P1267 Negative baseline diagnostic imaging does not exclude pulmonary embolism in patients with reccurrent syncope

INTRODUCTION

In patients who are admitted to a hospital due to episode of syncope, acute pulmonary embolism (PE) is rarely considered as a possible cause. This report presents two cases illustrating PE as a cause of syncope with elevated cardiac troponin (cTn) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels despite normal echocardiographic examination and negative Doppler ultrasound imaging.

Case 1: An 83-year-old woman admitted to the ER due to episodes of recurrent syncopes. According to her anamnesis, she had four episodes of syncopes during last three weeks without chest pain, dyspnea, palpitation or hemoptysis. ECG revealed a normal sinus rhythm with a heart rate of 70 bpm without ischemic changes. Laboratory tests revealed raised levels of cTn and NT-proBNP. Transthoracic echocardiography (TTE) demonstrated preserved left and right ventricular systolic functions without

any cardiac chamber enlargement and mild tricuspid regurgitation with a PAP of 35 mmHg. Patient’s pre-test probability for pulmonary embolism was low (Wells’ score < 2) but D-dimer level was elevated. Doppler imaging for detection of deep vein thrombosis was negative. Computed tomography pulmonary angiography (CTPA) showed filling defects in the pulmonary arteries consistent with pulmonary embolism (Panel A). The patient was discharged with rivaroxaban therapy without any complication.

Case 2: A 69- year-old woman presented to ER with symptoms of chest pain and recurrent episodes of syncope for the last 2 days. Her medical history revealed hypertension and hyperlipidemia. On admission ECG showed a normal sinus rhythm with a heart rate of 105 bpm and T-wave inversions in inferior leads. Laboratory tests showed elevated levels of cTn and NT-proBNP. TTE demonstrated normal left ventricular systolic function with an ejection fraction of 55% and normal right ventricular function and chamber size with a tricuspid annular plane systolic excursion of 22 mm. Diagnostic coronary angiography was performed to exclude acute ischemia revealed non-significant coronary artery stenosis. Doppler ultrasound imaging for detection of deep vein thrombosis was negative. CTPA showed filling defects in the bilateral main pulmonary arteries consistent with acute bilateral pulmonary embolism (Panel B-C). The patient was discharged with rivaroxaban therapy after four days of hospitalization period without any complication.

CONCLUSION

Elevated cTn and NT-proBNP leves on admission strongly suggest transient hemodynamic impairment causing cardiac injury and syncope. Normal admission ECG and TTE can exclude most possible acute cardiac causes of syncope. Although acute right ventricular dsyfunction is the most frequent finding of acute massive PE causing hemodymanic impairment resulting with syncope, diagnosis of acute PE should only be excluded with CTPA in patients with similar clinical characteristics despite normal TTE and negative venous Doppler ultrasound imaging.

Abstract P1267 Figure

P712 When Popeye had shortness of breath

A 61-year-old man presented to our clinic with progressive shortness-of-breath in the last 3 months. He had a history of hospitalization and endotracheal intubation due to acute pulmonary edema and type – I respiratory failure a week ago and discharged after diagnostic coronary angiography which demonstrating normal coronary arteries. Physical examination revealed bunching of the left biceps when he flexed his left arm which is consistent with rupture of distal biceps tendon (Panel A, Popeye Sign). A 12-lead electrocardiography (ECG) showed low QRS voltage in the limb leads and ST segment depression and asymmetrical T wave inversion in the anterolateral leads (Panel B). Transthoracic echocardiography (TTE) showed concentric left ventricular hypertrophy with left ventricular ejection fraction of 60% (Panel C). Pulsed wave-Doppler obtained from the mitral valve demonstrated restrictive filling pattern with high early diastolic velocity (E-wave) and low late diastolic filling (A-wave) peaks with E/A ratio > 2.0 and reduced lateral mitral annular diastolic velocities with E/e’ ratio > 15 which are compatible with impaired left ventricular diastolic function with elevated left ventricular filling pressures (Panel D-E). Biceps tendon rupture, low QRS voltage and left ventricular hypertrophy with restrictive filling pattern were considered suggestive of cardiac amyloidosis and patient was referred to hematology clinic for diagnostic work-up. Protein electrophoresis demonstrated monoclonal gammopathy in the serum and immunoelectrophoresis showed free lambda light chains. The patient diagnosed as AL amyloidosis with cardiac and musculoskeletal involvement.

