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Home , Myocardial infarction, Sinus tachycardia, ST elevation

01 - Vol. 16, No. 1, JANUARY 2020 BSMMU H.J. 16 The , 2019 AN, Almost

T ISLAM December

01 FAKHRUL UDDIN SUL Elevated , Y block and atrial , antero-septal & AV Accepted: ASHRAF ADHIKAR

,Bangabandhu Sheikh MujibMedical ,Bangabandhu Sheikh , Dhaka,Bangladesh. ST Acute ISLAM, MD. KRISHNA AL University Journal 2020; 16(1): 16-21 [email protected] any rhythm disturbance can be associated with acute myocardial , including bradyarrhythmias, supraventricular tachyarrhythmias, ventricular and . It is known that leads to severe metabolic and electrophysiological changes that induce silent or symptomatic life-threatening arrhythmias. most important assumption for key mechanism of in acute phase of coronary occlusion is microreentry due to inhomogeneity of electrical characteristics of ischemic myocardium. Cells of center of the ischemic zone have a relatively consistent increase in are not related to the severity of infarct but observations are not related to the severity of infarct from monitoring unit suggest that the mechanism in most of the cases is arrhythmias and cardiac . block (5.3%), complete and atrial ectopic block (5.3%), complete heart block and atrial hythmias in hythmias AV Alam, Department of Alam, Department of HASAN, SAMI NAZRUL T Arr arly deaths SAJAL KRISHNA BANERJEE A substantial 2 AMANA

-segment elevated myocardial infarction, Outcome. , Bangabandhu Sheikh Mujib Medical University , Bangabandhu Sheikh ,Dhaka,Bangladesh. Email: dr ,Dhaka,Bangladesh. Email: Y, mortality trends of ALAM, MANZOOR MAHMOOD, DIP MAHMOOD, ALAM, MANZOOR

Acute ST . Muhammad Khurshadul . Muhammad Khurshadul University : Dr achyarrhythmias were more common in anterior wall myocardial infarction, whereas achyarrhythmias were more common in , 2019 Arrhythmia, TIPU CHOWDHUR espondence Department of Cardiology .Despite decreasing Acute myocardial infarction (AMI) is 1 07 October ectopic. The incidence of mortality was 2%. Keywords: 1.7% each. T wall myocardial infarction. Among studied patients, 72% bradyarrhythmias were more common in inferior left ventricular failure 10%, cardiogenic & lengthening of had favourable outcome , followed by acute The commonest arrhythmias encountered were sinus hospital stay 8% each and death 2%.Conclusion: ventricular , ventricular ectopic, tachycardia followed by sinus , Abstract: of death worldwide with arrhythmia being infarction (AMI) is a major cause Background: Acute myocardial at and management of arrhythmias in the post-infarction period. Identification the most common determinant is The aim of the study MI has both short term and long term significance.Objective: an early period of acute STEMI in the first 48 hours of hospitalization and their in- to evaluate the pattern of arrhythmias in acute with acute STEMI were included in the study after considering hospital outcome. Methods: A total of 50 patients were observed for the first 48 hours of hospitalization for the inclusion and exclusion criteria. The patients at admission and continuous cardiac monitoring in the CCU. The detection of arrhythmia with baseline ECG & their in-hospital outcome were recorded in predesigned pattern of the arrhythmias during this period mean age was 53.38 ± 10.22 years ranging from 29 to 70 years. structured data collection sheet.Result: The of the patients had anterior wall ( anterior Most of the patients were male 42(84%). Majority (54%). in isolation was the most common extensive anterior) myocardial infarction followed by (22.8%), arrhythmia observed in 36.8% of patients degree (19.3%), ventricular ectopic (12.3%),first Myocardial Infarction and their in-hospital Outcome their in-hospital and Infarction Myocardial ess of Corr KHALED, MSI The Pattern of Cardiac of Cardiac The Pattern MOHAMMAD KHURSHADUL MOHAMMAD ol. 