UNASSIGNED: Marathon running poses unique cardiovascular challenges, sometimes leading to syncopal episodes. We present a case series of athletes who experienced pre-/syncope during the Zurich Marathon 2023, accompanied by elevated cardiac biomarkers.
UNASSIGNED: Eight athletes (2 females, 6 males) aged 21-35 years, with pre-/syncope and various additional diverse symptoms such as dizziness and palpitations during the (half-)marathon, were admitted to two emergency departments in Zurich, Switzerland. Clinical evaluations included electrocardiogram, echocardiography, telemetry, coronary computed tomography (CT) scans, and cardiac biomarker assessments. High-sensitive troponin T (hs-cTnT) was elevated in all cases at initial assessment and returned to normal at follow-up. All athletes who received CT scans had normal coronary and brain CT results. None of the eight athletes had underlying cardiovascular disease. Renal function normalized post-admission, and neurological symptoms resolved within hours. Creatinine levels indicated transient acute kidney injury. A common feature was inexperience in running, inadequate race preparation, particularly regarding fluid, electrolyte, and carbohydrate intake, along with pacing issues and lack of coping strategies with heat.
UNASSIGNED: From a clinician perspective, the case series highlights the challenge in the management of patients with a pre-/syncopal event during strenuous exercise and elevated cardiac biomarkers. Diverse initial symptoms prompted tailored investigations. Adequate training, medical assessments, and awareness of syncope triggers are essential for marathon participants. Caution and pacing strategies are crucial, especially among novices in competitive running. This information is pertinent given the growing popularity of marathon events and prompts a standardized diagnostic approach after these events.

Acute coronary syndrome (ACS) is common in people with chronic kidney disease (CKD) and is linked to poor short- and long-term outcomes. The diagnosis of myocardial infarction is challenging in patients with CKD as they have baseline elevated troponin levels. To date, there are no widely accepted guidelines to suggest what is a clinically significant change in troponin levels in these patients. We report a case of a patient with CKD who presented with chest pain to the emergency department (ED). His baseline troponin was high; however, the delta change was 11%. He was discharged from the ED for outpatient follow-up, but within 36 hours, he had significant ST elevation myocardial infarction (STEMI) with unstable hemodynamics and acute heart failure requiring urgent intubation and coronary revascularization. This case highlights the gap in clinical knowledge and practice in a relatively not uncommon presentation in emergency departments.

UNASSIGNED: Takotsubo syndrome is an acute cardiac condition usually involving abnormal regional left ventricular wall motion and impaired left ventricular contractility. It is due mainly to hyper-stimulation of the sympathetic nerve system, inducing an excess of catecholamines, usually triggered by intense psychological or physiological stress. The relationship between Takotsubo syndrome and the circulating stress hormones cortisol and copeptin (a surrogate marker of arginine vasopressin) has not been well documented.
UNASSIGNED: Here, we describe the dynamic changes in circulating cortisol and copeptin during an entire episode of Takotsubo syndrome in a post-partum woman after spontaneous vaginal delivery. The patient was diagnosed with inverted Takotsubo syndrome accompanied by HELLP syndrome. We found qualitative and quantitative changes in cortisol: a loss of circadian rhythm and a three-fold elevation in the plasma concentration of the hormone with a peak appearing several hours before circulating cardiac biomarkers began to rise. By contrast, levels of copeptin remained normal during the entire episode.
UNASSIGNED: Our findings indicate that the levels of cortisol change during Takotsubo syndrome whereas those of copeptin do not. This association between elevated cortisol and Takotsubo syndrome suggests that aberrant levels of this stress hormone may contribute to the observed cardiac pathology. We conclude that biochemical assays of circulating cortisol and cardiac biomarkers may be a useful complement to the diagnosis of Takotsubo syndrome by non-invasive cardiac imaging.

Immune checkpoint inhibitors (ICIs) are increasingly recognised to effectuate long-lasting therapeutic responses in solid tumours. However, ICI therapy can also result in various immune-related adverse events, such as ICI-associated myocarditis, a rare but serious complication. The clinical spectrum is wide and includes asymptomatic patients and patients with fulminant heart failure, making it challenging to diagnose this condition. Furthermore, the optimal diagnostic algorithm and treatment of ICI-associated myocarditis is unknown. In this review, we describe two cases on both ends of the spectrum and discuss the challenges in recognising, diagnosing and treating ICI-associated myocarditis.

