Nam Tran, Chun Shing Kwok, Sadie Bennett, Karim Ratib, Grant Heatlie and Thanh Phan
A 62-year-old female was admitted with severe left-sided chest pain, nausea and pre-syncope. She had widespread T wave inversion on ECG and elevated troponins and was suspected to have an acute coronary syndrome event. Invasive coronary angiogram revealed normal coronary anatomy with no flow-limiting lesions. Echocardiography and cardiac MRI revealed impaired left ventricular (LV) systolic impairment, a mobile LV apical thrombus and a moderate global pericardial effusion with no significant compromise. Full blood count analysis indicated the patient to have significant eosinophilia, and the patient was diagnosed with idiopathic eosinophilic myocarditis. She was commenced on Prednisolone and Apixaban, and eosinophil levels returned to normal after 10 days of steroids. Over the course of 3 months, the patient had a complete recovery of her LV function and resolution of the LV thrombus. This case highlights a rare, reversible case of idiopathic eosinophilic myocarditis which may present similar to acute coronary syndrome.
- Eosinophilic myocarditis (EM) is a rare disease that can exhibit symptoms similar to acute coronary syndrome events.
- The diagnosis of EM should be considered in patients with chest pain, normal coronary angiogram and pronounced eosinophilia levels.
- Endomyocardial biopsy is the gold standard diagnostic tool; however, it has a low sensitivity detection rate and its use is not indicated in some patients.
- Echocardiography is useful in the initial detection of cardiac involvement and complications. However, echocardiography lacks diagnostic specificity for all forms of myocarditis including EM.
- Cardiac magnetic resonance is a useful method and may add in diagnosing all forms of myocarditis including EM.
- Patients with EM should be identified promptly and treated with high doses of oral glucocorticoid to reduce the risk of permanent cardiac dysfunction.
Jamal N Khan, Timothy Griffiths, Tamseel Fatima, Leah Michael, Andreea Mihai, Zeeshan Mustafa, Kully Sandhu, Robert Butler, Simon Duckett and Grant Heatlie
Physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There are however no published data on the feasibility of PLSE. We sought to assess the feasibility, safety and robustness of PLSE and cardiologist-led stress echocardiography (CLSE) for coronary artery disease (CAD) assessment.
Retrospective analysis of 898 patients undergoing PLSE or CLSE for CAD assessment using exercise or dobutamine stress over 24 months. PLSE involved 2 cardiac physiologists (exercise) or 1 physiologist plus 1 cardiac nurse (dobutamine). A cardiology registrar was present in the echocardiography department during PLSE in case of medical complications. CLSE involved 1 physiologist and 1 trainee cardiologist who analysed the study and reviewed findings with an imaging cardiologist. Sixteen-segment wall motion scoring (WMS, WMSI) analysis was performed. Feasibility (stressor, image quality, proportion of completed studies, agreement with imaging cardiologist analysis) and safety (complication rate) were compared for PLSE and CLSE.
The majority of studies were CLSE (56.2%) and used dobutamine (68.7%). PLSE more commonly used exercise (69.2%). Overall, 96% of studies were successfully completed (>14 diagnostic segments in 98%, P = 0.899 PLSE vs CLSE). Commencement of PLSE was associated with an increase in annual SE’s performed for CAD assessment. Complication rates were comparably very low for PLSE and CLSE (0.8% vs 1.8%, P = 0.187). There was excellent agreement between PLSE and CLSE WMS interpretation of 480 myocardial segments at rest (κ = 0.87) and stress (κ = 0.70) and WMSI (ICCs and Pearson’s r >0.90, zero Bland–Altman mean bias).
This to our knowledge is the first study of the feasibility of PLSE. PLSE performed by well-trained physiologists is feasible and safe in contemporary practice. PLSE and CLSE interpretation of stress echocardiography for CAD agree very closely.
Vishal Sharma, Martin Stout, Keith Pearce, Allan L Klein, Maryam Alsharqi, Petros Nihoyannopoulos, Jamal Nasir Khan, Timothy Griffiths, Kully Sandhu, Sinead Cabezon, Chun Shing Kwok, Shanat Baig, Tamara Naneishvili, Vetton Chee Kay Lee, Arron Pasricha, Emily Robins, Prathap Kanagala, Tamseel Fatima, Andreea Mihai, Robert Butler, Simon Duckett, Grant Heatlie, Haotian Gu, Phil Chowienczyk, Linda Arnold, Sean Coffey, Margaret Loudon, Jo Wilson, Andrew Kennedy, Saul G Myerson, Bernard Prendergast, Alice M Jackson, Vera Lennie, Peter Lee Luke, Christopher James Eggett, Loakim Spyridopoulos, Timothy Simon Irvine, Nashwah Ismail, Anita Macnab, Caroline Bleakley, Mehdi Eskandari, Omar Aldalati, Almira Whittaker, Marilou Huang, Mark J Monaghan, Thomas J Turner, Conor Steele, Anna Barton, Alan C Cameron, Sonecki Piotr, Phang Gyee Vuei, Christos Voukalis, Hwee Phen Teh, Stavros Apostolakis, Chih Wong, Matthew M Y Lee, Nicolas E R Goodfield, Emma Lane, David Slessor, Richard Crawley, Theodoros Ntoskas, Farhanda Ahmad, Paul Woodmansey, Andrew J Fletcher, Shaun Robinson, Bushra S Rana, Liam Batchelor, Brogan McAdam, Caroline J Coats, Louise C Mayall, Niall G Campbell and Hannah Garnett