16, No. 1, January 2020 No. 1, January ol. 16, Addr Received: University Heart Journal Heart University V number of patients with acute myocardial infarction have some cardiac rhythm abnormality and most cases cardiac conduction disturbance develop within 48 hours following infarct onset. Deaths most commonly occur within first few hours of acute myocardial . E myocardial in a clinical setting consistent with acute myocardial and detection of elevated values of cardiac (-I/ CK-MB) above the 99th centile of the upper reference limit. coronary (CAD) in many developed countries, increasing number is noticed in developing countries. Introduction: Cardiovascular (CVDs) are the leading causes of death globally 01 - Vol. 16, No. 1, JANUARY 2020 BSMMU H.J. 17 17 able 2). All of the Alam et al. Alam 12.0 26.0 38.0 24.0 84.0 16.0 30.0 16.0 10.0 18.0 26.0 100.0 Percentage (%) Mohammad Khurshadul Khurshadul Mohammad able 1). After editing data analysis was carried 50 06 13 19 12 42 08 15 08 05 09 13 Frequency Patients less than 18 years of age. than 18 years of Patients less NSTEMI. the before documented arrhythmia Patients with episode of acute MI. history of MI. Patients with previous and . Patients with structural Exclusion Criteria: Exclusion 1. 2. 3. 4. 5. particular emphasis on the A detailed history with and general physical along with factors were noted examination was done. The patients thorough systemic first 48 hours of hospitalization for were observed for the with baseline ECG at admission detection of arrhythmia monitoring in the CCU.The pattern and continuous cardiac this period & their in-hospital of the arrhythmias during structured data outcome were recorded in predesigned collection sheet. Social Science out by using the Statistical Package for Continuous data (SPSS) version 20.0 windows software. data were were expressed as mean ± SD. Categorical Categorical data expressed as frequency and percentages. of less than were analyzed by Chi-Square test. P value was performed 0.05 was considered significant. The study Declaration according to the guidelines of the Helsinki committee and was approved by the University ethical Results: number of A total of 50 patients were studied. Maximum years (38%).The patients were from age group 51 to 60 from 29 to 70 mean age was 53.38 ± 10.22 years ranging years. Most of the patients were male 42(84%). of patients were female were wife. Highest number businessman 15(30%) (T followed by 76% of the patients had history of 38%, 64%, DM 40%, dyslipidemia 18% (T overweight 34% and family history of CAD able-I T AMI , 2018. ife ears ears Y Y W ears ears Socio-demographic variables Y Y Elevated Myocardial Elevated < 40 41 – 50 51 – 60 > 60 Male Businessman Female House Service Holder Retired Others , to December Acute ST Acute . Peri-infarction arrhythmias 3 oncentration. Whereas, cells in Whereas, cells oncentration. ariables total of 50 patients were included in Arrhythmias in Arrhythmias V A , BSMMU were initially approached and , BSMMU were initially approached .Before inclusion of the patient, purpose and .Before inclusion of the patient, purpose Patients 18 years of age or above. Patients with acute STEMI. consent. Patient who has given informed written otal the study with the patients procedure of the study was discussed from those who and informed written consent was taken agreed to participate in the study Inclusion Criteria: 1. 2. 