CME INDIA Case Presentation by Dr. N. K. Singh, MD, FICP, FACP, FRRSDI, Diabetologist Physician, Director – Diabetes and Heart Research Centre (DHRC), Dhanbad, Chairman – RSSDI Jharkhand, Editor – CME INDIA.

CME INDIA Case Study

“Most illnesses do not, as is generally thought, come like a bolt out of the blue. The ground is prepared for years through faulty diet, intemperance, overwork, and moral conflicts, slowly eroding the subject’s vitality” – Paul Tournier.

How Presented?

  • 51 yr. old male, was perfectly well. On 13th January 2023, went to the market. No past history of diabetes, no past history of any discomfort on usual exertion. Farmer by profession. Bidi smoker. Initially, he denied any history of hypertension, but later when his son came, told that 2 years back was detected having hypertension but took some drugs only for one month. Further, BP was never checked. So, he was not on any medications.
  • He was buying vegetables, in the meantime a motor cycle fell over the left forearm, resulting in fracture. Went immediately to an ortho hospital. Admitting BP – 190/100.
  • 1st ECG was done 20 minutes after the injury. There was no history of direct injury to chest neither any history of chest pain.
When ECG Led Decision Was “A Bolt from The Blue”

ECG No – 1

  • They routinely did ECG and sensing something unusual referred to an ICU care facility hospital.
  • Looks very well and cheerful.
When ECG Led Decision Was “A Bolt from The Blue”

Listen same story in video (Language – Hindi)


Now, what’s your opinion on ECG?

CME INDIA Discussion (14/01/2023)

Note: Following are the live comments on various CME INDIA WhatsApp groups. These are depicted here for learning.

Dr. S. K. Goenka, Begusarai:

  • Incidental finding of Severe MI, during preoperative procedure. Patient unaware due to being asymptomatic. Diabetic? Painless MI. Probably proximal LAD involved. STE in V1 is more than STE in aVR.
  • This case looks to be of Atypical Silent MI. On the other hand, can we get patients of MI with normal ECG?

Dr. Ripun Borpuzari, Sivasagar, Assam:

  • I got a young bank manager who had severe pain in left elbow without any known history; Came out to be acute IWMI years back!
  • Was he boozed at that time?

Dr. Arvind Ojha, Kolkata:

  • Cardiac biomarkers, Bp, echo?
  • Can it be apical hypertrophic cardiomyopathy?

Dr. N. K. Singh:

  • TROP T – Repeated twice-normal.
  • Non-alcoholic.
  • As stated by patient – Normotensive, but BP at admission 190/100.
  • Following ECHO done. I have not done it, but done by reliable expert👇
When ECG Led Decision Was “A Bolt from The Blue”

Dr. Bhavesh Shashikant Shah Kapadwanj, Kheda, Gujarat:

  • Vaccine history? Which vaccine?

Dr. N. K. Singh:

  • How this history helps?
  • He has not taken covid vaccine.
  • Now, posting today’s ECG (14/01/2023):
When ECG Led Decision Was “A Bolt from The Blue”

ECG No – 2

Dr. Ashish Ranjan Jha, DM Card, Ranchi:

  • Post traumatic.
  • Nothing to be done.
  • Like T Takotsubo.
  • Trop t not diagnostic as it can be positive due to trauma.

Dr. S. K. Goenka, Begusarai:

  • Do these findings occur due to air embolism in the coronary arteries, as a result of trauma which after self-resorption, lead to recovery?
  • Can a patient of Takotsubo recover within 24 hrs, as in this case?

Dr. Rakesh Biswas, Professor of Medicine, Hyderabad:

  • Thanks for sharing this very interesting case.
  • Yes, the earliest reported recovery ranges of Takotsubo from 3-7 days but I guess that’s because of under-reporting.

Dr. Ripun Borpuzari, Sivasagar, Assam:

  • Does not seem like. No Q in 1, avl and V5-6 typical of HOCM. Right?

Dr. Varun Kumar, DM Card., Sante Vita Hosp., Ranchi:

  • This is hyperacute phase of Antero septal MI with reciprocal changes. Probably caused by the stress of the trauma or may be unrelated.
  • Takosubo cardiomyopathy is a diagnosis of exclusion after doing angiography.
  • CAG should not be taken in first hand.
  • Seeing the 2nd ECG, the possibility of auto recanalization is there. Go for CAG.

Dr. Satish Kumar, Cardiologist, Wellmark Hospital, Bokaro:

  • Being a kind of MINOCA, Troponin may be positive in TTCMP, as myocardial Injury is there.
  • At least some Wall motion abnormality, if not the classical apical ballooning, or Reverse TTSMP, was expected.

Dr. Varun Kumar, DM Card., Sante Vita Hosp., Ranchi:

  • All this MINOCA & Tako-subo is a diagnosis of exclusion, when you are not getting any obstructive CAD in CAG.
  • There are certain criteria for diagnosing all this entity, when it fulfils that then only it should be diagnosed.

