Unexpected case of Graves` disease induced myocarditis: a case report

Myocarditis due to Graves` disease is rare and has a clinical presentation that mimics acute coronary syndrome. In this case report, a 50-year-old woman was admitted with a clinical presentation of very high-risk non-ST segment elevation myocardial infarction, new-onset atrial fibrillation, and acute heart failure. Normal coronary angiography and the presence of intra-myocardial late gadolinium enhancement based on cardiac MRI led to the diagnosis of myocarditis. The presence of thyroid nodules and elevated thyrotropin receptor antibodies indicated Graves` disease as the underlying cause of myocarditis. Management using Propylthiouracil and the guideline-directed medical therapy for heart failure successfully improved the patient's condition. Early diagnosis, effective care, and adequate knowledge of the relationship between hyperthyroidism and myocarditis, improve outcomes in Graves' disease-induced myocarditis.

The Influence of Special Military Training on Left Ventricular Adaptation to Exercise in Elite Air Force Soldiers

Purpose

The purpose of this study was to observe the influence of level physical training intensity on left ventricular (LV) adaptation in elite air force soldiers compared to regular basic military training.

Methods

The LV adaptation of special military physical training for elite air force soldiers was compared with basic military training for regular troops. A group of the nonmilitary subject was also evaluated as a control group. The presence of LV adaptation was evaluated using some echocardiography parameters, including LV mass index (LVMI), LV ejection fraction (LVEF), global longitudinal strain (GLS), and myocardial work index. The parameters of the myocardial work index include global constructive work (GCW), global wasted work (GWW), global work index (GWI), and global work efficiency (GWE).

Results

Forty-three elite air force soldiers underwent special military training, 43 regular troops underwent basic military training, and 23 nonmilitary subjects as a control group. Age, heart rate, blood pressure, and Cooper test results significantly differed among the three groups. Multivariate analysis among all groups showed that the level of physical training was associated with the LVMI (coefficient β = 6.061; 95% confidence interval [CI] = 1.91-10.22; P = 0.005), LVEF (coefficient β = -1.409; 95% CI = -2.41-[-0.41]; P = 0.006), LVGLS (coefficient β = 1.726; 95% CI = 1.20-2.25; P < 0.001), GWW (coefficient β = -13.875; 95% CI = -20.88-[-6.87]; P < 0.001), GWE (coefficient β = 0.954; 95% CI = 0.62-1.26; P < 0.001), GCW (coefficient β = 176.128; 95% CI = 121.16-231.10; P < 0.001), and GWI (coefficient β = 196.494; 95% CI = 144.61-248.38; P < 0.001).

Conclusions

Higher intensity of physical training observed in a special military training is associated with higher LV GLS, GWE, GCW, GWI, and lower GWW value suggesting greater physiological adaptation than the lower intensity training.

OR41. Hypertension and Abnormal Renal Function Increased the Risk of Ischemic Stroke in Anticoagulated EHRA type-1 Valvular Atrial Fibrillation

Aims

Atrial fibrillation increases the risk of stroke substantially, many scores have been developed to risk stratify these patients. Most of the studies have focused on non-valvular AF. The most widely used risk stratification score is the CHA2DS2-VASC score. Unfortunately, the validation of this score in valvular AF is poor. This study aimed to evaluate the clinical factors and echocardiographic parameters related to the incidence of ischemic stroke in anticoagulated EHRA (Evaluated Heartvalves, Rheumatic or Artificial) type-1 valvular AF patients.

Methods and Results

We conducted a retrospective cohort study based on data from the Indonesian Registry on Atrial Fibrillation (OneAF). Patients with EHRA type-1 valvular AF between January 2015 and December 2019 were analysed. The clinical outcome was an ischemic stroke that occurred during the monitoring period of January 2015 - December 2019. Among 329 AF patients with mitral stenosis or prosthetic heart valves, the incidence of ischemic stroke was 17 (5.2%). Multivariate logistic regression analysis showed that two clinical factors, i.e., history of hypertension (OR 5.59; 95% CI: 1.93-16.15; p= 0.001) and estimated Glomerular Filtration Rate (eGFR) ≤59 mL/min/m2 (OR 3.62; 95% CI: 1.30-10.02; p= 0.013) were independently associated with the incidence of ischemic stroke. No echocardiographic parameters were associated with the incidence of ischemic stroke in this population.

Conclusion

We observed that two clinical factors i.e., history of hypertension and abnormal renal function, were markedly associated with stroke incidence in anticoagulated EHRA type-1 valvular AF patients.

Coronary artery fistula features associated with clinical symptoms in adults with non coronary artery disease detected with coronary computed tomography angiography

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): National Cardiovascular Center Harapan Kita, Jakarta, Indonesia

Background

 Coronary artery fistula (CAF) is rare coronary artery anomaly (&lt;1% in general population). It is often diagnosed accidentally during coronary angiography. Most of CAF cases have no clinical significance, however, some may present with hemodynamic instabilities, requiring invasive or surgical intervention. Recently, coronary computed tomography angiography (CCTA) has been increasingly used to detect CAF at higher rates. Correlation between CAF and significance of clinical presentation, however, remains unclear.

Purpose

To evaluate association of CAF features with any symptomatic trends present in non coronary artery disease (CAD) patients.