3. Patients who admitted with acute STEMI in department of Patients who admitted with acute STEMI cardiology inclusion and included in this study considering the exclusion criteria. T Socio-Demographic the border zone between ischemic region and normal region and zone between ischemic the border and depolarized are only partially myocardium with larger amplitude. have action potentials consequently conduction take place in noticeably Slowing of impulse to arrhythmias. The cellular depressed areas leading method for reperfusion arrhythmias electrophysiological of different ions such as lactate emerge to include washout metabolic substance that have & potassium and toxic zone. accumulated in ischemic extracellular potassium c extracellular Age Groups The Pattern of Cardiac of Cardiac The Pattern are related with in-and out-hospital outcome of the are related with in-and available data of arrhythmias in patients, there is no This study was to document the patients of Bangladesh. in acute ST elevated MI within 48 pattern of arrhythmias outcome hours of hospitalization and their in-hospital among the population of Bangladesh. Methods: in Cardiology This observational study was conducted Department of BSMMU during July Sex Occupation 01 - Vol. 16, No. 1, JANUARY 2020 BSMMU H.J. 18 2.0 5.3 1.7 1.7 46.0 36.8 36.0 22.8 16.0 19.3 12.3 100.0 100.0 block ) were Percentage (%) Percentage (%) AV 4.0 18.0 82.0 40.0 60.0 64.0 36.0 76.0 24.0 38.0 62.0 34.0 10.0 52.0 100.0 able 7). ol. 16 No. 1, January 2020 No. 1, January ol. 16 V Percentage (%) Percentage 21 57 13 11 07 03 01 01 23 50 18 08 01 Frequency able-III able-IV T T Frequency subjects (n=57) Block achycardia AV T 09 41 20 30 32 18 38 12 19 31 17 05 26 02 50 Anterior Distribution of anatomical sites of MI Arrhythmia achycardia Frequency T Different types of arrhythmias documented in study entricular entricular Ectopic otal otal more commonin inferior wall myocardial infarction. This more commonin inferior wall myocardial of myocardial association between anatomical site is statistically infarction and types of cardiac arrhythmias very highly significant ( P=0.000) (T bradyarrhythmias (sinus bradycardia & bradyarrhythmias (sinus bradycardia & T Site of MI Inferior T Cardiac Sinus Anterior Sinus Bradycardia Antero-septal V Extensive V First Degree Complete Heart Block Atrial Ectopic able-II T acute Distribution of risk factors Distribution 12 hours of < , antero-septal& eight eight W eight ardiogenic shock & W c W Diabetic Hypertensive Smoker Present Absent Non Diabetic Non Hypertensive Non Smoker Absent Present Obese Under Over Normal able 5). blocks(first degree & complete heart able 4). inus bradycardia 22.8%,ventricular in anterior wall(anterior AV . able 3). common block 5.3%, complete heart block and atrial ectopic block 5.3%, complete heart block and able 6) achyarrhythmias (sinus & ventricular tachycardia) were otal Mellitus Hypertension Smoking Status Dyslipidaemia Family H/o CAD BMI Status extensive anterior) myocardial infarction, whereas 18 University Heart Journal Heart University hospitalization. Progressively arrhythmia occurrence decreased with time (T 72% patients had favorable outcome, followed by left ventricular failure 10%, T by anterior 46% of the patients had inferior MI followed anterior MI MI 36%, antero-septal MI16% and extensive 2% (T developed single Among the 50 patients 44 patients had and one arrhythmia, 5 developed double arrhythmias the first 48 hours patient developed triple arrhythmias in isolation was the of hospitalization. Sinus tachycardia in of patients most common arrhythmia observed in 36.8% followed by s degree tachycardia 19.3%, ventricular ectopic 12.3%,first AV & ventricular 1.7% each. Overall tachyarrhythmias (sinus patients and tachycardia) occurred in 56.1% bradyarrhythmias (sinus bradycardia & complete heart block) in 24.5%. Overall incidence of ventricular arrhythmias (ventricular tachycardia & ventricular ectopic) was 31.6% & Majority of arrhythmias (71.9%) occurred block ) was 7% (T lengthening of hospital stay 8% each and death 2% (T T more Risk Factors 01 - Vol. 16, No. 1, JANUARY 2020 BSMMU H.J. 19 , . . . 