 1-2 (moderate risk), and > 2 (high risk) had a positive likelihood ratio (LR+) of 0.31, 0.56 and 2.33, respectively.

Conclusion

It seems that, using the PSVT recurrence score we could screen the high-risk patients for PSVT recurrence (score>2) who need to be observed for at least 6-12 hours and receive cardiologist consultation in ED. In addition, the moderate and low-risk group (score 0-2) need to be observed for 1 hour and can be discharged from ED.

Tachycardia Changes Increase Neurological Deterioration in Patients with Acute Non-Cardioembolic Stroke: An ADS Post-Hoc Analysis

AIM

A previous randomized study showed that dual antiplatelet therapy (DAPT) with aspirin and cilostazol is not superior to aspirin monotherapy for patients with acute non-cardioembolic stroke; however, the reason for this remains uncertain. We focused on the unusual side effects of cilostazol, namely, tachycardia changes, and validated their influence on patients with acute non-cardioembolic stroke.

METHODS

This post-hoc study extracted data from the acute aspirin plus cilostazol dual therapy study (ADS) registry, a multicenter, prospective, randomized, open-label trial. Patients were randomly allocated to the dual group (aspirin plus cilostazol) and the aspirin monotherapy group (aspirin alone). Tachycardia changes were defined as ≥ 5% heart rate increase at 48 h after admission compared with that at admission. Baseline data and outcomes were validated with four divided groups: aspirin-non-tachycardia changes (AN), aspirin-tachycardia changes (AT), dual-non-tachycardia changes (DN), and dual-tachycardia changes (DT).

RESULTS

Finally, 1,188 patients were analyzed in this ADS post-hoc analysis (aspirin monotherapy group, 594; dual group, 594). The proportion of change in tachycardia was 19.2% in the aspirin monotherapy group and 38.2% in the dual group (p＜0.001^＊＊＊). Although the recurrences of symptomatic stroke and transient ischemic attack were not significantly different, the neurological deterioration was significantly different among the AN, AT, DN, and DT groups (p＜0.05^＊).

CONCLUSIONS

Tachycardia changes increase neurological deterioration even in patients with non-cardioembolic acute stroke. DAPT consisting of aspirin and cilostazol increases the proportion of tachycardia changes and is not superior to aspirin monotherapy.

Decreased Heart Rate Variability in COVID-19

Purpose

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which primarily infects the lower airways and binds to angiotensin-converting enzyme 2 (ACE2) on alveolar epithelial cells. ACE2 is widely expressed not only in the lungs but also in the cardiovascular system. Therefore, SARS-CoV-2 can also damage the myocardium. This report aimed to highlight decreased heart rate variability (HRV) and cardiac injury caused by SARS-CoV-2.

Materials and Methods

We evaluated three COVID-19 patients who died. Patients' data were collected from electronic medical records. We collected patient's information, including baseline information, lab results, body temperature, heart rate (HR), clinical outcome and other related data. We calculated the HRV and the difference between the expected and actual heart rate changes as the body temperature increased.

Results

As of March 14, 2020, 3 (2.2%) of 136 patients with COVID-19 in Tianjin died in the early stage of the COVID-19 epidemic. The immediate cause of death for Case 1, Case 2, and Case 3 was cardiogenic shock, cardiac arrest and cardiac arrest, respectively. The HRV were substantially decreased in the whole course of all three cases. The actual increases in heart rate were 5 beats/min, 13 beats/min, and 4 beats/min, respectively, less than expected as their temperature increased. Troponin I and Creatine Kinase MB isoenzyme (CK-MB) were substantially increased only in Case 3, for whom the diagnosis of virus-related cardiac injury could not be made until day 7. In all three cases, decreased in HRV and HR changes occurred earlier than increases in cardiac biomarkers (e.g., troponin I and CK-MB).

Conclusions

In conclusion, COVID-19 could affect HRV and counteract tachycardia in response to increases in body temperature. The decreases of HRV and HR changes happened earlier than the increases of myocardial markers (troponin I and CK-MB). It suggested the decreases of HRV and HR changes might help predict cardiac injury earlier than myocardial markers in COVID-19, thus its early identification might help improve patient prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44231-022-00024-1.

Postural orthostatic tachycardia syndrome and orthostatic hypotension in post-acute sequelae of COVID-19 during pregnancy: a case report

BACKGROUND

Patients with post-acute sequelae of COVID-19 (PASC) often experience the addition of new symptoms after recovery from COVID-19 illness. These may include orthostatic intolerance and autonomic dysfunction, and postural orthostatic tachycardia syndrome has been described to occur in a proportion of patients with PASC.

