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Lin KS, Kurnick A, Goel R, Gorbut I, Friedman A, Schrem E, McFarlane SI, Bukharovich I. Myocardial Bridging of Mid-left Anterior Descending Artery (LAD) Presenting As Transient Left Bundle Branch Block During Nuclear Stress Test. Cureus 2024; 16:e54654. [PMID: 38523980 PMCID: PMC10959828 DOI: 10.7759/cureus.54654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Transient left bundle branch block occurring during a nuclear stress test in the setting of myocardial bridging is a relatively rare finding. We report a case of a 75-year-old male who presented with typical stable angina. Serial troponins were negative, and the electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy and T-wave inversions in the lateral leads. The nuclear stress test was non-ischemic but showed a transient left bundle branch block associated with chest pain and shortness of breath that occurred right after the administration of regadenoson. Coronary angiography revealed non-obstructive coronary artery disease and a mid-LAD myocardial bridge.
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Affiliation(s)
- Kai Shiang Lin
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Adam Kurnick
- Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Ridhima Goel
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Igal Gorbut
- Internal Medicine, Saba University School of Medicine, Saba, NLD
| | - Adam Friedman
- Cardiology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Ezra Schrem
- Cardiology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Samy I McFarlane
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
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Malik M, Farooqi MS, Karim R, Khan S, Rind IA. Memory T-Waves: An Uncharted Territory in T-Wave Inversions. Cureus 2023; 15:e47620. [PMID: 38022234 PMCID: PMC10667626 DOI: 10.7759/cureus.47620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
T-wave inversions on electrocardiograms (ECGs) can present a diagnostic challenge due to their association with various underlying causes. One less-explored cause is memory T-waves, a phenomenon characterized by T-wave inversions, often seen in chest and inferior leads, following a period of abnormal ventricular conduction. In this case report, we discuss the intriguing case of an 80-year-old woman who recently underwent percutaneous coronary intervention (PCI) for a myocardial infarction and subsequently developed memory T-waves. We are also discussing how important it can be to understand and recognize memory T-waves, as it will avoid further unnecessary tests and longer hospital stays.
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Affiliation(s)
- Munzir Malik
- Acute Medicine, Wrexham Maelor Hospital, Wrexham, GBR
| | | | | | - Saleem Khan
- Medicine, Betsi Cadwaladr University Health Board, Wrexham, GBR
| | - Irfan Ali Rind
- Cardiology, Betsi Cadwaladr University Health Board, Wrexham, GBR
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Kumar N, Waheed S, Siddiqui A, Tamiz A. Necrotizing acute pancreatitis with electrocardiogram changes masquerading acute coronary syndrome. Oxf Med Case Reports 2023; 2023:omad055. [PMID: 37377724 PMCID: PMC10292648 DOI: 10.1093/omcr/omad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/29/2023] [Accepted: 05/12/2023] [Indexed: 06/29/2023] Open
Abstract
Acute pancreatitis (AP) refers to the acute inflammation of the pancreas; however, if there is concurrent necrosis, it is called necrotizing acute pancreatitis (NAP). The diagnosis is sometimes difficult because it might mimic acute coronary syndrome (ACS). We report a case of a 28-year-old male, who presented to the emergency department (ED) with severe epigastric pain, shortness of breath and diaphoresis for 4-5 h. The initial electrocardiogram (ECG) showed marked sinus bradycardia with an incomplete left bundle branch block. Considering the clinical presentation and ECG changes, he was managed as ACS and was rushed to catheterization laboratory for a coronary angiogram, which was reported normal. Subsequently, his serum pancreatic enzymes were elevated, and computed tomography of the abdomen showed NAP. In ED settings, it is difficult to differentiate between the two, particularly when AP presents with ECG manifestations masquerading as ACS.