11 11 19 . In this Alam et al. Alam who found incidence of 7 10 . In the present According to the This is comparable . incidence of anterior where majority of 8 blocks almost double 5 who found ventricular 13 AV andNagabhushana et al., block 4% & 3% respectively found sinus tachycardia were and Sinha at el., 12 Mohammad Khurshadul Khurshadul Mohammad 9 AV 10 commonest arrhythmia was sinus entricular tachycardia was 19.3%, 5 block was 5.3%. who found sinus bradycardia 22% who found , H.M., 12 14 AV According to Rajhans et al., According to Rajhans where overall incidence of anterior wall 7 who observed 70% of cases were smoker who observed 70% , majority of the patients had anterior wall ( , majority of the patients had anterior wall . In the current study the second commonest , which is very close to findings of this study , which is very close 5 found 36% of cases were dyslipidaemic, which found 36% of cases were 5 , antero-septal& extensive anterior) myocardial and Sinha at el., 9 . In other studies by Maturaju, N.&Chandrashekhar blocks was 7%, compared to other studies like H.M., Hypertension (64%) was the second commonest Hypertension (64%) risk factors include DM (40%), after smoking . Other overweight (34%) and family history dyslipidemia (38%), of CAD (18%). wall myocardial infarction (58%). most common In this study sinus tachycardia was the arrhythmia observed in 36.8% cases. study by Patil, B.M., with the current tachycardia (40%), which is comparable study socioeconomic population like our country may contribute population like socioeconomic predominance. to this male patients that 76% of the analysis revealed Risk factors of comparable with study of smoking. This is had history Patil, B.M., diabetes were 66% and 54% hypertension and respectively who observed first degree the commonest arrhythmias seen in 30% & 31% cases the commonest arrhythmias seen in 30% respectively which is arrhythmia was sinus bradycardia 22.8%, et al., comparable with other studies by Nagabhushana and Rathod at al., &19% respectively .V of Maturaju, N. which is comparable with other studies &Chandrashekhar to study byRathod at al., ectopic in 17% patients.In this study overall incidence of AV Marangmei et al., arrhythmias occurred within 12 hours of hospitalization. Patil, B.M., the present study is comparable with In this study anterior the study of infarction (54%).This is comparable with Rajhans et al., which was 44%. was higher (56%) than inferior wall Similarly according to Mhatre et al. ventricular tachycardia 20% & 25% respectively study ventricular ectopic was 12.3%. This is in conformity with study by Chiwhane at el., In this study majority of arrhythmias (71.9%) occurred within 12 hours of hospitalization. Similar findings were also observed by Patil, B.M., i.e. 15%. This disparity in incidence may be attributed to the small sample size in the current study study first degree 4 ) otal 30% T 2.0 8.0 8.0 10.0 72.0 12.3 15.8 71.9 100.0 100.0 who found Patil at el., 6 Elevated Myocardial Elevated Percentage (%) Percentage (%) Percentage hythmias after hythmias r compared to AMI. ery Highly Significant Acute ST Acute 01 04 05 50 04 36 Bradyarrhythmia 07 09 57 41 Arrhythmia Frequency aximum number of patients in Frequency able-V 70% male m able-VI able-VII T = 0.000 (V T T &Chowdhury et al., 5 Arrhythmias in Arrhythmias 32 17 49 2309 01 16 24 25 . In-hospital outcomes hospitalization(n=57) observed 7 achyarrhythmia T ) = 19.348; P entricular Failure 2 who found the V 4 Appearance of Appearance Arrhythmia As females are given less attention and access to ime of appearance of individual ar of individual ime of appearance T Cardiac Association between anatomical sites of myocardial Association between anatomical sites ime of infarction and types of cardiac arrhythmias (n = 49) infarction and types of cardiac arrhythmias otal otal otal female. the facilities is limited particularly in low Death 24 – 48 Hours observed 77.50% male compared to 22.50% female & Rajhans et al., The Pattern of Cardiac of Cardiac The Pattern 12 – 24 Hours mean age