Dr. D. P. Khaitan, Cardiologist Physician, Gaya (Now Ahmedabad):

  • This is most likely the case of Takotsubo cardiomyopathy – post traumatic cases in a young reported.
  • This post traumatic ECG is having these changes:
  • 1st ECG:
    • @ Limbs leads ST depression of varying degree in most of the leads -I, aVL, II, aVF except lead III and aVL with ST elevation.
    • Clear cut T inversion in aVL
    • @ Chest leads
    • ST elevation over leads
    • V1-4 maximum over V3
    • and ST depression over V5-6 // T tends to start inverted from V3 and extend to V6
    • @ S in V1 plus R in V6 is greater than 35 mm with ST and T changes in favour of LVH with systolic overload
    • Comments
    • ST elevation
    • During the initial stage of myocardial stunning there is a current if injury
    • maximum over the subendocardial leading to ST elevation. This ST elevation persists for 1-3 days in cases of Tokosubo cardiomyopathy.
    • ST elevation pattern is not possible to be collaborated with ac.
  • 2nd s second ECG shows
    • @ ST depression in the limb leads except in aVR
    • Some leads showing T inversion as, well
    • @Leads V1-2 with taller T waves
    • @ Evidence of LVH
    • Comments
    • Please auscultate –
    • Sometimes resultant MR might be present
    • LVOT dynamic obstruction might persists due to the collar LVOT oedema.
    • Nonspecific T inversion persist for a longer period even for weeks together.
  • Since chambers dimensions are normal on cardiac echo, the findings consistent with LVH might be due to LV dynamic contraction as a result of dynamic LVOT obstruction.

Dr. Ramesh Raju, Chennai:

  • This is extreme case of early repolarisation syndrome.
  • The point to note is j point elevation in all leads. That’s characteristic of ERS.
  • Since the j point is much elevated the ST segment seems elevated. Note also it’s concave upwards and not coving.
  • Takotsubo will not show normal echo.

Dr. D. P. Khaitan:

  • Early repolarization syndrome does not come to normal – they persist as such because these are related to ionic mechanism.
  • Even Takotsubo cardiomyopathy might occur with J point elevation, which indicates only that myocardial injury being maximum. starts with J point.
  • The up concavity only indicates more pressure gradient in between epicardium and endocardium – which might occur in T- cardiomyopathy.
  • Normal cardiac echo done after one day of the episode does not exclude T-cardiomyopathy. Hyperdynamic phase might be off after one day.

Dr. Ramesh Raju:

  • The first ECG machine is also underdamped.
  • Under damping: the condition in which damping of an oscillator causes it to return to equilibrium with the amplitude gradually decreasing to zero; system returns to equilibrium faster but overshoots and crosses the equilibrium position one or more times.
  • All sharp and pointed.  What was early repolarisation was made to like anterior wall MI.
When ECG Led Decision Was “A Bolt from The Blue”

Dr. D. P. Khaitan:

  • Sir this sort of either under or overdamping would not produce so much of ST deviation.
  • A slight decrease or increase in R height might occur-but not the admixture of ST elevation and depression both simultaneously.
  • With due regards to our colleagues – they are correct in their statement about the impact of under / overdamping on ECG.
  • But Sir how this possible to have the both ST elevation and ST depression both in the same ECG system simultaneously?

Dr. Basab Ghosh, Agartala:

  • Is CAG indicated in this case?

Dr. D. P. Khaitan, Gaya:

  • By seeing the 2nd ECG of this case, to my opinion CAG is not indicated.
  • If we assume the normalization after auto thrombolysis – the 2nd ECG is not showing the ECG evidence of reperfusion changes -which are usually in the form of Symmetrical deep T inversion due to myocardial oedema as a result of reperfusion.

Dr. Deepak Gupta, DM Card., Samford Hospital, Ranchi:

  • ECG changes is incidental finding and doesn’t relate to CAD. Marked ST changes are present in all leads. Echo has to review again by some expert. If no hypertrophy of LV, Septum and LV wall must have sparking feature s/o disarray myocardium.

Dr. N. K. Singh:

  • ECHO repeated on 15th Jan 23:

Echo is suggestive of Marked LVH, Grade 2 diastolic dysfunction,  E/E′-14.4, normal colour flow, Speckled appearance of myocardium, EF -62%,Reduced GLS(-10.2%), No RWMA.

Dr. Deepak Gupta, DM Card., Ranchi:

  • Granular and sparkling hyperechogenic septum and Lv wall is very common cause of
  • Nonspecific repolarization abnormalities.
  • Some pt. later on diagnosed as HCM OR RCM.
  • Even nonspecific repolarization abnormalities may cause SCD.
  • MRI or cardiac biopsy may lead some diagnosis,
  • Clearly HYPERTROPHIC LV with sparkling myocardium. This explain ECG changes.

