Pre-workout Induced Demand Ischemia

Background: Cardiac injury after subarachnoid hemorrhage (SAH) is a well-recognized phenomenon with electrocardiogram (ECG) changes, arrhythmias and myocardial dysfunction. Neurocardiac injury has been commonly reported with increased severity of SAH, however much of the evidence has focused on high grade SAH requiring hemodynamic support or mechanical ventilation. In this study we focused on neurocardiac injury with high grade World Federation of Neurological Surgeons (WFNS) grade 3-5 SAH requiring intensive care management. Methods: Patients admitted to our intensive care unit from 2009-2019 with an WFNS 3-5 aneurysmal SAH with an echocardiogram within 7 days of admission were included in our study. Electrocardiogram, cardiac biomarkers and data regarding mortality and neurological complications were collected retrospectively. Results: A total of 242 patients were included in our study analysis with 11 (5%), 89 (37%), and 142 (59%) had WFNS grade 3, 4 or 5 SAH, respectively. Of the 95 patients that underwent echocardiography in the first week, 38 (40%) had a reduced ejection fraction, which was mild (LVEF 40-52%) in 13 (14%), moderate (LVEF 30-39%) in 14 (15%), and severe (LVEF < 30%) in 11 (12%). Independent predictors of reduced ejection fraction included a lower presenting GCS score (OR 1.2 per one point reduction in (Glasgow Coma Score) GCS, 95% CI 1.0-1.5, p = 0.03), elevated troponin T concentration (OR 6.1, 95% CI 1.2-31.3, p = 0.03) and T wave inversion on ECG (OR 9.1, 95% CI 1.6-52.3, p = 0.01). In patients with reduced ejection fraction, classical apical wall motion abnormality was more prevalent in older populations (median age 64 years (apical) vs 50 years (basal wall motion abnormality) and 52 years (other) p = 0.03). In all wall motion abnormality groups, there was a female predominance. Classic Takotsubo wall motion was associated with an anterior SAH aneurysm location (p = 0.03) and highest proportion of moderate to severe LV dysfunction (p = 0.04). ICU mortality did not differ based on the pattern of wall motion abnormalities. Conclusion: Predictors of neurocardiac injury in high grade SAH include troponin elevation, T wave abnormalities and lower presenting GCS. Aneurysm location was associated with wall motion abnormalities and degree of LV dysfunction. Patients with WFNS 3-5 SAH are at increased risk of neurocardiac injury. ECG changes, cardiac biomarker elevation and aneurysm location can help identify patients who warrant echocardiography.

Background: Intracerebral hemorrhage (ICH) often carries cardiac implications, and serum troponin has been suggested as a predictive biomarker for patients with ICH and other stroke subtypes. We aimed to determine whether previously described associations between troponin and worse outcomes in ICH patients varied based on the presence of atrial fibrillation (AF). Methods: We performed a single-center cohort study using data from consecutive ICH patients admitted over 12 months. ICH characteristics and 3-month outcomes were prospectively collected, while admission troponin levels were retrospectively abstracted. We performed ordinal and binary logistic regression to determine associations between elevated troponins (>0.05 ng/mL) and 3-month outcomes (using the modified Rankin Scale [mRS]), with multivariable models adjusted for relevant demographics, ICH severity, and comorbidities including AF, anticoagulation use, coronary artery disease (CAD), and chronic kidney disease (CKD). An interaction variable combining elevated troponin and AF was also included in our models. Results: Of 261 ICH patients with troponin measured on admission, 17% (n=44) had elevated troponins. Patients with elevated troponins were not significantly older than patients with normal troponin levels (mean age 74.8±13.6 vs. 70.4±15.4, p=0.08), but were more likely to have AF (36% vs. 21%, p=0.03), CAD (32% vs. 15%, p=0.007), and CKD (16% vs. 5%, p=0.006); ICH size, location, and other predictors were not significantly different between groups. In adjusted models, neither elevated troponin nor AF were independently associated with worse outcomes. However, the interaction between the two was significant (p=0.003), and the presence of elevated admission troponin in the context of AF was significantly associated with worse outcomes (ordinal: common OR 9.8 [95% CI 2.0-47.8]; binary (mRS 4-6): OR 14.4 [95% CI 1.9-106.4]). Conclusions: Troponin may be a useful predictive biomarker in ICH patients with underlying AF, potentially signaling higher levels of cardiac and systemic stress in patients with lower cardiac reserve.