of the patients 53.61 ± 12.43 years & 53 ± 10 years respectively Among the study subjects 42 (84%) were male and 8(16%) were female. Similar male preponderance was found in almost all studies on arrhythmia in Chi-square (X T T Outcome Cardiac < 12 Hours T T Acute Left Discussion: The age distribution in this present study ranged from 29 to 70 years with maximum number of patients in the age group 51 to 6o years. This is comparable with findings of Patil at el., this similar age group. The mean age in this present study was 53.38 ± 10.22 years, which is comparable with the studies of Patil, B.M., Lengthening of Hospital Stay Favorable Outcome Anterior Inferior 01 - Vol. 16, No. 1, JANUARY 2020 BSMMU H.J. 20 , , , M. ascular V Int J Adv International A., Braunwald, Acute , Bangabandhu Int J Adv Med, block and atrial block and Adnan S.D., Naheed, ‘Incidence of cardiac illiams, J., Rayner A. S., Somoons, M., ., Bonow W of the AV fe, , P , 2015;2(1):21-25. ed, Philadelphia, Saunders, , I.I., ol. 16 No. 1, January 2020 No. 1, January ol. 16 International Journal of , Dhaka. th , 101(15): 1182–1189. V , 2017;5(1):335-343. opean Journal of Epidemiology council ., Libby Heart Eur . &Patil, D.R. .M., Rajpal, D.R. & Shah, M.R. ‘A , F -elevation myocardial infarction after achyarrhythmias were more common achyarrhythmias ickramasinghe, K., T Alam, D.S., Fakir Alpert, J. S., Jaf s Heart Disease, 8 W ol.138, p. e4-34. International Journal of Medical Research VE) Study’, ., V , R., 38-40. , P .R., Khatana, P 2017;4(4):1144-49. ownsend, N., 2015,‘The epidemiology of cardiovascular asmin, I. et al. ‘The Bangladesh Risk of T T culation. Bhatnagar and disease in the UK 2014; Thygesen, K., Chaitman, B. R. and White, H. D., 2018, ‘2018 ESC/ACC/ Chaitman, B. R. and White, H. D., 2018, ‘2018 of MI’, AHA/WHF Fourth Universal Definition Cir E., Braunwald’ Antman, EM., 2008, ‘ST elevation myocardial infarction: Antman, EM., 2008, ‘ST elevation myocardial Management’, in Zipes, D.P pp. 1276-9. Patil, P infarction arrhythmias in patients with acute myocardial ’, during the first 48 hours of the onset of chest Med. infarction Patil, B.M. ‘Study on site of acute myocardial associated with arrhythmias and outcome’, Journal of Advances in Medicine Chowdhury Events (BRA A., 2016;1(4): 2015;30(7):577-587. Rajhans, R. & Narayanan, M. ‘Assessment of arrhythmias in 50 patients of ST : a 24 hour Holter study’, 2017;4(3):734-40. Mhatre, M.A., Sirur clinical study of arrhythmias associated with acute myocardial infarction and thrombolysis’, Research in Medical Sciences Maturaju, N. & Chandrashekhar, H.M. ‘The pattern of arrhythmias during first 48 hours of acute myocardial infarction’, Sheikh Mujib Medical University Reference: 1. in anterior wall myocardial infarction, whereas wall myocardial in anterior more common in inferior wall bradyarrhythmias were The incidence of mortality was 2%. myocardial infarction. Conflict of interest: of interest. Authors has no conflict Acknowledgements: a postgraduate thesis.The authors This research was all the patients who have participated would like to thank trial. Financial support was in this randomized controlled obtained from the research tachycardia, ventricular ectopic, ventricular ectopic, tachycardia, hours developed within 12 of arrhythmias ectopic. Most of hospitalization. 2. 3. 4. 5. 6. 7. 8. 9. 