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Affiliation(s)
- Nirdosh Kumar
- Correspondence address. Department of Emergency Medicine, Aga Khan University Hospital Karachi, Stadium Road PO Box 3500, Karachi, Pakistan. Tel: +923327468542; Fax: +92 21 3493 4294; E-mail:
| | - Shahan Waheed
- Department of Emergency Medicine, Aga Khan University Hospital Karachi, Pakistan
| | - Amnah Siddiqui
- Department of Emergency Medicine, Aga Khan University Hospital Karachi, Pakistan
| | - Ahmed Tamiz
- Department of Cardiology, Aga Khan University Hospital Karachi, Pakistan
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Siroky GP, Mehta D. Diagnosing a wide complex tachycardia using basic electrophysiologic properties of the cardiac conduction system. J Arrhythm 2021; 38:115-117. [PMID: 35222757 PMCID: PMC8851580 DOI: 10.1002/joa3.12657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Gregory P. Siroky
- Department of Cardiology Division of Electrophysiology Mount Sinai MorningsideIcahn School of Medicine at Mount Sinai New York New York USA
| | - Davendra Mehta
- Department of Cardiology Division of Electrophysiology Mount Sinai MorningsideIcahn School of Medicine at Mount Sinai New York New York USA
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Johnson JA, Haq KT, Lutz KJ, Peters KK, Paternostro KA, Craig NE, Stencel NWL, Hawkinson LF, Khayyat-Kholghi M, Tereshchenko LG. Electrophysiological ventricular substrate of stroke: a prospective cohort study in the Atherosclerosis Risk in Communities (ARIC) study. BMJ Open 2021; 11:e048542. [PMID: 34479935 PMCID: PMC8420653 DOI: 10.1136/bmjopen-2020-048542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 08/16/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES The goal of the study was to determine an association of cardiac ventricular substrate with thrombotic stroke (TS), cardioembolic stroke (ES) and intracerebral haemorrhage (ICH). DESIGN Prospective cohort study. SETTING The Atherosclerosis Risk in Communities (ARIC) study in 1987-1989 enrolled adults (45-64 years), selected as a probability sample from four US communities (Minneapolis, Minnesota; Washington, Maryland; Forsyth, North Carolina; Jackson, Mississippi). Visit 2 was in 1990-1992, visit 3 in 1993-1995, visit 4 in 1996-1998 and visit 5 in 2011-2013. PARTICIPANTS ARIC participants with analysable ECGs and no history of stroke were included (n=14 479; age 54±6 y; 55% female; 24% black). Ventricular substrate was characterised by cardiac memory, spatial QRS-T angle (QRS-Ta), sum absolute QRST integral (SAIQRST), spatial ventricular gradient magnitude (SVGmag), premature ventricular contractions (PVCs) and tachycardia-dependent intermittent bundle branch block (TD-IBBB) on 12-lead ECG at visits 1-5. OUTCOME Adjudicated TS included a first definite or probable thrombotic cerebral infarction, ES-a first definite or probable non-carotid cardioembolic brain infarction. Definite ICH was included if it was the only stroke event. RESULTS Over a median 24.5 years follow-up, there were 899 TS, 400 ES and 120 ICH events. Cox proportional hazard risk models were adjusted for demographics, cardiovascular disease, risk factors, atrial fibrillation, atrial substrate and left ventricular hypertrophy. After adjustment, PVCs (HR 1.72; 95% CI 1.02 to 2.92), QRS-Ta (HR 1.15; 95% CI 1.03 to 1.28), SAIQRST (HR 1.20; 95% CI 1.07 to 1.34) and time-updated SVGmag (HR 1.19; 95% CI 1.08 to 1.32) associated with ES. Similarly, PVCs (HR 1.53; 95% CI 1.03 to 2.26), QRS-Ta (HR 1.08; 95% CI 1.01 to 1.16), SAIQRST (HR 1.07; 95% CI 1.01 to 1.14) and time-updated SVGmag (HR 1.11; 95% CI 1.04 to 1.19) associated with TS. TD-IBBB (HR 3.28; 95% CI 1.03 to 10.46) and time-updated SVGmag (HR 1.23; 95% CI 1.03 to 1.47) were associated with ICH. CONCLUSIONS PVC burden (reflected by cardiac memory) is associated with ischaemic stroke. Transient cardiac memory (likely through TD-IBBB) precedes ICH.
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Affiliation(s)
- John A Johnson
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kazi T Haq
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Katherine J Lutz
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kyle K Peters
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kevin A Paternostro
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Natalie E Craig
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nathan W L Stencel
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Lila F Hawkinson
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Maedeh Khayyat-Kholghi
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Larisa G Tereshchenko
- Department of Medicine, Cardiovascular Division or Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Gunaseelan R, Sasikumar M, Aswin K, Nithya B, Balamurugan N, Vivekanandan M. Memory T-Waves, a Rare Cause of T-Wave Inversion in the Emergency Department. J Emerg Trauma Shock 2021; 13:312-316. [PMID: 33897151 PMCID: PMC8047955 DOI: 10.4103/jets.jets_70_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/22/2020] [Indexed: 12/02/2022] Open
Abstract
One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.
