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Open access

Sadie Bennett, Duwarakan Satchithananda, and Gareth Law

Summary

A 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus.

Learning points:

  • Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus.
  • A large and mobile LV thrombus is associated with an increased risk of embolic events.
  • Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients.
  • NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults.
  • To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus.
  • Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.
Open access

Nam Tran, Chun Shing Kwok, Sadie Bennett, Karim Ratib, Grant Heatlie, and Thanh Phan

Summary

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.

Learning points:

  • 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.
Open access

Sadie Bennett, Arzu Cubukcu, Chun Wai Wong, Timothy Griffiths, Cheryl Oxley, Diane Barker, Simon Duckett, Duwarakan Satchithananda, Ashish Patwala, Grant Heatlie, and Chun Shing Kwok

Background: Anthracycline agents are known to be effective treatments for solid tumors and hematological malignancies. Although these agents improve survival, their use is associated with cardiotoxic effects, which most commonly manifests as left ventricular systolic dysfunction (LVSD). As such guidelines recommend the periodic assessment of left ventricular ejection fraction (LVEF). However, as diastolic dysfunction likely proceeds systolic impairment in this setting, the role of Tei index may offer additional benefit in detecting subclinical LVSD.

Methods: We conducted a systematic review to investigate the evidence for the use of Tei index in assessing for subclinical cardiotoxicity in patients receiving anticancer agents. A search of Medline and EMBASE was performed and relevant studies were reviewed and narratively synthesized.

Results: A total of 13 studies were included with a total of 800 patients (mean age range 46-62 years, percentage of male participants ranged from 0%-86.9%). An increase in Tei index was observed in 11 studies, which suggesting a decline in cardiac function following chemotherapy. Out of these, 6 studies indicated that the Tei index is a useful parameter in predicting cardiotoxic LVSD. Furthermore, 5 studies indicated Tei index to be superior to LVEF in detecting subclinical cardiotoxicity.

Conclusions: While there are some studies that suggest that Tei index may be a useful indicator in assessing for subclinical anthracycline related cardiotoxicity, the findings are inconsistent so more studies are needed before the evaluation of Tei index should be performed routinely in patients receiving chemotherapy.

Open access

Sadie Bennett, Chun Wai Wong, Timothy Griffiths, Martin Stout, Jamal Nasir Khan, Simon Duckett, Grant Heatlie, and Chun Shing Kwok

Background

Echocardiographic evaluation of left ventricular ejection fraction (LVEF) is used in the risk stratification of patients with an acute myocardial infarction (AMI). However, the prognostic value of the Tei index, an alternative measure of global cardiac function, in AMI patients is not well established.

Methods

We conducted a systematic review, using MEDLINE and EMBASE, to evaluate the prognostic value of the Tei index in predicting adverse outcomes in patients presenting with AMI. The data was collected and narratively synthesised.

Results

A total of 16 studies were including in this review with 2886 participants (mean age was 60 years from 14 studies, the proportion of male patients 69.8% from 14 studies). Patient follow-up duration ranged from during the AMI hospitalisation stay to 57.8 months. Tei index showed a significant association with heart failure episodes, reinfarction, death and left ventricular thrombus formation in 14 out of the 16 studies. However, in one of these studies, Tei index was only significantly predictive of cardiac events in patients where LVEF was <40%. In two further studies, Tei index was not associated with predicting adverse outcomes once LVEF, left ventricular end-systolic volume index and left ventricular early filling time was taken into consideration. In the two remaining studies, there was no prognostic value of Tei index in relation to patient outcomes.

Conclusions

Tei index may be an important prognostic marker in AMI patients, however, more studies are needed to better understand when it should be used routinely within clinical practice.