5 . AMI. In Advanced 14 who found acute 10 & CHB. VT This slight disparity in This slight disparity . . According to the study of Patil, B.M., and Marangmei et al. 12 where majority of arrhythmias (90%) of arrhythmias where majority , which is also well supported by study of , which is also well endency to go in shock was more common endency to go in shock 4 , BSMMU and small sample size may have T . . , antero-septal& extensive anterior) myocardial VT 10 Patil at el., Single centere study Sampling method was purposive, so there was risk of selectionbias. Result of the study might be influenced by relatively small ersamplesize. block ) were more common in inferior wall myocardial block ) were more common in inferior wall 1% patients respectively Conclusion: The commonest arrhythmias encountered were sinus tachycardia followed by sinus bradycardia, ventricular Though the findings in this study are mostly in agreement with previous studies on arrhythmias in acute STEMI, some findings were insignificant or in consistent. This may be due to the following limitations: • • • left ventricular failure and cardiogenic shock in 17% & left ventricular failure 1 In the current study tachyarrhythmias (sinus tachycardia In the current study tachyarrhythmias (sinus in anterior and ventricular tachycardia) were more common wall (anterior infarction, whereas bradyarrhythmias( sinusbradycardia& AV site of infarction. This association between anatomical arrhythmias is myocardial infarction and types of cardiac Similar statistically very highly significant (p=0.000). of myocardial association between anatomical site infarction and types of cardiac arrhythmias were observed by Rathod at al., In this study there was one death (2%) that occurred in a In this study there was one death (2%) within 12 hours patient with anterior MI who developed VT of hospitalization. in University quality of CCU & ICU management of STEMI Cardiac Center in this study contributed to lower in-hospital mortality Sinhaet al., In the current study 87.7% arrhythmias occurred within 24 occurred within study 87.7% arrhythmias In the current study is in conformity with This hours of hospitalization. by the overall incidence of mortality was 15%, where majority the overall incidence of mortality was 15%, hospitalization & of mortality occurred within 24 hours of most of the deaths occurred in the present study 10% patients developed acute left the present study 8% cardiogenic shock which are ventricular failure and of Sinhaet al., comparable with study occurred during the first 24 hours hospitalization. the first 24 hours occurred during favorable outcome, Similar outcome 72% of patients had all studies on arrhythmia in was found in almost incidence can be attributed to the small sample size in the incidence can be attributed present study in CHB and 20 University Heart Journal Heart University 01 - Vol. 16, No. 1, JANUARY 2020 BSMMU H.J. 21 , 21 Alam et al. Alam Jounal of Medical Journal of The Association of Journal of The Mohammad Khurshadul Khurshadul Mohammad , 2018;66:54-58. International Archives of Integrated Medicine Archives of Integrated International A. & Pradeep. ‘Study of Rhythm Disturbances in ‘Study of Rhythm A. & Pradeep. , 2014;28(3):175-78. infarction ’, infarction Society 2014; 1(4):32-41. Chiwhane, Infarction’, Acute Myocardial Physician of Devi, K.B., Raut, S.S., Chongtham, Marangmei, L., Singh, S.K., of cardiac arrhythmia in acute D.S. & Singh, K.B. ‘Profile within 48 hours of admission: myocardial infarction patients at RIMS Imphala’, A hospital based study 13. 14. J. Evid. A. ‘Study of Elevated Myocardial Elevated Acute Myocardial A. ‘Incidence of various A. ‘Incidence Acute ST Acute Arrhythmias in . 2018;5(39):2772-77. ., Rathod, G.B. & Parikh, ., Rathod, G.B. & Parikh, Arrhythmias in Arrhythmias , P Agrawal, D. & Jain, Agrawal, D. International Journal of Medical Research and International Journal of ., , 2015;3(7):682-88. irupakshappa. ‘Study of irupakshappa. ‘Study of arrhythmias and its prognosis in different type of ST segment and its prognosis in different arrhythmias first 72 hours’, infarction in elevation myocardial Healthc Based Med. M. G.K., Ranganatha, S., Ranjithkumar, Nagabhushana, &V various cardiac arrhythmias in patients of acute myocardial various cardiac arrhythmias Sinha, R.P Infarction ’, Review Rathod,S., Parmar 11. 10. 12. The Pattern of Cardiac of Cardiac The Pattern