Prognostic value of 2D echocardiography in patients presenting with acute chest pain and non-diagnostic ECG for ST-elevation myocardial infarction

61-Year-Old Man With Nausea and Vomiting

Use of Cardiac Magnetic Resonance Imaging to Distinguish Between Acute Myocarditis and Takotsubo Cardiomyopathy

Nutrition plays a critical role in supporting physical performance and recovery in athletes. Adequate intake of macronutrients and micronutrients, proper hydration, and appropriate supplementation can influence endurance, strength, and speed during training and competition. This study aims to analyze the role of nutrition in optimizing athlete performance and recovery by examining nutritional requirements, hydration strategies, supplement use, and dietary patterns that support muscle regeneration. A literature review approach was employed, analyzing scientific articles, books, and recent research reports on sports nutrition, physical recovery, and supplementation. Data were analyzed descriptively and analytically to identify the relationship between nutrient intake and physical performance indicators, as well as the effectiveness of recovery strategies following athletic activities.mThe findings indicate that balanced consumption of carbohydrates, proteins, healthy fats, vitamins, and minerals enhances energy capacity, accelerates muscle recovery, and reduces fatigue and injury risk. Proper hydration also supports bodily homeostasis and maintains performance during training or competition. Targeted supplementation, when applied appropriately, can further enhance physiological adaptation and muscle tissue regeneration. Overall, systematic nutrition planning and personalized nutrient intake are essential for improving performance and accelerating recovery in athletes. These findings provide practical guidance for coaches, sports nutritionists, and athletes in developing effective nutritional strategies to support athletic achievement and long-term health.

Not All Perioperative Myocardial Infarctions Can Be Prevented with Preoperative Revascularization

Background: It is unclear whether lipoprotein(a) – Lp(a) – concentration is affected during acute admissions in patients with ischaemic heart disease (IHD). We investigated whether Lp(a) concentration was acutely affected in patients admitted to hospital with elevated serum troponin T concentration. Methods: We analysed the variability of serum Lp(a) concentrations and its correlation with high levels of troponin T in patients with IHD who were admitted to the cardiology department in Changi General Hospital in Singapore over a year. Elevated Lp(a) was defined as ≥120 nmol/l. Results: The median serum Lp(a) concentration of 75 patients at baseline and follow-up as outpatients were 143.2 nmol/l (interquartile range (IQR) 90.9–186.0) and 141.4 nmol/l (IQR 76.2–197.0) respectively, p=0.049. Increased troponin T level at baseline was associated with ≥20% higher Lp(a) concentration at follow-up. Multivariable ordinal logistic regression analysis showed 38% increase with higher Lp(a) concentration at follow-up for a 1 unit increase in loge troponin T (OR 1.38, 95% CI [1.08–1.76]; p=0.011). Elevated baseline troponin T was associated with a ≥30% increase of Lp(a) concentration at follow up (OR 1.31 [1.01–1.70]; p=0.045). In patients with severely elevated troponin T level ≥500 ng/l at baseline, 13.6% were reclassified as having elevated Lp(a). There were six patients with an elevation of Lp(a) >50% (range 50.9–184.9%) when rechecked as an outpatient; all of them had an initial baseline elevated troponin T level of >14 ng/l. Conclusion: There is clinically significant variability of Lp(a) in patients with elevated troponin T concentration and they may have a falsely lowered Lp(a) concentration during acute admission to hospital. Patients with Lp(a) concentrations 70–120 nmol/l measured when troponin T was elevated or during acute clinical events should have their Lp(a) concentrations retested during follow-up as an outpatient.

The purpose of the present study was to examine characteristics of multi-ingredient pre-workout supplement (MIPS) users, their common patterns/habits of MIPS ingestion, and their associated feelings about the effectiveness and safety of this class of supplements. An online electronic survey was distributed through social media to assess self-reported supplementation practices and preferences among adult males and females who reported regular MIPS use. A total of 1045 individuals responded, with 872 of these individuals (males: n = 636, 72.9%; females: n = 233, 26.7%; mean ± SD; age = 27.7 ± 7.9 years; training age = 8.2 ± 7.3 years) completing the survey. The majority of respondents reported the length of current or past MIPS consumption as greater than one year (n = 630, 72.2%), with ingestion frequencies primarily of four (n = 210, 24.1%) or five (n = 212, 24.3%) days per week of training. In addition, the three most popular goals for ingesting MIPS were increased energy and focus (n = 776, 89.0%), muscular endurance (n = 325, 37.3%), and blood flow or “pump” (n = 322, 37.0%). Although most users reported ingesting one serving size with each use, 14% reported ingesting two or more, and 18% indicated they ingest MIPS more than once per day. Importantly, over half (54%) of the respondents reported experiencing side-effects following MIPS use, including skin reactions, heart abnormalities, and nausea. Females were more likely than males to experience these side effects, despite being less likely to consume two or more serving sizes per dose. Our findings also indicated that MIPS users should consume no more than the recommended serving size of a given supplement, as the potentially significant variability in the caffeine content of MIPS products is compounded as more doses are consumed. Furthermore, MIPS users should minimize the ingestion of other supplements which contain high levels of niacin and caffeine, as the concurrent consumption of such products may put users above the tolerable upper limits for these substances.

