Faculty of Medicine

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QT PROLONGATION AND VENTRICULAR ARRHYTHMIA IN METHADONE USER PRESENTING WITH SEVERE HYPOKALEMIA
(Institute of Knowledge Management, 2022-12-16)
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Mario Jovanoski
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Elena Grueva Nastevska
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Hajber Taravari
Introduction: Severe hypokalemia is a serious, life-threatening condition that can lead to muscle weakness, paralysis, fatigue and different types of cardiac rhythm disturbances including QT prolongation and furthermore lethal arrhythmias. On the other hand, prolongation of the QT interval can be exacerbated in methadone users who receive high doses of the drug. Methadone is a drug that is mostly used as a replacement therapy for opiates, and it is known that it can interfere in the cardiac action potential cycle. Case report: We present a case of 39y/old male who visited our clinic brought by an ambulance due to palpitations, fatigue and muscle weakness in the arms and legs. The patients’ symptoms aggravated in the past 2 weeks when he lost the ability to do the everyday activities and finally to walk, because of extreme weakness of the extremities. On the day of the admission, he experienced a syncope for the first time in his life. His initial ECG revealed sinus rhythm with prolonged QT interval and polymorphic ventricular extrasystoles, which evolved in nonsustained ventricular tachycardia. His initial laboratory finding showed severe hypokalemia, and his previous medical history revealed use of methadone replacement therapy for approximately 20 years. The patient was closely monitored in the intensive care unit, and potassium replacement therapy was immediately initiated by the use of intravenous potassium infusion. Toxicologist and nephrologist were also included in the treatment in order to reduce the methadone dose and to exclude a secondary cause of severe hypokalemia. The patient’s condition improved after 9 days, when the potassium level was in normal range and the rhythm disturbances completely resolved. Conclusion: This case highlights the importance of timely recognition of severe electrolytic abnormalities that can lead to dangerous arrhythmias. Careful replacement with 24h monitoring and frequent laboratory analysis is required until the potassium level reaches the target range and until the heart rhythm stabilizes. This case also reveals the importance of the significance of the follow up of every drug addict that receives methadone replacement therapy on a primary level, in order to exclude QT prolongation. In these cases, the dose of methadone should be reduced or replaced with another medication, in order to prevent potentially lethal arrhythmias.
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Papillary muscle rupture as a complication of acute myocardial infarction
(2021-02)
Elena Grueva Nastevska
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Zivko Petrovski
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Vladislava Karanfilova Grueva
Papillary muscle rupture is one of the rarest complications, with incidence of 1-5% 1 in patients with acute myocardial infarction (AMI), and usually happens 5-7 days after the initial event. This complication has a high mortality of 50% in the first 24hours, often leading to decompensation and pulmonary edema. The acute rupture and the severe dysfunction of the mitral leaflet finally result in a severe mitral regurgitation and in most of the cases leads to cardiogenic shock and death. The competence of the mitral valve is maintained by the actions of the anterolateral and posteromedial papillary muscles, but this mechanical complication occurs dominantly on the posteromedial muscle, with greater incidence of more than ten times compared to the anterolateral one. Transthoracic echocardiography (TTE) is a diagnostic tool with 65-85% sensitivity in visualizing structural abnormalities of the heart and is the most available and fast method in diagnostic this mechanical complication. Beside the structural abnormalities that can be detected, echocardiography can provide precise assessment of the regurgitant jet through the color doppler and continuous doppler ultrasound. It is very important to follow the guidelines from both the European and the American heart associations that recommend urgent echocardiography in patients that become hemodynamically unstable during or after acute myocardial infarction. However, the diagnosis of papillary muscle rupture is not always easy because patients are often elderly and frequently diagnosed with a particularly severe clinical presentation, or hemodynamic instability, which are all factors associated with high operative mortality. The only definite treatment for this condition is the cardiosurgical treatment, which in the last 10 years has an improved success and reduced mortality2. Intra-aortic balloon counter-pulsation may be necessary for severely unstable patients, or other mechanical circulatory support devices. Mitral valve repair can be done in patients who have a partial papillary muscle rupture, in case of detachment of the main insertion of a head which still remains fixed to the remnant papillary muscle via muscular bridges, unlike the complete rupture (or rupture of the main head) where mitral valve replacement is the main surgical therapy because complete post-MI papillary muscle rupture generally requires MVR due to the friable infarcted tissue. We describe a clinical case of a patient with severe mitral regurgitation after acute myocardial infarction and discuss the management for such patients in the current era