CASE SUMMARY

In this report, we present a 32-year-old pregnant woman (G3P2) who experiences severe orthostatic symptoms as part of her PASC syndrome, which is decoupled from normal physiologic changes of pregnancy. At 25 weeks of gestation, she was evaluated for increasing episodes of dyspnoea, marked tachycardia with minimal exertion, intermittent non-exertional chest pain, and presyncope. This patient had a moderate course of COVID-19 at 12 weeks of gestation, for which she received monoclonal antibody therapy (casirivimab/imdevimab). The patient then had complete resolution of COVID-19 symptoms and felt well for 1 month prior to developing orthostatic symptoms at 25 weeks of gestation. Evaluation with a NASA Lean Test revealed marked orthostatic tachycardia, as well as delayed orthostatic hypotension. Given her COVID-19 illness 4 months prior, PASC involving autonomic dysfunction was diagnosed.

DISCUSSION

Patients with orthostatic symptoms in PASC should be carefully evaluated with dedicated active stand tests, such as the NASA Lean Test, to characterize the autonomic response to standing. In pregnant patients, an understanding of normal pregnancy physiology is crucial to correctly identify abnormal findings in such tests.

Postural orthostatic tachycardia syndrome as a sequela of COVID-19

Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mechanisms of post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess POTS in patients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or β-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.

Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer

PURPOSE

Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored.

METHODS

Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission.

RESULTS

Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission.

CONCLUSION

Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.

Uncontrolled high blood pressure under total intravenous anesthesia with propofol and remifentanil: A case report

BACKGROUND

Although propofol generally reduces blood pressure, rarely, it causes hypertension. However, the mechanism by which propofol increases blood pressure has not been established, and so far, there are only a few reported cases.

CASE SUMMARY

A 46-year-old woman, diagnosed with thyroid cancer, was administered general anesthesia with propofol and remifentanil for a thyroid lobectomy. An increase in the concentrations of intravenous anesthetics further increased her blood pressure. The blood pressure remained stable when anesthesia was maintained with sevoflurane and remifentanil after the interruption of propofol administration.

CONCLUSION

We concluded that propofol administration was the cause of increased blood pressure.

Wearable Technology Leads to Initial Workup of Graves' Disease in an Adolescent Female

Graves' disease is the most common form of hyperthyroidism in the pediatric population. While the most prevalent symptoms seen in children with Graves' disease include goiter and excessive sweating (Minamitani et al., 2017), diagnosis is frequently delayed due to presentation with non-specific symptoms (Léger et al., 2018). This case report is of a 12-year-old female who presented to her pediatrician with a one month history of episodes of tachycardia both with physical exertion and at rest. Notably, these episodes were discovered on her electronic smartwatch by its heart rate monitoring feature. Further pertinent positives elicited in the patient's review of systems included increasing anxiety, diaphoresis, intermittent hand tremors, and recent weight loss. These findings led to further workup that included thyroid studies, culminating in a diagnosis of Graves' disease. Indeed, this patient's smartwatch aided in her initial presentation to her physician and allowed for prompt workup and diagnosis. There exist limited studies to date on the use of smartwatches to detect cardiac-related conditions in children, which may be due to the absence of Food and Drug Administration approval for certain cardiac-related smartwatch features in this patient population.

A Comprehensive Review of Left Ventricular Summit Ventricular Arrhythmias

The catheter ablation of idiopathic ventricular arrhythmias is accepted as a first-line treatment as it successfully eliminates about 90.0% of such arrhythmias. One of the most challenging ventricular arrhythmias originates from the left ventricular summit (LVS), a triangular epicardial space with the left main bifurcation as its apex. This area accounts for about 14.0% of LV arrhythmias. The complex anatomy of this region, accompanied by proximity to the major epicardial coronary arteries and the presence of a thick fat pad in this region, renders it a challenging area for catheter ablation. This article presents a review of the anatomy of the LVS and relevant regions and discusses novel mapping and ablation techniques for eliminating LVS ventricular arrhythmias. Additionally, we elaborate on the electrocardiographic (ECG) manifestations of arrhythmias from the LVS and their successful ablation via the direct approach and the adjacent structures.

Understanding the EKG changes in methemoglobinemia

Methemoglobin is a form of hemoglobin that has been oxidized, changing its heme iron configuration from the ferrous to the ferric state. Unlike normal hemoglobin, methemoglobin does not bind oxygen and as a result, cannot deliver oxygen to the tissues. At the presentation in the emergency department, an electrocardiogram (EKG) is usually performed as a reflex for patients admitted for shortness of breath to rule out acute coronary syndrome. Very limited data is available on EKG abnormalities in patients with methemoglobinemia. In this study, we retrospectively analyzed the pattern of EKG changes in patients with methemoglobinemia.

Postural tachycardia syndrome among adolescents

Postural tachycardia syndrome (PoTS) is a polymorphic clinical syndrome that is underdiagnosed, especially in adolescents. It is a form of dysautonomia, but its exact physiopathology remains elusive. Several pathologies can mimic PoTS; it is characterized by heterogeneous symptoms that accompany a disproportionate tachycardia upon the upright position. It can significantly impact the patients' quality of life. Only a Schellong test is useful for making the diagnosis. Treatment in PoTS is primarily symptomatic with the main goal being to restore the patient's condition as quickly as possible. We report here the diagnosis and management of seven adolescents, aged 11-16, who have been followed up since 2015.

