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PP-031: AN UNUSUAL CLINICAL STATE: ATRIAL FIBRILLATION DUE TO MAD-HONEY INTOXICATION
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Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
RCA is one of the probable underlying mechanisms. Another and more common underlying mechanism is wrapped LAD. However, acute pericarditis/myocarditis, early repolarization, presence of collateral circulation or coronary abnormalities make it difficult to identify the culprit lesion. In the present case, ST segment elevation in leads II, III, aVF (III > II) and V5–6 (>2 mm) and ST depression in leads aVL and V1–3 mimic ECG findings of occlusion of distal segment of a dominant RCA. However, distal portion of a type III LAD was occluded. Major ECG findings of distal LAD occlusions are ST segment elevation in leads I, V1–6, II, III and aVF (II > III). The most likely mechanism of the findings in our case might be the occlusion of the two branches of distal LAD which perfuse the inferior and lateral walls of the left ventricle.
patient was hospitalized to the coronary care unit. Blood cultures were drawn. Empirical antibiotherapy was started. Emergency surgery was planned, but cardiovascular collapse and sudden death occurred just before the insertion of an intraaortic balloon pump. Corynebacterium striatum was isolated in the blood culture. Although, cardiogenic shock was the probable cause of death, it was not possible to determine the exact etiology as the relatives refused an autopsy. Conclusions: VSR is a rare but fatal complication of MI. Infective endocarditis might occur in the cases with late diagnosis. Early diagnosis and emergency surgery might be crucial in the success of treatment. Friday, 25 March 2011
08:30–10:00
Arrhythmias and Antiarrhythmic Therapy: New Horizons
Figure 1. 12-lead ECG shows ST segment elevation in leads II, III, aVF and V3–6 and ST depression in leads aVL, V1–2.
PP-030 ASSOCIATION OF VENTRICULAR SEPTAL RUPTURE, INFECTIVE ENDOCARDITIS AND INTRACARDIAC THROMBUS FOLLOWING MYOCARDIAL INFARCTION: FIRST CASE REPORT M. Tekinalp, U. Dogan, C. Duman, A. Soylu. Department of Cardiology, Selcuk University, Meram School of Medicine, Konya, Turkey Objective: Mechanical complications of myocardial infarction (MI) are fatal, especially if they are not diagnosed and treated expeditiously. Herein, we describe for the first time the association of ventricular septal rupture (VSR), intracardiac thrombus and infective endocarditis in a patient with a recent history of MI. Methods: A 57-year-old man who had had an acute MI 46 days ago presented with ten-day history of shortness of breath, fever and fatigue. It was reported that the patient had refused coronary angiography, received fibrinolytic therapy within ten hours of chest pain and ST segment resolution was achieved. Echocardiography at discharge showed poor left ventricular function (LVEF: 25%) without valvular regurgitation or pericardial effusion. Body temperature was 38.5 oC at the time of presentation; heart rate and blood pressure were 118/min and 100/60 mmHg, respectively. Cardiac examination revealed a 3/6 pansystolic murmur best heard in the mesocardiac region. A complete blood count revealed leukocytosis [WBC: 18250/mL (normal values= 4000–10000/mL)] and thrombocytopenia [Platelet: 21100/mL (normal values= 150000–400000/mL)]. The blood levels of urea nitrogen [150 mg/dL (normal value = 17–43 mg/dL)], creatinine [2.5 mg/dL (normal value= 0.7–1.2 mg/dL)], sensitive CRP [97.9 mg/L (normal value= 0–10 mg/dL)], procalcitonin [34.13 ng/ml (normal value <0.1 ng/ml)] and troponin-I [0.45 ng/mL (normal values = 0.0–0.04 ng/mL)] were increased. RBBB and pathological Q waves in the inferior leads were present in the ECG. Transthoracic echocardiography revealed a rupture of the muscular interventricular septum and a mobile mass which was attached to the defect and was considered to be a vegetation. Furthermore, a mobile thrombus in the left ventricular apical region was notified. The right side of the heart was dilated. The pulmonary to systemic blood flow ratio was 1.98. Transesophageal echocardiography confirmed these findings and the length of the defect was measured as 2.2 cm. The
