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Background Myocardial infarction (MI) with non-obstructive coronary arteries presenting with ST-segment elevation can be challenging. Understanding the cardiac and non-cardiac causes aid in identifying the underlying diagnosis and deciding on the management. Neurological insult resulting in a mismatch of oxygen supply or demand to cardiomyocytes can lead to type 2 MI. Acute brain injury, such as intracranial haemorrhage, can induce cardiac dysfunction secondary to brain–heart interaction via hypothalamic–pituitary–adrenal axis and catecholamine surge. Case summary A 50-year-old Caucasian male who vaped cannabis presented with epileptic seizures. A Glasgow coma scale of 7/15 necessitated urgent intubation. Electrocardiogram showed ST-segment elevation in inferior leads. Computed tomography of the head suggested intracerebral haemorrhage. He was stabilized in the intensive care unit (ICU). Subsequent imaging confirmed anterior communicating cerebral artery aneurysm and haematoma. Echocardiogram showed severe left ventricular dysfunction and hypokinesia in the left circumflex (LCx) territory. After step down from ICU, cardiac magnetic resonance imaging revealed transmural MI and myocardial oedema at LCx territory. Coronary angiogram was normal. Patient was treated with Levetiracetam and heart failure regimen. A cardiac defibrillator was implanted for secondary prevention and he was scheduled for elective neurosurgical intervention. A follow-up outpatient echocardiogram was normal. Discussion Myocardial infarction with non-obstructive coronary arteries is uncommon. Though the majority is due to either plaque disruption or myocarditis, non-cardiac causes, such as acute neurological insults and substance use, should be considered. Scrutinizing the clinical presentation and using a meticulous approach with appropriate investigations are required to reach the correct diagnosis and appropriate management.

Background Ventricular tachycardia (VT) is often misdiagnosed as supraventricular tachycardia with aberrancy. Twelve-lead electrocardiogram remains a key diagnostic tool to differentiate them while providing insights to aid localization of VT. The use of Valsalva manoeuvre (VM) in terminating VT is not conventionally recommended due to lack of robust evidence of its effectiveness and poor understanding of its mechanism in terminating VT. Case summary A 74-year-old man with history of ischaemic heart disease was admitted with broad complex tachycardia. VT-1 was diagnosed following failed tachycardia termination by adenosine. Haemodynamic compromise necessitated synchronized cardioversion with successful reversion. However, a different VT-2 occurred after cardioversion. VM led to successful termination of VT-2. Subsequently, recurrent episodes of VT-2 occurred with consistent termination by VM. Transthoracic echocardiogram, cardiac magnetic resonance imaging, and a coronary angiogram were performed. Findings suggested that these are likely scar-related VT. VT-1 originated from an anteroseptal scar, whilst VT-2, responsive to VM, likely originated from the Purkinje fibres. Patient remained eurhythmic after Day 1 following amiodarone and beta-blocker initiation. An implantable cardioverter-defibrillator was implanted prior to discharge. Discussion VM is one of the vagal manoeuvres which are commonly used as initial management of supraventricular tachycardia. Its role in management of VT is obscure. Anecdotal case series recorded its successful use for managing particular VT. Exact mechanism remains elusive although postulated to involve change in cardiac size during strain and release of acetylcholine.

Funding Acknowledgements No Funding Background Dobutamine stress echocardiography (DSE) has been used as a safe stress modality for assessing myocardial ischemia. Acute myocardial infarction is one of the rare complications of DSE. In this report, we will discuss a case of a 60 year old lady who developed anterior ST-segment elevation myocardial infarction(STEMI) after a negative DSE. Case report 60 year old lady with a background of PCI to LAD in 2009 presented with angina , a repeat angiogram showed mild to moderate in stent restenosis (ISR) within the LAD but instant wave-free ratio (IFR ) was 0.94 , Fractional Flow Reserve(FFR) 0.84 and negative IVUS studies. Despite that, the patient continued to have chest pain with effort and therefore a DSE was requested. The patient was stressed with intravenous Dobutamine with a maximum dose of 40mcg/kg/min plus 600mcg of atropine. There was no evidence of ischemia. The Patient developed chest pain 15 minutes later. ECG was done and showed ST elevation in anterior leads. Urgent angiography was undertaken which showed acute thrombotic occlusion in the mid LAD with TIMI 0 flow (within the area where ISR had been seen previously) (fig1) . Percutaneous intervention was undertaken and TIMI III flow was restored. Discussion Acute STEMI within a few hours after normal DSE is very rare with an incidence of 0.02% (range 0.00% to 0.10%) Plaque destabilisation and rupture are the possible underlying mechanisms behind coronary occlusion. Interestingly, most of the cases happen within 30 mins after the test. The activation of sympathetic nervous system leads to increased catecholamines, blood viscosity, arterial pressure and heart rate, which are accompanied by detectable increase in platelet aggregation and decrease in fibrinolytic activity that both tend to favour thrombosis. This could lead to propagation of mural thrombus overlying a small plaque erosion that might otherwise have been harmless. Another interesting learning point is the correlation between chronotropic incompetence (CI) and myocardial ischaemia. Low basal heart rate is one of the predictors of CI (baseline average heart rate of 60 bpm in our case, and she managed to achieve only 81% of target Heart rate (THR) despite the maximum dose of dobutamine and atropine). Many studies examined the significance of CI. Impaired Chronotropic response is associated with an increased risk of mortality and MI. Possible explanation is that patients with CI fail to demonstrate or underestimate extent of ischemia. With the experience of our case and similar cases from the literature, we suggest symptoms of chest pain should be seriously attended even after a normal DSE. The risk of life-threatening complication should be informed to patients and enough time should be taken for observation post stress test. More research is needed to clarify the role of DSE in CI patients on account of its potential normal result with submaximal THR and risk of life threatening cardiac event. Abstract P245 Figure. Coronary Angiogram fig1