Dr. D. P. Khaitan:

  • I do agree Sir.
  • Even nonspecific repolarization abnormalities may cause SCD.
  • Previous echo totally missed marked LVH, Gr2 diastolic dysfunction, although does not seem to have RWMA.  As today revealed by his son, 2 yrs. back detected hypertensive, but took drugs only for 2 months and later stopped, never rechecked too.
  • I have noticed the evidence of LVH on this ECG and also mentioned the same.
  • The evidence of sparkling myocardium might indicate? HOCM or might indicate due to HTN.Granular sparkling is an echocardiographic finding that is not specific for amyloidosis but has also been reported in end-stage renal disease, hypertrophic cardiomyopathy, and Friedreich cardiomyopathy.
  • On ECG, the diagnosis of amyloidosis is based on low voltage QRS with conduction abnormality. Here there is LVH with no conduction abnormality.
  • But I do agree that such changes occur only in 70-74 % of cases.
  • Yes, Amyloidosis should be excluded.

Dr. Digambar Naik, Goa:

  • Please do work up for amyloid cardiomyopathy.
  • Speckle tracking is almost classical for amyloidosis.

Dr. Satish Kumar, Cardiologist, Bokaro:

  • “Cherry on Top” – Amyloidosis indeed.

Dr. Venkatesh Molio, Maregoan, Goa:

  • Cherry red spot, apical sparing is suggestive of amyloid restrictive cardiomyopathy, also look for thickened Interatrial septum.

Dr. Sudipta Mondal, Sreechitra Hospital, Thiruvananthapuram, Kerala:

  • Overall looks traumatic Takotsubo with spontaneous resolution. But CAG should be done to rule out CAD. ECHO looks concentric LVH rather than HCM.

Course and Further Planning

  • After doing 2nd ECHO, as LV systolic function was normal, no regional wall motion abnormalities (RWMA), in spite of first going for CAG as advised, party decided to return to previous hospital. As learnt, he underwent fixation of fracture (1 hr surgery under brachial anaesthesia). He did not receive anti-ischaemic therapy or LMWH, was on Telmisartan and Metoprolol /Anti-platelets.
  • He is doing fine post-operatively.
  • He has promised to go for CAG after 2 days. CAG will be updated later if available.

ECG No 3 on 15th Jan 23:

When ECG Led Decision Was “A Bolt from The Blue”

CME INDIA Learning Edge

(By Dr. D. P. Khaitan)

This ECG has changed my thinking.

There is taller peaked T over Leads V1 -4 having a mild asymmetry with ascending limb and straight falling of the descending limb with somewhat ST elevation with slurring.
To me this convinces to be the case of Early repolarization syndrome.
Such picture was not present previously
Autonomic fluctuation might bring this ERS to be prominent now.
Evidence of LVH is there – the combination of SV1 plus Run V6 more than 35mm with systolic strain (ST -T changes)
ST depression on the frontal leads at times are associated with LVH
Or might indicate some nonspecific changes resultant of possible post traumatic? coronary spasm on 1st ECG
The initial ECG with ST elevation might be due to – Post traumatic coronary spasm which might be painless
The 2nd ECG shows – the disappearance of ST elevation with appearance of asymmetrical T over leads V1-2 There are associated ST depression elsewhere.
Comments
The patient met with post traumatic coronary spasm. The associated mild coronary plaque might be the adding factor.
No surprise the associated HTN works as a risk factor for nonsignificant coronary atherosclerosis.
LVH with systolic strain might be due to associated HTN
As time passes the early repolarization T wave has become prominent now by typical T over precordial leads V1-4
In a nutshell
Acute post traumatic coronary spasm with pre-existing LVH due to HTN
Associated early repolarization syndrome
Very interesting case
D/D
HOCM

CME INDIA Learning Points

  • Sometimes in clinical medicine all that glitters is not Gold.
  • Repeat ECGs and Echocardiography scans can be invaluable.
  • History does not necessarily follow findings.
  • CME India platform’s live discussions do provide priceless insights to manage the cases.
  • Present case needs further evaluation by CAG, Cardiac MRI and Biopsy .

CME INDIA Tail Piece

  • Clinical Clues to the Diagnosis of Cardiac Amyloidosis

Transthyretin Amyloidosis (ATTR-CM)

Patients with ATTR-CM commonly present with dyspnea, fatigue, and edema.

  • These findings are nonspecific and often misdiagnosed as nonamyloid HFpEF, a missed opportunity.
  • Assessment of myocardial wall thickness on echocardiogram is helpful.
  • The presence of moderate to severe left ventricular (LV) thickening (wall thickness ≥14 mm) should trigger consideration of ATTR-CM especially if there is discordance between wall thickness on echocardiogram and QRS voltage on ECG.
  • Key to diagnosis is a high index of suspicion.
  • Family history is of particular importance because an inherited form of ATTRv, the Val122Ile mutation, is observed almost exclusively in black patients. It is associated with a greater burden of autonomic and peripheral neuropathy and worse outcomes.

References:

  1. https://www.ahajournals.org/doi/10.1161/JAHA.118.011194
  2. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2020/03/30/12/17/takotsubo-syndrome#:~:text=The%20most%20common%20symptoms%20are,pressure%2C%20and%20systolic%20ejection%20murmur.
  3. https://skdesu.com/en/takotsubo-broken-heart-syndrome/


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