PP-031 AN UNUSUAL CLINICAL STATE: ATRIAL FIBRILLATION DUE TO MAD-HONEY INTOXICATION M.E. Memetoglu1 , A. Kalkan2 , S. Kurtcan3 , V. Kara4 , G. Ertas5 , A.S. Cetinkaya5 , S. Talay6 , N. Tutar7 , S. Yesilkaya7 . 1 Department of Cardiovascular Surgery, Gumushane State Hospital, Gumushane, Turkey; 2 Department of Emergency Medicine, Karadeniz Technical University, Trabzon, Turkey; 3 Department of Radiology, Gumushane State Hospital, Gumushane, Turkey; 4 Department of Chest Surgery, Gumushane State Hospital, Gumushane, Turkey; 5 Department of Cardiology, Gumushane State Hospital, Gumushane, Turkey; 6 Department of Cardiovascular Surgery, Erzurum Training and Research Hospital, Erzurum, Turkey; 7 Department of Chest Diseases, Gumushane State Hospital, Gumushane, Turkey Objective: Although cases of acute mad honey intoxication have been reported earlier, life-threatening atrial fibrillation with slow ventricular rate due to mad honey intoxication is a rare seen clinical state. We report a case of 53-year-old man presented with severe bradycardia and his electrocardiographic manifestation following ingestion of mad honey. Methods: In March 2010, a 53-year-old man was admitted to our emergency department with sudden development of nausea, vomitting, general weakness. Upon history-taking from patient’s relatives, we learned that the symptoms had began within 2 hours of eating a few spoonfuls of honey, which was known as “madhoney”, Turkish honey from the Black Sea coast of Turkey. Surface electrocardiography revealed atrial fibrillation, with a ventricular rate of 30 beats/min (Fig. 1).
Figure 1. Surface electrocardiography revealed atrial fibrillation, with a ventricular rate of 30 beats/min.
Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
Results: The patient was given 0.5 mg of atropine, and parenteral fluid was administered. The patient’s heart rate and blood pressure returned to normal limits within twenty minutes; sinus rhythm was restored rapidly. Intravenous sodium chloride infusion (100 cc/h) was continued for 24 hours. He was monitored for 24 hours, during monitoring no type of arhythm or bradycardia was seen. Transthoracic echocardiography showed normal left ventricular systolic function without any regional wall motion abnormality. His symptoms improved with conservative management, which comprised bed rest and intravenous fluid therapy and as the clinical condition had stabilized, he was discharged from hospital on the next day with 97 beats/min hearth rate and normal sinus rhytm. Conclusions: “Mad honey intoxication” may occur after ingestion of grayanotoxin contaminated honey. Mad honey is used in the Black Sea Region as an alternative medicine for the treatment of gastric pains, bowel disorders, hypertension, and it is believed to be a sexual stimulant. Although the Black Sea Honey (Mad Honey) toxicity is rare, it’s clinical manifestations and cardiac rhythm problems may occur in various states including atrial fibrillation with severe bradycardia. Generally, supportive care is sufficient as a treatment for mad-honey intoxication. PP-032 EVALUATION OF CARDIAC AUTONOMIC FUNCTIONS BY HEART RATE VARIABILITY, QT DISPERSION AND HEART RATE RECOVERY INDEX IN PATIENTS WITH SUBCLINICAL HYPOTHYROIDISM U. Canpolat, H. Yorgun, H. Sunman, S. Okutucu, B. Evranos, G. Fatihoglu, L. Sahiner, E.B. Kaya, K. Aytemir, L. Tokgozoglu, G. Kabakci, A. Oto. Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: The impact of subclinical hypothyroidism (SH) on cardiovascular autonomic function and ventricular repolarization has not been yet clarified. The aim of our study was to evaluate the QT dispersion (index of heterogeneity of repolarization), heart rate variability (HRV), heart rate recovery index (HHRI), in SH patients. Methods: The study included 38 patients (21 women and 17 men; mean age 51.3±11.7 years) with SH, as detected by elevated serum TSH levels (>4.5 mIU/l; range, 0.27–4.2) and normal free thyroid hormones (FT3 and FT4) and 30 euthyroid control subjects. Patients with metabolic, cardiac, neurological disease or any other systemic disease that could affect autonomic activity were excluded from the study. Patients with SH and control subjects underwent a complete history, physical examination, 12-lead ECG, 24-h ambulatory ECG monitoring and Treadmill exercise test. HRR indices were calculated by subtracting first, second and third minute HR from the maximal HR and designated as HRR1, HRR2 and HRR3. To demonstrate the effect of treatment with L-thyroxine on all cardiac autonomic functions, 20 patients with SH were randomly assigned to Lthyroxine therapy. All the subjects were evaluated at enrollment and 6 months later. Results: Patients with SH revealed higher QT dispersion and lower HRV measures than healthy controls (p < 0.001 for all). In SH patients, the standard deviation of N–Ns (SDNN) was reversely related to TSH (r = −0.38, p = 0.003), while low frequency (LF)/ high frequency (HF) ratio was positively related to TSH (r = 0.55, p = 0.003). Additionally, in SH patients both QT dispersion and QTc dispersion were positively related to TSH (r = 0.51 and r = 0.61, p < 0.001 for both). No significant differences were observed in the changes of HR, exercise tolerance (metabolic equivalents), or systolic and diastolic blood pressures at rest or during exercise between the groups, whereas mean HRR2 (22.5±8.3 vs 35.9±14.3, p < 0.001) and HRR3 (21.4±13.1 vs 31.2±13.0, p = 0.003) were significantly lower during exercise testing in the SH patients compared to controls (p < 0.001, respectively). After 6 months, the patients who treated with L-thyroxine showed reduction in QT dispersion and increase of HRV parameters.
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Conclusions: Subclinical hypothyroidism can effect autonomic modulation of heart rate and cause increased heterogeneity of ventricular recovery times. Early L-thyroxine treatment may be initiated not only prevent progression to overt hypothyroidism but also to improve abnormal cardiac autonomic functions and ventricular repolarization heterogeneity. PP-033 EVALUATION OF ENDOTHELIAL FUNCTION WITH FLOW-MEDIATED DILATATION DURING ATRIAL FIBRILLATION AND AFTER RESTORATION OF SINUS RHYTHM U. Canpolat, H. Yorgun, H. Sunman, A.H. Ates, A. Ulgen, K.M. Gurses, L. Sahiner, E. Kaya, K. Aytemir, L. Tokgozoglu, G. Kabakci, A. Oto. Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: Endothelial dysfunction is evidenced by heart beat variation in circulatory dynamics during atrial fibrillation (AF). The aim of the present study is to show endothelial dysfunction in patients with AF and reversibility of endothelial dysfunction after restoration of normal sinus rhythm. Methods: Flow-mediated dilatation (FMD) of the brachial artery were measured using high-resolution ultrasound in 32 patients with persistent AF who underwent electrical cardioversion and in 25 control subjects. In patients who remained in sinus rhythm after cardioversion, these measurements were repeated after 24 hours (n = 30) and 1 month (n = 29). Results: Compared with control subjects, patients (n = 30) showed lower FMD during AF (7.5±3.2% vs. 13.1±2.1%, respectively, p < 0.001). In 29 patients who remained in sinus rhythm, FMD increased at both 24 hours (8.0±3.2% vs. 11.6±4.6%, p = 0.021) and 1 month (8.2±3.2% vs. 12.4±4.7%, p < 0.001). Conclusions: Atrial fibrillation is associated with impairment in endothelial function that improves after sinus rhythm restoration. PP-034 A RARE CAUSE OF ATRIAL FIBRILLATION: EUROPEAN HORNET STING S. Okutucu1 , C. Sabanov1 , E. Abdulhayoglu2 , B. Evranos1 , L. Sahiner1 , E.B. Kaya1 , N.M. Aksu2 , B. Erbil2 , K. Aytemir1 , H. Ozkutlu1 , A. Oto1 . 