New drugs come not only with benefits but also with unexpected toxicities which need to be promptly recognized and managed. Starting from a scholar case of acute heart failure with preserved ejection fraction following the administration of trabectedin (ET-743, Yondelis®) in a patient with a metastatic solitary fibrous tumor, we performed a systematic review of the literature encompassing the results of previous cardiac safety analysis published ten years ago, a review of clinical trials published during the last 10 years as well as single-case descriptions related to trabectedin cardiotoxicity. The estimated incidence of cardiac toxicity was 3,4% among patients receiving trabectedin, with recent data suggesting a higher rate of heart failure than previously recognized. Previous or concomitant anthracyclines exposure may represent a risk factor. Assaying for NT-pro-BNP may be useful for the early detection of individuals with trabectedin-induced heart failure.

OBJECTIVE: A review study on the biochemistry of epilepsy showed that in epileptic patients, serum glucose and cholesterol concentrations are low, sodium is unaffected, potassium increases, glucose is high and mild hypocalcemia. We have conducted a biochemical study on sudden unexpected death in epilepsy (SUDEP) cases in an attempt to establish the characteristic biochemical values to diagnose these deaths.
METHODS: This was a hospital based case-control study done at All India Institute of Medical Sciences, New Delhi for one year. Twenty SUDEP cases and 20 age- and sex-matched controls were included in the study. Femoral blood, cerebrospinal fluid, vitreous humor, and pericardial fluid were biochemically analyzed for sodium, potassium, calcium, glucose, N-acetyl- cysteine activated creatine kinase (CK-NAC) and isoenzyme CK-MB.
RESULTS: Serum sodium, CK-MB and CK-NAC level was found significantly increased and potassium level was found decreased in SUDEP cases in comparison to non-epileptic deaths. Likewise, in CSF, sodium and CK-NAC was found increased and potassium level was found decreased in SUDEP cases. In vitreous humor, sodium and CK-MB level was found increased and potassium level was found decreased in SUDEP cases in comparison to non-epileptic deaths. In pericardial fluid, sodium, CK-NAC and CK-MB level was found increased and potassium level was found decreased in SUDEP cases in comparison to non-epileptic deaths.
CONCLUSIONS: It concludes that high sodium level and low potassium level could be associated with SUDEP. However, this is a small size study, a larger study is needed to verify the findings. Furthermore, it is difficult to conclude whether these findings are exclusive to SUDEP.

The purpose of this study was to identify cardiac biomarkers of disordered eating. Mean R wave amplitude (mV), mean T wave amplitude (mV), QRS interval (sec), QTc interval (sec), and Tpeak-Tend interval (sec) were assessed via electrocardiography among women with clinical (n = 53) and subclinical (n = 56) eating disorder symptoms versus asymptomatic controls (n = 32). QRS and QTc intervals were significantly longer and mean T and R wave amplitudes significantly lower among women with clinical symptoms compared to asymptomatic controls. QTc interval length was significantly longer and mean R wave amplitude was significantly lower among women with subclinical symptoms versus asymptomatic controls. Decreased mean R wave amplitude yielded a comparable effect size as QTc when differentiating between asymptomatic and subclinical groups and a larger effect size than QTc when differentiating between asymptomatic and clinical groups, representing a promising clinical biomarker.

Nuclear imaging modalities using 123Iodine-metaiodobenzylguanidine (123I-MIBG) and bone seeking tracers identify early cardiac involvement in ATTRm amyloidosis patients. However, little is known whether results from 123I-MIBG scintigraphy actually correlate to markers for either cardiac autonomic neuropathy or cardiomyopathy.
All TTR mutation carriers and ATTRm patients who underwent both 123I-MIBG and 99mTechnetium-hydroxymethylene diphosphonate (99mTc-HDP) scintigraphy were included. Cardiomyopathy was defined as NT-proBNP > 365 ng/L, and cardiac autonomic neuropathy as abnormal cardiovascular reflexes at autonomic function tests. Late 123I-MIBG heart-to-mediastinum ratio (HMR) < 2.0 or wash-out > 20%, and any cardiac 99mTc-HDP uptake were considered as abnormal.
39 patients (13 carriers and 26 ATTRm patients) were included in this study. Patients with cardiomyopathy, with or without cardiac autonomic neuropathy, had lower late HMR than similar patients without cardiomyopathy [median 1.1 (range 1.0-1.5) and 1.5(1.2-2.6) vs 2.4 (1.4-3.8) and 2.5 (1.5-3.7), respectively, P < 0.001]. Late HMR and wash-out (inversely) correlated with NT-proBNP r = - 0.652 (P < 0.001) and r = 0.756 (P < 0.001), respectively. Furthermore, late HMR and wash-out (inversely) correlated with cardiac 99mTc-HDP uptake r = - 0.663 (P < 0.001) and r = 0.617 (P < 0.001), respectively.
In case of heart failure, 123I-MIBG scintigraphy reflects cardiomyopathy rather than cardiac autonomic neuropathy in ATTRm patients and TTR mutation carriers. 123I-MIBG scintigraphy may already be abnormal before any cardiac bone tracer uptake is visible.