Biceps tendon rupture is a rare finding of amyloidosis due to musculoskeletal involvement. In the setting of acute pulmonary edema and/or heart failure with preserved ejection fraction with massive left ventricular hypertrophy, restrictive filling pattern, low QRS voltage and spontaneous tendon rupture should raise clinical suspicion of amyloidosis with cardiac and musculoskeletal involvement.

Abstract P712 Figure.

P1772 Assesment of total atrial conduction time in patients with atrioventricular nodal reentrant tachycardia with and without drug-induced type 1 Brugada pattern and control subjects

Background

Most forms of atrioventricular nodal reentrant tachycardia (AVNRT) are created by reentry between 2 (or more) atrial connections to the AV node. There is a high prevalence of drug-induced type 1 Brugada ECG pattern (DI-Type1-BrP) among patients with AVNRT. Atrial vulnerability and structural remodeling that leads to reentrant circuits in AVNRT is largely unknown. PA-TDI interval assessed by tissue Doppler imaging is a useful technique to determine total atrial conduction time (TACT) which reflects atrial remodeling and arrhythmic substrate.

Purpose

In this prospective study, we aimed to assess TACT in patients with AVNRT with and without DI-Type1-BrP and control subjects.

Methods

Study population consisted of 62 consecutive patients (age 44 ± 12 years; 74% women) undergoing electrophysiological study and ablation for symptomatic, drug-resistant AVNRT and 42 age and sex matched control subjects. All patients and control subjects underwent ajmaline challenge test and tissue Doppler imaging.

Results

A DI-Type1-BrP was uncovered in 24 of 62 patients with AVNRT (38.7%). PA-TDI interval was longer in patients with AVNRT with or without DI-Type1-BrP compared to control subjects (124 ± 12 ms vs 119 ± 14 ms vs 105 ± 11 ms; P < 0.001, respectively). PA-TDI interval was similar in patients with AVNRT with or without DI-Type1-BrP (124 ± 12 ms vs 119 ± 14 ms; P = NS, respectively). PA-TDI interval was significantly correlated with P-wave duration on the surface ECG (r = 0.23; P = 0.02). Left atrial volume index and left atrial phasic functions were similar in patients with AVNRT with or without DI-Type1-BrP and control subjects.

Conclusion

TACT is prolonged in patients with AVNRT. Further studies are needed to determine the underlying factor(s) such as DI-Type1-BrP that leads to prolonged atrial conduction time.

Epicardial fat, body mass index, and triglyceride are independent contributors of serum fibroblast growth factor 21 level in obese premenopausal women

PURPOSE

The hormone fibroblast growth factor 21 (FGF-21) regulates carbohydrate and lipid homeostasis. FGF-21 represents an attractive novel therapy for obesity since administration of FGF-21 has been shown to improve metabolic abnormalities in obese animal models. We investigated FGF-21 and its relationship with epicardial fat thickness (EFT), metabolic parameters, and inflammatory markers in premenopausal obese women compared to controls with similar Systematic Coronary Risk Evaluation (SCORE) project risk profiles.

METHODS

Forty-five obese premenopausal women with body mass index (BMI) ≥30 kg/m(2) and 41 control premenopausal women with BMI <25 kg/m(2) with similar SCORE project risk profiles were included in this case-control study. EFT was evaluated by two-dimensional transthoracic echocardiography. Serum FGF-21 was measured with an ELISA kit.

RESULTS

FGF-21 and EFT were significantly higher in obese women compared to controls (p < 0.001). Multiple stepwise linear regression analysis showed that EFT, BMI, and triglycerides (TG) independently contributed to FGF-21 (R(2) = 0.757, p < 0.001). However, homeostasis model assessment of insulin resistance (HOMA-IR), visceral ectopic fat, and inflammatory markers were not found as a direct contributor to serum FGF-21 level (p > 0.05).

CONCLUSIONS

EFT, BMI, and TG may play an important role in predicting serum FGF-21 level which may be a potential therapeutic target in cardiometabolic disorders in the future.