1 Department of Cardiology, Hacettepe University, Ankara, Turkey; 2 Department of Emergency Medicine, Hacettepe University, Ankara, Turkey Objective: Hornet stings have been associated with a wide variety of local and systemic reactions including anaphylaxis. We briefly describe a 30-years-old man who experienced an atrial fibrillation episode caused by a European hornet (Vespa Crabro Linnaeus) envenomation. Methods: A 30-year-old man was admitted to our Emergency Department (ED) with complaints of palpitations, shortness of breath, dizziness and headache lasting for 2 hours. He had a history of hornet sting on his left shoulder one day before. He had mild pain and tingling sensation at the site of the sting. He did not have any cardiovascular or systemic illnesses and was not taking any medication or herbal products. On arrival to the ED, he had a blood pressure of 111/63 mmHg, respirations 20 breaths/min, oral temperature of 36.7°C, and oxygen saturation of 99% on room air. Cardiovascular examination was unremarkable except for an irregular tachycardic pulse. He had a small erythematous area on his left shoulder with no barb or venom sac. Electrocardiogram revealed atrial fibrillation with a rapid ventricular response. Complete blood count and serum biochemistry were normal. Thyroid function tests and cardiac biomarkers were normal too. Results: He was anticoagulated with low-molecular weight heparin. Intravenous propafenone was initiated for pharmacological cardioversion (loading dose of 1 mg/kg over 10 min+ followed by 2 mg/min for 30 min). At the 25th minute of infusion patient returned to normal sinus rhythm. Transthoracic echocardiography revealed normal left ventricular systolic function and diameters,
Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
RCA is one of the probable underlying mechanisms. Another and more common underlying mechanism is wrapped LAD. However, acute pericarditis/myocarditis, early repolarization, presence of collateral circulation or coronary abnormalities make it difficult to identify the culprit lesion. In the present case, ST segment elevation in leads II, III, aVF (III > II) and V5–6 (>2 mm) and ST depression in leads aVL and V1–3 mimic ECG findings of occlusion of distal segment of a dominant RCA. However, distal portion of a type III LAD was occluded. Major ECG findings of distal LAD occlusions are ST segment elevation in leads I, V1–6, II, III and aVF (II > III). The most likely mechanism of the findings in our case might be the occlusion of the two branches of distal LAD which perfuse the inferior and lateral walls of the left ventricle.
patient was hospitalized to the coronary care unit. Blood cultures were drawn. Empirical antibiotherapy was started. Emergency surgery was planned, but cardiovascular collapse and sudden death occurred just before the insertion of an intraaortic balloon pump. Corynebacterium striatum was isolated in the blood culture. Although, cardiogenic shock was the probable cause of death, it was not possible to determine the exact etiology as the relatives refused an autopsy. Conclusions: VSR is a rare but fatal complication of MI. Infective endocarditis might occur in the cases with late diagnosis. Early diagnosis and emergency surgery might be crucial in the success of treatment. Friday, 25 March 2011
08:30–10:00
Arrhythmias and Antiarrhythmic Therapy: New Horizons
Figure 1. 12-lead ECG shows ST segment elevation in leads II, III, aVF and V3–6 and ST depression in leads aVL, V1–2.