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Affiliation(s)
- R Gunaseelan
- Department of Emergency Medicine, Jawarharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - M Sasikumar
- Department of Emergency Medicine, Jawarharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - K Aswin
- Department of Emergency Medicine, Jawarharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - B Nithya
- Department of Emergency Medicine, Jawarharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - N Balamurugan
- Department of Emergency Medicine, Jawarharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - M Vivekanandan
- Department of Emergency Medicine, Jawarharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Tafoya C, Singh A. Cardiac Memory: A Case Report and Review of the Literature. J Emerg Med 2019; 57:85-93. [PMID: 31047746 DOI: 10.1016/j.jemermed.2019.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND A variety of clinical syndromes can cause T-wave inversion (TWI), ranging from life-threatening events to benign conditions. One benign cause of TWI is cardiac memory, which is characterized by the transient inversion of T-waves following abnormal activation of the ventricles, commonly due to intermittent left bundle branch block (LBBB), tachydysrhythmias, electrical pacing, or ventricular pre-excitation. CASE REPORT A 72-year-old man presented to the emergency department with chest pain, nausea, vomiting, and headache. Upon arrival, his electrocardiogram (ECG) showed new-onset LBBB with appropriate secondary ST-T wave changes. A subsequent ECG showed disappearance of LBBB and newly inverted T-waves in precordial leads V1-V5, followed by a repeat ECG that again showed LBBB. Serial troponin testing was unremarkable. During hospitalization, echocardiogram and nuclear perfusion stress test were normal. The transient TWIs in this patient were believed to be due to cardiac memory. We performed a literature review and identified 39 published cases of cardiac memory. The most common etiology for cardiac memory was after cardiac pacemaker placement, followed by intermittent LBBB (as was seen in our patient), and post-tachydysrhythmia. Patient ages ranged from 21 to 88 years, with an equal number of cases reported in men and women. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cardiac memory is a poorly understood, rarely observed phenomenon that can occur in the setting of intermittent LBBB. Testing for acute cardiac ischemia and underlying coronary artery disease is still recommended, as the diagnosis of cardiac memory can only be made after negative workup.
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Affiliation(s)
- Chelsea Tafoya
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, California
| | - Amandeep Singh
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, California
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Seibolt L, Maestas C, Lazkani M, Fatima U, Loli A, Chesser M. Rate-related left bundle branch block and cardiac memory in a patient with bradycardia: Case report and literature review. Clin Cardiol 2018; 41:1097-1102. [PMID: 29920728 DOI: 10.1002/clc.22997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 06/08/2018] [Accepted: 06/12/2018] [Indexed: 11/08/2022] Open
Abstract
Rate-related left bundle branch block (LBBB) is a well-studied phenomenon. Cardiac memory is another physiologic phenomenon in which T-wave abnormalities occur in the absence of ischemia. The association between these 2 phenomena has been described in several case reports. A literature review was performed through Ovid and PubMed, where at total of 93 cases of rate-related LBBB were identified. Cases were reviewed, and data were collected on rates of appearance and disappearance as well as the presence or absence of cardiac memory. There is some overlap in the rate at which LBBB appears. Cardiac memory is associated with rate-related LBBB in several cases, but its true prevalence is unknown. Cardiac memory is a phenomenon that is well described in the literature but is often underrecognized in clinical practice. As a consequence of overlooking this phenomenon and not including cardiac memory in the differential when T-wave abnormalities are observed, patients may be subjected to unnecessary invasive diagnostic testing.
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Affiliation(s)
- Luke Seibolt
- Department of Cardiology, Banner University, Medical Center, Phoenix, Arizona
| | - Camila Maestas
- Department of Internal Medicine, Banner University Medical Center, Phoenix, Arizona
| | - Mohamad Lazkani
- Department of Cardiology, Banner University, Medical Center, Phoenix, Arizona
| | - Umaima Fatima
- Department of Cardiology, Phoenix Veterans Affairs Medical Center, Phoenix, Arizona
| | - Akil Loli
- Department of Cardiology, Banner University, Medical Center, Phoenix, Arizona
| | - Michael Chesser
- Department of Internal Medicine, Phoenix Veterans Affairs Medical Center, Phoenix, Arizona
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