BACKGROUND: We performed a retrospective case-control study to assess the values of cardiac troponin I (cTnI) in a large number of patients admitted to the emergency department (ED) with different types of trauma.
METHODS: The study population consisted of all patients aged 18 years or older admitted to the local ED with all types of traumas over a 1-year period. Results of cTnI were compared with those of 125 consecutive blood donors and 25 non-cardiac chest pain ED patients.
RESULTS: The final study population consisted of 380 trauma patients, 10 with isolated abdominal trauma, 99 with isolated trauma of the limbs, 49 with isolated chest trauma, 145 with isolated head trauma and 77 with polytrauma. The concentration of cTnI did not differ among the three study populations, but the frequency of measurable values was substantially higher in patients with trauma (63%) than in blood donors and non-cardiac chest pain ED patients (both 20%). The frequency of cTnI values above the 99th percentile of the reference range was significantly higher in trauma patients (20%) than in blood donors (0%) and noncardiac chest pain ED patients (8%). Increased cTnI values were more frequent after head trauma (21%), chest trauma (27%) and polytrauma (29%) compared to patients with abdominal (0%) or limbs trauma (8%).
CONCLUSIONS: These results suggest that the measurement of cardiac troponin may be advisable to identify potential cardiac involvement in trauma patients, especially in those with polytrauma and head or chest trauma.
UNASSIGNED: Ovu retrospektivnu anamnestičku studiju sproveli smo u cilju određivanja vrednosti srčanog troponina I (cTnI) kod velikog broja pacijenata primljenih na odeljenje urgentne medicine sa različitim vrstama trauma.
METHODS: Populacija u ovoj studiji sastojala se od pacijenata starih 18 godina ili više sa svim vrstama trauma koji su primljeni na lokalno odeljenje hitne službe tokom perioda od godinu dana. Rezultati cTnI upoređeni su sa rezultatima 125 uzastopnih davalaca krvi i 25 pacijenata sa bolom u grudima koji nije bio srčanog porekla sa odeljenja hitne službe.
UNASSIGNED: Konačnu populaciju u ovoj studiji činilo je 380 pacijenata sa traumama, 10 sa izolovanim povredama abdomena, 99 sa izolovanim povredama udova, 49 sa izolovanim povredama grudnog koša, 145 sa izolovanim povredama glave i 77 sa politraumom. Koncentracija cTnI nije se razlikovala između tri populacije u studiji, ali je učestalost merljivih vrednosti bila značajno veća kod pacijenata sa traumom (63%) nego kod davalaca krvi i bolesnika sa odeljenja za hitnu pomoć koji su imali bol u grudima koji nije bio srčanog porekla (oba po 20%). Učestalost vrednosti cTnI iznad 99-og percentila u referentnom opsegu bila je značajno veća kod pacijenata sa traumama (20%) nego kod davalaca krvi (0%) i pacijenata sa odeljenja hitne službe sa bolom u grudima nesrčanog porekla (8%). Povišene vrednosti cTnI bile su češće posle povreda glave (21%), povreda grudnog koša (27%) i politraume (29%) u poređenju s pacijentima sa povredama abdomena (0%) ili udova (8%).
UNASSIGNED: Ovi rezultati pokazuju da bi se merenje srčanog troponina moglo savetovati radi identifikovanja potencijalnog učešća srca kod pacijenata sa traumama, naročito kod onih sa politraumom ili povredama glave ili grudi.

A 12-year-old male child with Down syndrome, who had recovered from congenital heart disease, succumbed to severe varicella myocarditis. His clinical presentation at admission mimicked acute coronary syndrome. Analysis of this case throws insight into several aspects of varicella myocarditis.