Methods

 This was a single-center, observational, analytic cross-sectional study. A total 45 cases of CAF with no documented CAD or non-significant stenosis CAD diagnosed by coronary CT angiography were collected from 10,175 consecutive patients in National Cardiovascular Center Harapan Kita spanning 5-years from January 2015 to December 2019. The imaging findings, morphologic features and relevant clinical history were recorded and analyzed.

Results

 The prevalence of CAF determined with CCTA in our study was 0.44%. Among 45 patients with CAF, thirty (67%) were female. Mean age was 49.4 ± 12.9 years. Most common symptoms reported, in decreasing frequency, were chest pain (60%), dyspnea (22.2%), palpitation/arrhythmia (11.2%), syncope (4.4%) and general weakness (2.2%). Most common site of CAF origin was the left anterior descending artery (66.7%), followed by right coronary artery (51.1%). The fistula most commonly terminated in the main pulmonary artery (75.5%). The CAF size, in descending order, were small (35.6%), medium (33.3%), and large (20%). Mixed and multiple CAF were presented in 5 cases (11.1%). Aneurysm formation were identified in 10 cases (22.2%). CAF were mainly associated with congenital atrial and ventricular septal defects (6.7%; 4.4%, respectively). Other coexistent cardiac abnormalities presented with CAF were pulmonary hypertension (8.9%), infective endocarditis (4.4%), and pericardial effusion (2.2%). Large-sized CAF was significantly associated with chest pain and palpitation/arrhythmia (p = 0.017; p = 0.003, respectively). Aneurysm formation revealed to be significantly associated with chest pain and palpitation/arrhythmia (p = 0.044; p = 0.006, respectively) as well. Mixed and multiple CAF were significantly correlated with syncope (p = 0.003). CAF with concomitant cardiac diseases (congenital heart disease, pulmonary hypertension, valvular heart disease) were significantly associated with symptoms of chest pain and palpitation/arrhythmia as compared to isolated CAF only (p = 0.004; p = 0.007, respectively).

Conclusion

 CAF features (large-sized, mixed and multiple, aneurysmal and presence of concomitant cardiac disease) were associated with significant trends of clinical symptoms in adults without CAD.

Trainees’ perceptions and expectations of formal academic mentoring during the COVID-19 pandemic in Indonesian cardiology residency programs

PURPOSE

During medical residency programs, physicians develop their professional identities as specialists and encounter high expectations in terms of achieving competencies. The responsibilities of medical trainees include caring for patients, balancing work with personal life, and weathering stress, depression, and burnout. Formal academic mentoring programs strive to ease these burdens. The coronavirus disease 2019 (COVID-19) pandemic has altered the trainee–academic mentor relationship, and solutions are needed to address these challenges. The present study aimed to evaluate the formal academic mentoring process through trainees’ perceptions and expectations of formal mentoring programs during COVID-19 in Indonesian cardiology residency programs.

METHODS

This cross-sectional study used a self-administered online questionnaire to capture trainees’ perceptions and expectations regarding academic mentoring programs in 3 cardiology residency programs in Indonesia from October to November 2020. The questionnaire was developed before data collection. Perceptions of the existing mentoring programs were compared with expectations.

RESULTS

Responses were gathered from 169 out of 174 residents (response rate, 97.3%). Most trainees reported having direct contact with COVID-19 patients (88.82%). They stated that changes had taken place in the mode and frequency of communication with their academic advisors during the pandemic. Significant differences were found between trainees’ perceptions of the existing mentoring programs and their expectations for academic mentoring programs (P<0.001).

CONCLUSION

Despite the challenges of interacting with their academic mentors, trainees still perceived academic mentors as a vital resource. Study programs need to consider trainees’ expectations when designing academic mentoring programs.

P194 Trimetazidine preserves right ventricular function on pulmonary arterial hypertension patients in national cardiovascular center harapan kita hospital indonesia

Funding Acknowledgements

National Cardiovascular Center Harapan Kita Hospital

Background

Right ventricular dysfunction is the worst mortality predictor in pulmonary arterial hypertension (PAH). Recent animal PAH studies have demonstrated the benefit of partial fatty acid inhibitor such as trimetazidine in improving right ventricular function. Therefore, we hypothesize that trimetazidine can improve right ventricular ejection fraction (RVEF) in PAH patients.

Purpose

Investigating the effect of  trimetazidine on right ventricle function in PAH patients.

Methods

We conducted 3 months randomized double blind placebo controlled trial on PAH patients at outpatient clinic in National Cardiovascular Center Harapan Kita Hospital Indonesia. Those who fulfilled the inclusion criteria will be randomized into trimetazidine or placebo group for 3 months on top of their standard PAH regime. Clinical and cardiovascular magnetic resonance imaging (CMR) parameters will be evaluated before and after 3 months therapy. The primary outcome of this study is the differences of RVEF from CMR.

Results

We randomly enrolled 26 PAH patients equally to receive placebo or trimetazidine for 3 months on top of their standard PAH regime. Total of 10 patients in each group was able to finish the study. There was significant improvement of RVEF in trimetazidine group 3.78 + 1.5% compared to placebo 2.76 + 1.6% (p 0.008, CI 1.96 to 10.96). Furthermore, we also observed improvement of functional capacity in trimetazidine group 0.24 + 0.09 compared to placebo -0.44 + 0.16 (p 0.002, CI 0.28 s/d 1.08).

Conclusions

Trimetazidine therapy for 3 months on top of standard PAH regime significantly improve RVEF and functional capacity in PAH patients.

Abstract P194 Figure. Effect of trimetazidine on RV function