[Case report: persistent fever after SARS-CoV-2 infection]

A 44-year-old man had persistent fever following a severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection. Because of progressive sinus tachycardia, thyroid hormones were measured which showed hyperthyroidism. Thyroid sonography revealed enlargement of the thyroid gland with hypoechoic areas with blurred margins. We diagnosed subacute granulomatous thyroiditis associated with SARS-CoV‑2 infection and initiated therapy with prednisolone. This therapy resulted in rapid improvement of the patient's clinical condition and complete remission after three months.

[Heart rate control in shock]

Heart rate is well established in the diagnosis of shock; however, the mechanisms regulating heart rate, systemic resistance and blood pressure remain unclear. The concept of heart rate control in shock-related tachycardia has been known for about 50 years. Elevated heart rates in septic shock have been identified as an indicator of increasingly inefficient hemodynamics, worsening perfusion and organ function as well as of an unfavourable prognosis. Many drugs used for heart rate control also lower blood pressure. The challenge of this therapeutic concept is achieving optimal heart rate control without provoking critical hypotension. Only in recent years has the development of highly cardioselective, short- and ultrashort-acting β‑blockers such as esmolol and landiolol made it possible to prove the feasibility and usefulness of heart rate control in certain types of shock.

The Relationship Between Tachycardia After Laparoscopic Sleeve Gastrectomy and the Development of Postoperative Complications

BACKGROUND

Bariatric surgery can be associated with severe complications. Tachycardia is an important indicator of certain complications, such as anastomotic leak and hemorrhage. Our aim was to examine the relationship between tachycardia following sleeve gastrectomy and the appearance of associated complications.

METHODS

Patients who underwent sleeve gastrectomy over a 2-year period were included in the study. Participants were divided into two groups: the first included patients who suffered from postoperative tachycardia and the second patients with normal postoperative heart rates. Complications in both groups were examined. Other parameters that predict the onset of complications were also reviewed.

RESULTS

A total of 457 patients were included. Postoperative tachycardia was measured in 181 (39.6%) patients; 17 (3.7%) suffered from bleeding and 4 (1%) from staple line leakage. Postoperative bleeding was more common among patients with tachycardia than among those without (14 (7.7%) vs. 3 (1.1%), respectively). Patients in the tachycardia group had more staple line leakages than those in the normal heart rate group (3 (2%) vs. 1 (0%), respectively); tachycardia was also attributed to postoperative pain or other minor complications in 160 (88%) patients. Age ≥ 40 years was found to be predictive factor for postoperative complications.

CONCLUSIONS

The most common causes of tachycardia postoperatively were pain and minor complications. Tachycardia is an essential indicator of postoperative minor and major complications, mainly staple line leakage and bleeding. This should prompt immediate medical intervention in order to avoid serious adverse events.

NaHCO3, L-arginine, and vitamin C supplemented vegetable diet ameliorates tachycardia and polycythemia in the broiler chicken

The study aimed to investigate if vegetable-based high-energy mash diets supplemented with NaHCO₃, L-arginine + vitamin C, and vegetable oils were effective against tachycardia and polycythemia in the broiler chicken. A total of 256 Ross-308 day-old male broiler chicks were randomly distributed into eight dietary treatment groups in a three-way ANOVA with 2 × 2 × 2 factorial arrangement (three factors, i.e., NaHCO₃, L-arginine + vitamin C, and vegetable oil each with two levels, e.g., 0 and 0.1% of NaHCO₃ and L-arginine + vitamin C; 3 and 4% of vegetable oil supplemented with basal diet) for a period of 35 days. Iso-caloric and iso-nitrogenous diets were formulated and supplied ad libitum. The final live weight (FLW), average daily feed intake (ADFI), average daily gain (ADG), feed efficiency (FE), carcass traits, cardio-pulmonary morphometry, total protein (TP), hemoglobin (Hb), triiodothyronine (T₃), incidence of tachycardia, and polycythemia were examined. Supplementation of NaHCO₃ increased 2.2% ADFI, 5.5% FE, and 23.2% TP. The L-arginine + vitamin C increased 2.4% FLW and decreased 1.9% heart rate. Vegetable oil increased 1.3% ADFI, 4.2% ADG, 8.6% FE, 23.1% Hb, and 15.5% PCV. The NaHCO₃, L-arginine + vitamin C, and vegetable oil additively interacted to increase 31.5% T₃ at the expense of 21.1% of the weight of the right ventricle (RV). The RV:TV, carcass traits, and hemato-biochemical indices remained within normal range irrespective of the levels of the supplementations of the test ingredients. It was concluded that vegetable-based high-energy mash diets were not susceptible to tachycardia and polycythemia. The addition of NaHCO₃ and L-arginine + vitamin C ameliorated the propensity of tachycardia and polycythemia without deteriorating performance, carcass traits, and hemato-biochemical indices of the broiler chicken in a dose-dependent manner.