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ABSTRACT Background: Non-ST-Elevation ACS (NSTE-ACS) is a part of ACS which require some special attentions. Multivessel coronary disease (MVD) is common in patients with NSTE-ACS and associated with difficulties in determining the main target of revascularization. ECG is the first-line diagnostic tool in the assessment of patients with suspected ACS. However, the utility of the ECG in localizing coronary culprit lesions in NSTE-ACS is not well established. This study was conducted to evaluate whether the pattern of the ischemic signs in ECG can be used to identify the coronary culprit vessel in patients with NSTE-ACS. Methods: This is a single-centered cross-sectional study using secondary data. The data of all 101 patients with NSTE-ACS who were planned for revascularization procedure between January 2021 and December 2021 were collected from medical record. ECG with ischemic signs were classified to three locations of suspected coronary vessel with culprit lesions and it will be compared to its corresponding angiographic data. The accuracy data will be presented including both sensitivity and specificity. Results: This study involved 75 men (74.3%) and 26 women (25.7%) with mean age 61.2±9.1 years old. There were 72 patients presented with ischemic signs form ECG with identifiable culprit vessel to be suspected. The sensitivity and specificity of ischemic signs ECG in localizing culprit vessels from angiography were 37.0% and 85.5% in LAD distribution, 38.1% and 81.3% in LCX distribution, and 41.1% and 85.1% in RCA distribution, respectively. Conclusion: Overall ischemic signs in ECG gave impression of modest accuracy with conspicuous key points that ECG distribution have high specificity in detecting culprit vessels but with low sensitivity. Thus, ischemic signs from initial ECG can be used to detect culprit vessels in NSTE-ACS patients. Keyword: Culprit Lesion, ECG, NSTEMI, UAP, PCI

Background COVID-19 became a main health problem and causes heavy impact, especially for healthcare system. Managing ST-Segment Elevation Myocardial Infarction (STEMI) patients before COVID-19 pandemic was already challenging enough for Healthcare Professionals (HCP) to pursue time-sensitive treatment. After COVID-19 pandemic, the time-sensitive treatment of pursuing door-to-balloon (DTB) time put a lot more burden to HCP. In this study, We sought to analyze how a change in protocol of PPCI in STEMI patients before and during the pandemic influence the performance of DTB in the hospital. Methods This is a single-centered retrospective observational study among STEMI patients which was treated by PPCI. Secondary data from the medical record were collected consecutively from April 2018 to January 2022 (46 months). We compared DTB performances before and during the pandemic. Result During 46 months period, the total population of this research was 880 patients. There were total 358 patients underwent PPCI before the pandemic and 522 patients after the pandemic. Modified protocol with the addition step to prevent the spread of COVID-19 had been implemented since April 2020. DTB increased significantly during the pandemic (90 (70-124) minutes vs 97 (76-135) minutes, p 0.002). The proportion of the patients who achieved DTB under 90 min was also significantly decreasing (56.4% vs 47.9%, p 0.0013). Conclusion It is necessary for PPCI center to modify PPCI workflow during the pandemic. A decent workflow should consider practicality and simplicity without compromising HCP and patient safety. Implementing modified PPCI workflow during the pandemic significantly increased DTB time but it is still within the limit of being reasonable and acceptable for the benefit of the patients.

Rheumatic heart disease (RHD) remains a significant cardiovascular burden in the world even though it is no longer common in affluent countries. Centuries of history surrounding this disease provide us with a thorough understanding of its pathophysiology. Infections in the throat, skin, or mucosa are the gateway for Group A Streptococcus (GAS) to penetrate our immune system. A significant inflammatory response to the heart is caused by an immunologic cascade triggered by GAS antigen cross-reactivity. This exaggerated immune response is primarily responsible for cardiac dysfunction. Recurrent inflammatory processes damage all layers of the heart, including the endocardium, myocardium, and pericardium. A vicious immunological cycle involving inflammatory mediators, angiotensin II, and TGF-β promotes extracellular matrix remodeling, resulting in myocardial fibrosis. Myocardial fibrosis appears to be a prevalent occurrence in patients with RHD. The presence of myocardial fibrosis, which causes left ventricular dysfunction in RHD, might be utilized to determine options for treatment and might also be used to predict the outcome of interventions in patients with RHD. This emerging concept of myocardial fibrosis needs to be explored comprehensively in order to be optimally utilized in the treatment of RHD.

When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT Background: Particular ischemic process that portrayed in Electrocardiogram (ECG) changes bear similar depiction to different conditions, one of them is hypokalemia. On the other hand, Treadmill Test (TMT) has been used for decades for risk stratifying and diagnosing coronary artery disease as a non-invasive, safe and affordable screening test. However, using ECG changes as interpretation, TMT could have incidence of false positive results reported in various conditions, one of which is hypokalemia. The aim is to report a case of positive ischemic response resemblance in TMT of patient with severe hypokalemia. Case Illustration: A-43-years-old female with history of unstable angina pectoris with risk factors of diabetes mellitus and hypertension underwent several examinations. Computed Tomography Coronary Angiography (CTCA) showed a 60% stenosis lesion in Left Anterior Descending (LAD) coronary artery. Within 3 minutes of TMT the ECG showed ST-segment depression in lead II, III, aVF, V1-V6 and prominent elevation in lead aVR. Fear of left main coronary artery occlusion, the test was terminated and the patient was immediately planned for urgent Percutaneous Coronary Intervention (PCI). The result indicated non-significant coronary lesion. Potassium concentration of 1.87 mmol per liter and troponin levels were normal. Unbeknownst before, the patient had multiple episodes of vomiting for a whole day and felt dehydrated prior to the TMT. Patient then treated for potassium implementation and discharged uneventfully. Conclusion: Hypokalemia could induce widespread ST-Segment depression or ST-Segment elevation in right limb lead. Peculiarly in context of stress testing or accompanied with chest pain, it is difficult to differentiate ECG changes in hypokalemia with true myocardial ischemia. Hypokalemia should be considered when TMT result is not concordance with true myocardial ischemia.

Background: Patients with rheumatic mitral stenosis (MS) experience changes in left ventricular (LV) dimensions after mitral valve surgery. We sought to investigate changes in LV dimensional parameters after mitral valve surgery and find out whether the same changes occurred in different extents of myocardial fibrosis. Methods: This prospective observational study comprised 43 patients with rheumatic MS planned for mitral valve surgery between October 2017 and April 2018 in National Cardiovascular Center Harapan Kita (NCCHK) Jakarta. All the patients underwent cardiac magnetic resonance imaging based on the late gadolinium enhancement (LGE) protocol for myocardial fibrosis assessment prior to surgery. The patients were classified according to the estimated fibrosis volume considered to influence hemodynamic performance (myocardial fibrosis