ObjectiveEmergency physicians experience difficulty in determining the disposition of patients with elevated troponin I levels using emergency room tests. In this study, we aimed to investigate factors that could discriminate between the occurrence of type 1 myocardial infarction (T1MI) and type 2 myocardial infarction (T2MI) in patients with elevated troponin I levels.MethodsPatients admitted to the emergency department between January 1, 2017 and June 30, 2017 with elevated troponin I levels who underwent subsequent cardiac biomarker testing were included. Samples for baseline blood tests, such as cardiac biomarker levels, were collected within approximately 10 minutes of admission. Electrocardiogram, transthoracic echocardiography, and percutaneous coronary intervention results were retrospectively examined via patient report and chart reviews.ResultsDuring the study period, 169 of 234 (72%) patients were diagnosed with T2MI and 65 (28%) were diagnosed with T1MI. Among various factors, typical chest pain (odds ratio [OR], 4.40; 95% confidence interval [CI], 1.46 to 13.24; P=0.008), high troponin I levels (OR, 1.50; 95% CI, 1.19 to 1.90; P<0.001), high cholesterol (OR, 1.01; 95% CI, 1.00 to 1.02; P=0.008), and low D-dimer levels (OR, 0.87; 95% CI, 0.77 to 0.98; P=0.027) were significantly associated with T1MI incidence.ConclusionOur findings in this study indicate that typical chest pain, high levels of troponin I and cholesterol, and low levels of D-dimer were associated with the diagnosis of T1MI. Further studies are suggested to determine the cut-off values for accurate diagnosis of T1MI in the ED.

Stroke is one of the leading causes of morbidity and mortality. Cardiac troponins have been found to be increased in other conditions apart from the cardiac diseases, such as stroke. The aim of the study was to assess the correlation between elevated troponin I levels and stroke outcome. This retrospective study included 198 acute ischemic stroke patients in whom troponin I levels have been obtained at admission. Exclusion criteria were concomitant acute coronary syndrome, congestive heart failure, pulmonary embolism, renal failure, rhabdomyolysis and septic conditions. There was a statistically significant difference in the proportion of deaths during hospitalization (p = 0.041) and modified Rankin Scale scores (p = 0.016) between the group of patients with elevated troponin I levels and the control group. Prior ischemic strokes were more common in the group with elevated troponin I levels (p = 0.032). No other differences were observed. Our study showed that patients with elevated initial troponin I levels are associated with unfavorable outcome or death. Stroke may be associated with mild elevation of troponin levels, contrary to higher levels which are usually related to other conditions.

Background: Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after stroke is independently associated with death among a more heterogeneous US population remains unclear. Furthermore, only a few studies have evaluated the association between the magnitude of troponin elevation and subsequent mortality, patterns of dynamic troponin changes over time, or whether troponin elevation is related to specific causes of death. Methods: Using data collected in the American Heart Association's ‘Get With The Guidelines' stroke registry between 2008 and 2012 at a tertiary care US hospital, we used logistic regression to evaluate the independent relationship between troponin elevation and mortality after adjusting for demographic and clinical characteristics. We then assessed whether the magnitude of troponin elevation was related to in-hospital mortality by calculating mortality rates according to tertiles of peak troponin levels. Dynamic troponin changes over time were evaluated as well. To better understand whether troponin elevation identified patients most likely to die due to a specific cause of death, investigators blinded from troponin values reviewed all in-hospital deaths, and the association between troponin elevation and mortality was evaluated among patients with cardiac, neurologic, or other causes of death. Results: Of 1,145 ischemic stroke patients, 199 (17%) had elevated troponin levels. Troponin-positive patients had more cardiovascular risk factors, more intensive medical therapy, and greater use of cardiac procedures. These individuals had higher in-hospital mortality rates than troponin-negative patients (27 vs. 8%, p < 0.001), and this association persisted after adjustment for 13 clinical and management variables (OR 4.28, 95% CI 2.40-7.63). Any troponin elevation was associated with higher mortality, even at very low peak troponin levels (mortality rates 24-29% across tertiles of troponin). Patients with persistently rising troponin levels had fewer anticoagulant and antiatherosclerotic therapies, with markedly worse outcomes. Furthermore, troponin-positive patients had higher rates of all categories of death: neurologic (17 vs. 7%), cardiac (5 vs. <1%), and other causes of death (5 vs. <1%; p < 0.001 for all comparisons). Conclusions: Ischemic stroke patients with abnormal troponin levels are at higher risk of in-hospital death, even after accounting for demographic and clinical characteristics, and any degree of troponin elevation identifies this higher level of risk. Troponins that continue to rise during the hospitalization identify stroke patients at markedly higher risk of mortality, and both neurologic and non-neurologically mediated mortality rates are higher when troponin is elevated.