The aim of the study was to evaluate the pediatric emergency department (PED) in a main teaching hospital. Retrospective review of all children presented to PED at King Abdulaziz University Hospital from September to November 2014 was performed. We classified priority into the following 5 stages: 1, need resuscitation; 2, emergent; 3, urgent; 4, less urgent; and 5, nonurgent. A total of 2567 children (58.9% boys) attended PED for 3 months. Toddler age group was the highest. Respiratory complaints were the commonest (36%), followed by gastrointestinal complaints (20%). The majority were classified as priority 3 (52.3%) and priority 4 (30.7%). The admission rate was 12.3% and the mean (range) length of stay (LOS) was 5.85 (0.2-25) hours. Saudi nationals were less likely to wait for 5 hours or longer, less likely to be admitted, but more likely to leave PED without being evaluated. There was a negative correlation between higher priorities and time from triage to PED. There was a positive correlation between the higher priorities and LOS. Most children who were seen in PED were priority 3 and therefore needed to be seen. However, a considerable percentage of priority 4 and 5 could have been seen in ambulatory clinics. Most lower priorities were Saudi nationals who were most likely to leave without being seen. Prolonged LOS, overcrowding, and high percentage of admission are the main challenges

Background Transient ischemic dilatation (TID) of the left ventricle is a potential marker of high risk obstructive coronary artery disease on stress myocardial perfusion imaging (MPI). There is, however, interstudy variation in the diagnostic performance of TID for identification of severe and extensive coronary disease anatomy, and varied prognostic implications in the published literature. Methods We searched MEDLINE, EMBASE, and COCHRANE databases for studies where TID was compared with invasive or CT coronary angiography for evaluation of coronary artery stenosis. Two reviewers independently evaluated and abstracted data from each study. A bivariate random effects model was used to derive pooled sensitivities and specificities, in order to account for correlation between TID in MPI and anatomic disease severity. Results A total of 525 articles were reviewed, of which 51 met inclusion criteria. Thirty-one studies contributed to the analysis, representing a total of 2037 patients in the diagnostic meta-analysis and 9003 patients in the review of prognosis. The ratio above which TID was deemed present ranged from 1.13 to 1.38. Pooled sensitivity was 44% (95% CI 30%-60%) and specificity was 88% (95% CI 83%-92%) for the detection of extensive or severe anatomic coronary artery disease. Analysis of outcome data demonstrated increased cardiac event rates in patients with TID and an abnormal MPI. In otherwise normal perfusion, TID is an indicator of poor prognosis in patients with diabetes and/or a history of coronary disease. Conclusions Among patients undergoing MPI, the presence of TID is specific for the detection of extensive or severe coronary artery disease. Electronic supplementary material The online version of this article (doi:10.1007/s12350-017-1040-7) contains supplementary material, which is available to authorized users.

عندما بدأت الحفریات الأثریة فی فلسطین کان الأثریون التوراتیون یفسرون المکتشفاتالأثریة وفقا للمعرفة المستمدة من الکتاب المقدس وکتابات جوزیفوس فیلافی وتطبیقهاعلى المواقع الأثریة فی فلسطین، وکان من أهدافهم إیجاد الصلة بین فلسطینوالروایات التوراتیة، ومحاولة إیضاح ما جاء فی التوراة من خلال المکتشفات الأثری ة.وسنتناول فی هذه الورقة البحثیة إشکالیة تلک المصادر، وسنتطرق إلى الحرمالإبراهیمی فی مدینة الخلیل کنموذج حی لتهوید هذا المعلم الأثری، وستشمل الدراسةالحدیث عن نشأة الحرم منذ البدایات الأولى وحتى الوقت الحاضر، وسنناقشالإدعاءات الإسرائیلیة فی قضیة تهوید هذا الموقع الأثری من قبل السلطاتالإسرائیلیة.♦