62 32nd World Congress of Internal Medicine (October 24-28, 2014) WCIM 2014
PS 0060 Cardiology
Takotsubo Cardiomyopathy in the Recovery Phase of Dobutamine Stress Echocardiography in an Elderly Male
Vinesh APPADURAI1, Rohan POULTER1, Corina PREDA1, Atefeh HAGHI1, Matthew MARRINAN1
Sunshine Coast Hospital and Health Service, Australia1, University of Queensland, Australia2 Case Report: A 72 year old male underwent a dobutamine stress echocardiography (DSE) for assessment of atypical chest pain and dyspnoea. Past medical history includ- ed chronic obstructive pulmonary disease, hypertension, type 2 diabetes mellitus and smoking history. The baseline electrocardiogram (ECG) and vital signs were within nor- mal limits. The resting echocardiogram showed normal valve function, left ventricular size, ventricular wall thickness and systolic function with an ejection fraction of 65%.
Dobutamine was infused according to the protocol 10 mcg/kg/min increasing in 3 minute intervals to achieve a maximum heart rate of 148 beats per minute at 50 mcg/
kg/min. During stress, he experienced minor “indigestion”symptoms without distinct ECG changes. Imaging at 70% of peak heart rate and 85% of peak heart rate showed no inducible wall motion abnormalities. 5 minutes into recovery phase, he became hy- potensive and developed progressive chest pain associated with ST-elevation of 4mm in antero-lateral and inferior leads. The recovery echocardiogram showed mid and distal septal akinesis, a dyskinetic apex, vigorous basal septal and lateral wall motion.
Coronary angiogram revealed normal coronary arteries with left ventricular systolic dysfunction. Troponin I peaked at 2.3μg/L and a diagnosis of dobutamine-induced takotsubo cardiomyopathy (TC). Patient was discharged 48 hours later. A transthoracic echocardiogram 3 months post-discharge revealed an ejection fraction of 71% and normal left ventricular function and patient denied chest pain or heart failure symp- toms.
Conclusion: This is only the second case of a dobutamine-induced stress cardiomy- opathy to have occurred in an elderly male and the fi rst during the non-stress phase.
TC is uncommon adverse effect of DSE in female patients but rarely documented in males. May refl ect sex differences in the myocardial threshold to resist catecholamine induced TC and advise caution when administering dobutamine protocols.
PS 0061 Cardiology
A Fortunate Sequela: Adhesive Pericardium Prevent from Left Ventricle Free Wall Rupture
Cheng-Wei LIU1, Heng-Hsu LIN1 Far Eastern Memorial Hospital, Taiwan R.O.C1
The 74-year-old woman presented to our emergency department with 2-day ongoing chest pain. She had a medical history of pericarditis ten years ago. A electrocardio- gram (Panel A) revealed large R wave in leads V1-V2, ST-segment depressions and T- wave inversions in leads V1-V5, compatible with posterior wall myocardial infarction.
Q waves and minimal ST-segment elevation in inferior leads also appeared. A chest X-ray showed lung edema. The fi rst and peak CK, CK-MB, troponin-I valued 398IU/ml, 25U/ml, 0.609ng/ml respectively. A transthoracic echocardiogram (Panel B) demon- strated a large pseudoanerysm protruding into posterolateral direction, surrounded by a thick and calcifi ed pericardium. With stable hemodynamic status and resolved chest pain after medical treatment, cardiac catheterization and surgery were deferred. She lost follow-up at our out patient department. Ventricular free wall rupture accounts for approximately ten percentage of mortality. Fortunately, adhesive pericardium due to previous pericarditis may act as a breakwater against tsunami and saved her life.
PS 0062 Cardiology
A Comparison of 12 Lead Electrocardiogram and 2d-Echocardiography Derived Ejection Fraction among Patients with Depressed Ejection Fraction
Jaime AHERRERA1, Paul REGANIT1, Felix PUNZALAN1, Raul JARA1, Ramon ABARQUEZ1
Philippine General Hospital, Philippines1
Introduction: A 12 lead electrocardiogram continues to be the most frequently or- dered test in cardiology. In third world countries where access to 2D echocardiogram is limited, the value of the ECG as a tool in determining patients with depressed ejec- tion fraction (EF) should be investigated. We aim to compare the computed ejection fraction by electrocardiogram with the ejection fraction taken from a transthoracic 2D echocardiogram in patients with an echocardiogram derived EF < 50%.
Methods: Patients with an echocardiographically derived EF of < 50% were be included. The EF by ECG was computed using the formula = (2.264 x aVR QRS am- plitude) + (age x 0.645). Descriptive statistics was used to present Results: Since age of the patient is used to derive the EF by ECG, data would be further stratifi ed by age group.
Results: A total of 129 participants were included in the analysis. The EF computed by ECG using aVR was less than 50% in 71%. The mean EF taken by 2D echocardi- ography was 37% (SD: 8%), while the mean EF computed using ECG was 44.5% (SD:
10%). The sensitivity and specifi city of ECG to detect a severely depressed ejection fraction (<35%) was also determined at 39% and 86%, respectively. Among those 40 years old and below, the sensitivity and specifi city of an ECG to predict an EF < 35%
is 100% and 20%, respectively. Among those older than 40 years old, the sensitivity and specifi city was 20% and 96%, respectively.
Conclusion: Previous studies have repeatedly demonstrated the importance of LVEF.
A rapid and readily available estimation method of EF is crucial in the management of the vast majority of cardiac patients, especially in third world countries.
PS 0063 Cardiology
Association of Framingham Risk Score with Serum Concentration of Urea and Creatinine
Nazar Mohd Zabadi MOHD AZAHAR1, Ambigga KRISHNAPILLAI2, Adibah Hanum SAHARI1, Khalid YUSOFF3
Universiti Teknologi MARA, Malaysia1, National Defence University of Malaysia, Malaysia2, Universiti Teknologi MARA, Malaysia3
Background: Individuals with chronic kidney disease experience higher mortality and adverse cardiovascular event rates. This study will describe the association between serum urea and creatinine level with different groups of Framingham Risk Score.
Methods: Respondents who met the inclusion criteria and gave consent to participate will be recruited. This cross sectional study was conducted in Raub, Malaysia between July 2010 and June 2011. Blood pressure was measured twice and the average was recorded. Venous blood samples were taken for Fasting Serum Lipid, Fasting Blood Glucose and for the determination of urea and creatinine concentration.
Results: There were 480 respondents recruited in this study with 42.5% of respond- ents were males (mean age±SD, 59±10.2 years). Urea concentration was found significantly higher in males (4.8±1.84 mmol/L) compared to females (4.2±1.77 mmol/L) (p<0.001). Creatinine concentration was found signifi cantly higher in males (88±31.45 mmol/L) compared to females (63.6±22.38 mmol/L) (p<0.001). Bivari- ate correlations found that age was significantly correlated with urea (r= 0.255, p<0.001) and creatinine (r=0.233, p<0.001) of the respondents. One way between groups analysis revealed that mean concentration of urea was signifi cantly highest in the high risk group, followed by moderate and low risk group of the Framingham Risk Score (F(2,438)=13.622, p<0.001). Creatinine concentration also was found signifi cantly highest in the high risk group followed by moderate and low risk group (F(2,438)=38.348, p<0.001).
Conclusions: Serum urea and creatinine level were signifi cantly highest among the high risk for CVD group. Increasing public health awareness and aggressive lifestyle modifi cation programmes are essential in combating this serious health problem.