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Pulmonary embolism and COVID-19
(2020-10-03)
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Elena Grueva Nastevska
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Bushljetikj Oliver
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Since December 2019, the severe acute respiratory syndrome coronavirus (SARS-CoV-2) outbreak has reached pandemic proportion and has become a public health crisis of unprecedented magnitude. Although coronavirus disease-2019(COVID-19) primarily targets the respiratory system, the cardiovascular system can also be affected in a significant percentage among the patients. Cardiac injuries appear to be a prominent feature of the COVID-19 infection as they occur in 20-30% of the hospitalized patients and are often responsible for deadly outcome. Pulmonary vascular complications such as pulmonary embolism are frequently present, with higher prevalence in COVID-19 than usually encountered in critically ill patients who do not suffer from infection. Moreover, there is a rising evidence that traditional risk factors for PE are not commonly encountered among the patients with COVID-19 infection but rather independent biological and clinical findings, with the inflammation as a main contributor of thromboembolism. The endothelial dysfunction, abnormal hemostasis, severe lung inflammation and disseminated intravascular coagulation play a central role in the predisposition to venous thromboembolic events. Integrated approach of heart and lung multimodality imaging has a crucial role in different clinical scenarios and is of great importance in the diagnosis, management, risk stratification and prognosis of patients with COVID-19, providing a base for further clinical decision making. Routine history, physical examination, laboratory testing, electrocardiography, and plain x-ray imaging may offer the required information in some of the cases but the overlap between COVID-19 and typical cardiovascular diagnoses such as acute myocardial infarction, heart failure and acute pulmonary embolism, mandate advanced imaging techniques to assist in differential diagnosis and treatment. Baseline CT is the most used tool to confirm diagnosis and to give information about the disease extent and severity, but it is also a reference for subsequent imaging follow-up. According to some studies, the sensitivity of chest CT for COVID-19 was 97%. In the clinical scenario of a patient with COVID-19, who has just undergone CT of the lungs but the findings cannot explain the severity of respiratory failure, CT pulmonary angiography should be considered to exclude/confirm pulmonary embolism. We hereby report a case of 72y/old patient who was admitted at our clinic ( which is not a Covid-center) with severe chest pain and signs of hemodynamic instability. His ECG revealed a heart rate of 125/min , right axis deviation and S1Q3T3 pattern. Bedside echo showed severely dilated RV with reduced systolic function and features of pulmonary hypertension. His laboratory findings were consistent with leukocytosis with lymphopenia, elevated CRP, extremely elevated D-dimers and high troponin. Anticoagulation was immediately initiated by using UFH. The patient was referred to CT angiography and it revealed bilateral filling defects in the main pulmonary arteries. Bilateral peripheral ground-glass opacities and small areas of consolidation were also present which raised the suspicion of COVID-19 infection. The swab for SAS-COV-2 was positive. The patient underwent systemic fibrinolysis with full-dose alteplase, with rapid hemodynamic and respiratory success. His further treatment included therapeutic dose of LMWH, parenteral antibiotic and gastroprotective treatment. The repeated echocardiographic exam showed a clear improvement of the hemodynamics of the RV, a reduction of RV dilatation and of pulmonary pressures and reduction of vena cava diameter. The patient was transferred for further treatment at the COVID department and was discharged 2 weeks later after his full recovery and was advised to continue with oral anticoagulant therapy and to use Rivaroxaban 15mg twice daily for 3 weeks and afterwards 20mg once daily. Conclusion: PTE is frequently observed among COVID-19 patients and this complication can happen in the absence of major predisposing factors. COVID-19 pneumonia seems to confirm the impact of severe respiratory infection as a precipitant factor for acute venous thrombo-embolism and the causal relationship. Multimodality imaging in COVID-19 patients with suspected cardiac involvement by using POCUS, chest CT and pulmonary angiography is of crucial importance for rapid differential diagnosis and treatment especially in patients with hemodynamic instability. The use of systemic thrombolysis in haemodynamically unstable patients is the first and more appropriate therapeutic strategy, considering the current guidelines recommendations for management of acute PE. However, thrombocytopenia occurs in a non-neglectable proportion of patients with COVID-19 infection and is an independent predictor of increased mortality in these patients. The reperfusion strategy of COVID-19 patients must be tailored according to the severity of thrombocytopenia where catheter directed treatment might be potential first line therapeutic approach.
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Fulminant myocarditis in COVID-19 - Case report
(Macedonian Pharmaceutical Association = Македонско фармацевтско друштво, 2021-01)
Elena Grueva Nastevska
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Elma Kandic
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Vladislav Gruev
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