52-Year-Old Woman With Fever, Diaphoresis, and Abdominal Pain

BackgroundEosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis. Cardiac involvement is the major cause of morbidity and mortality in these patients. Early recognition and treatment initiation for such manifestations are key to improved patient outcomes.Case summaryWe report the case of a 60-year-old man with a history of therapy-resistant asthma and rhinitis. He presented with acute chest pain, sinus tachycardia, and marked peripheral eosinophilia. Transthoracic echocardiogram (TTE) showed segmental anterior left ventricular (LV) wall motion abnormalities with impaired systolic function (LV ejection fraction 45%) and a small pericardial effusion. Invasive coronary angiography revealed unobstructed coronary arteries. Cardiac magnetic resonance imaging confirmed the TTE findings and demonstrated oedema and active inflammation of the anterior and anteroseptal LV segments [Short inversion time recovery (STIR)-T2] and an unusual pattern of non-ischaemic late gadolinium enhancement extending across multiple coronary territories. Autoantibody testing detected a positive P-ANCA and myeloperoxidase (MPO) antibodies. Overall, the investigation findings supported a diagnosis of ANCA-positive EGPA with acute myocardial involvement. He was initially treated with high-dose corticosteroids, cyclophosphamide, and rituximab. The patient had a good symptomatic and biochemical (normalized troponin T and MPO titre) recovery. In addition, subsequent TTE showed improvement of LV systolic function and resolution of regional wall motion abnormalities.DiscussionIn this case, prompt diagnosis facilitated early initiation of immunosuppressive therapy and disease remission. CMR provides non-invasive assessment of myocardial tissue characterization and, used in conjunction with other tools, can be instrumental in detecting myocardial involvement in EGPA.

Background: Immune checkpoint inhibitors (ICI) have shown efficacy in treating a wide spectrum of malignancies, but have a known risk of cancer therapy related cardiac toxicity. We present a case that demonstrates how conduction system disease can rapidly progress in a patient with suspected nivolumab (PD1) induced fulminant myocarditis. Case: An 82-year-old male with a history of esophageal carcinoma presented with agonal breathing and altered mental status. He had received his second dose of PD1 therapy three days prior. He was intubated and admitted for hypoxic respiratory failure and elevated troponin. His initial EKG demonstrated new marked 1st degree AV block with right bundle branch block (RBBB) morphology. A stat echocardiogram noted an EF of 60-65% with no wall motion abnormalities. Decision-making: On Day 2, Mobitz Type I block was appreciated on telemetry. The patient met criteria for acute myocarditis with his clinical presentation, new conduction system disease, and high sensitivity troponin of 13,000. Given recent PD1 therapy, lack of infectious prodrome, and lack of prior heart disease, suspicion for ICI induced myocarditis was high. High dose steroid therapy was initiated. On Day 3, the patient was noted to have alternating left bundle branch block and RBBB. On Day 4, he progressed to complete heart block, prompting transvenous pacemaker (PM) placement with subsequent permanent PM placement. A repeat echo showed global hypokinesis with an EF of 40-45% and reduced RV function. He also required vasopressor support meeting criteria for fulminant myocarditis. Due to his hemodynamic instability and low clinical suspicion, he did not receive cardiac catheterization. Cardiac MRI and cardiac biopsy were not readily available in this institution. Conclusion: The clinical findings, lack of infectious prodrome, and worsening arrhythmia requiring pacing and vasopressor support, in patient with recent PD1 treatment suggests nivolumab induced fulminant myocarditis. In institutions without advanced testing infrastructure, rapid recognition of progressive conduction system disease may be used as an early marker for diagnosis, treatment initiation, and referral to tertiary care centers for advanced management of fulminant ICI myocarditis.