PP-030 ASSOCIATION OF VENTRICULAR SEPTAL RUPTURE, INFECTIVE ENDOCARDITIS AND INTRACARDIAC THROMBUS FOLLOWING MYOCARDIAL INFARCTION: FIRST CASE REPORT M. Tekinalp, U. Dogan, C. Duman, A. Soylu. Department of Cardiology, Selcuk University, Meram School of Medicine, Konya, Turkey Objective: Mechanical complications of myocardial infarction (MI) are fatal, especially if they are not diagnosed and treated expeditiously. Herein, we describe for the first time the association of ventricular septal rupture (VSR), intracardiac thrombus and infective endocarditis in a patient with a recent history of MI. Methods: A 57-year-old man who had had an acute MI 46 days ago presented with ten-day history of shortness of breath, fever and fatigue. It was reported that the patient had refused coronary angiography, received fibrinolytic therapy within ten hours of chest pain and ST segment resolution was achieved. Echocardiography at discharge showed poor left ventricular function (LVEF: 25%) without valvular regurgitation or pericardial effusion. Body temperature was 38.5 oC at the time of presentation; heart rate and blood pressure were 118/min and 100/60 mmHg, respectively. Cardiac examination revealed a 3/6 pansystolic murmur best heard in the mesocardiac region. A complete blood count revealed leukocytosis [WBC: 18250/mL (normal values= 4000–10000/mL)] and thrombocytopenia [Platelet: 21100/mL (normal values= 150000–400000/mL)]. The blood levels of urea nitrogen [150 mg/dL (normal value = 17–43 mg/dL)], creatinine [2.5 mg/dL (normal value= 0.7–1.2 mg/dL)], sensitive CRP [97.9 mg/L (normal value= 0–10 mg/dL)], procalcitonin [34.13 ng/ml (normal value <0.1 ng/ml)] and troponin-I [0.45 ng/mL (normal values = 0.0–0.04 ng/mL)] were increased. RBBB and pathological Q waves in the inferior leads were present in the ECG. Transthoracic echocardiography revealed a rupture of the muscular interventricular septum and a mobile mass which was attached to the defect and was considered to be a vegetation. Furthermore, a mobile thrombus in the left ventricular apical region was notified. The right side of the heart was dilated. The pulmonary to systemic blood flow ratio was 1.98. Transesophageal echocardiography confirmed these findings and the length of the defect was measured as 2.2 cm. The
PP-031 AN UNUSUAL CLINICAL STATE: ATRIAL FIBRILLATION DUE TO MAD-HONEY INTOXICATION M.E. Memetoglu1 , A. Kalkan2 , S. Kurtcan3 , V. Kara4 , G. Ertas5 , A.S. Cetinkaya5 , S. Talay6 , N. Tutar7 , S. Yesilkaya7 . 1 Department of Cardiovascular Surgery, Gumushane State Hospital, Gumushane, Turkey; 2 Department of Emergency Medicine, Karadeniz Technical University, Trabzon, Turkey; 3 Department of Radiology, Gumushane State Hospital, Gumushane, Turkey; 4 Department of Chest Surgery, Gumushane State Hospital, Gumushane, Turkey; 5 Department of Cardiology, Gumushane State Hospital, Gumushane, Turkey; 6 Department of Cardiovascular Surgery, Erzurum Training and Research Hospital, Erzurum, Turkey; 7 Department of Chest Diseases, Gumushane State Hospital, Gumushane, Turkey Objective: Although cases of acute mad honey intoxication have been reported earlier, life-threatening atrial fibrillation with slow ventricular rate due to mad honey intoxication is a rare seen clinical state. We report a case of 53-year-old man presented with severe bradycardia and his electrocardiographic manifestation following ingestion of mad honey. Methods: In March 2010, a 53-year-old man was admitted to our emergency department with sudden development of nausea, vomitting, general weakness. Upon history-taking from patient’s relatives, we learned that the symptoms had began within 2 hours of eating a few spoonfuls of honey, which was known as “madhoney”, Turkish honey from the Black Sea coast of Turkey. Surface electrocardiography revealed atrial fibrillation, with a ventricular rate of 30 beats/min (Fig. 1).
Figure 1. Surface electrocardiography revealed atrial fibrillation, with a ventricular rate of 30 beats/min.
Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
Results: The patient was given 0.5 mg of atropine, and parenteral fluid was administered. The patient’s heart rate and blood pressure returned to normal limits within twenty minutes; sinus rhythm was restored rapidly. Intravenous sodium chloride infusion (100 cc/h) was continued for 24 hours. He was monitored for 24 hours, during monitoring no type of arhythm or bradycardia was seen. Transthoracic echocardiography showed normal left ventricular systolic function without any regional wall motion abnormality. His symptoms improved with conservative management, which comprised bed rest and intravenous fluid therapy and as the clinical condition had stabilized, he was discharged from hospital on the next day with 97 beats/min hearth rate and normal sinus rhytm. Conclusions: “Mad honey intoxication” may occur after ingestion of grayanotoxin contaminated honey. Mad honey is used in the Black Sea Region as an alternative medicine for the treatment of gastric pains, bowel disorders, hypertension, and it is believed to be a sexual stimulant. Although the Black Sea Honey (Mad Honey) toxicity is rare, it’s clinical manifestations and cardiac rhythm problems may occur in various states including atrial fibrillation with severe bradycardia. Generally, supportive care is sufficient as a treatment for mad-honey intoxication. PP-032 EVALUATION OF CARDIAC AUTONOMIC FUNCTIONS BY HEART RATE VARIABILITY, QT DISPERSION AND HEART RATE RECOVERY INDEX IN PATIENTS WITH SUBCLINICAL HYPOTHYROIDISM U. Canpolat, H. Yorgun, H. Sunman, S. Okutucu, B. Evranos, G. Fatihoglu, L. Sahiner, E.B. Kaya, K. Aytemir, L. Tokgozoglu, G. Kabakci, A. Oto. Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: The impact of subclinical hypothyroidism (SH) on cardiovascular autonomic function and ventricular repolarization has not been yet clarified. The aim of our study was to evaluate the QT dispersion (index of heterogeneity of repolarization), heart rate variability (HRV), heart rate recovery index (HHRI), in SH patients. Methods: The study included 38 patients (21 women and 17 men; mean age 51.3±11.7 years) with SH, as detected by elevated serum TSH levels (>4.5 mIU/l; range, 0.27–4.2) and normal free thyroid hormones (FT3 and FT4) and 30 euthyroid control subjects. Patients with metabolic, cardiac, neurological disease or any other systemic disease that could affect autonomic activity were excluded from the study. Patients with SH and control subjects underwent a complete history, physical examination, 12-lead ECG, 24-h ambulatory ECG monitoring and Treadmill exercise test. HRR indices were calculated by subtracting first, second and third minute HR from the maximal HR and designated as HRR1, HRR2 and HRR3. To demonstrate the effect of treatment with L-thyroxine on all cardiac autonomic functions, 20 patients with SH were randomly assigned to Lthyroxine therapy. All the subjects were evaluated at enrollment and 6 months later. Results: Patients with SH revealed higher QT dispersion and lower HRV measures than healthy controls (p < 0.001 for all). In SH patients, the standard deviation of N–Ns (SDNN) was reversely related to TSH (r = −0.38, p = 0.003), while low frequency (LF)/ high frequency (HF) ratio was positively related to TSH (r = 0.55, p = 0.003). Additionally, in SH patients both QT dispersion and QTc dispersion were positively related to TSH (r = 0.51 and r = 0.61, p < 0.001 for both). No significant differences were observed in the changes of HR, exercise tolerance (metabolic equivalents), or systolic and diastolic blood pressures at rest or during exercise between the groups, whereas mean HRR2 (22.5±8.3 vs 35.9±14.3, p < 0.001) and HRR3 (21.4±13.1 vs 31.2±13.0, p = 0.003) were significantly lower during exercise testing in the SH patients compared to controls (p < 0.001, respectively). After 6 months, the patients who treated with L-thyroxine showed reduction in QT dispersion and increase of HRV parameters.
S113
Conclusions: Subclinical hypothyroidism can effect autonomic modulation of heart rate and cause increased heterogeneity of ventricular recovery times. Early L-thyroxine treatment may be initiated not only prevent progression to overt hypothyroidism but also to improve abnormal cardiac autonomic functions and ventricular repolarization heterogeneity. PP-033 EVALUATION OF ENDOTHELIAL FUNCTION WITH FLOW-MEDIATED DILATATION DURING ATRIAL FIBRILLATION AND AFTER RESTORATION OF SINUS RHYTHM U. Canpolat, H. Yorgun, H. Sunman, A.H. Ates, A. Ulgen, K.M. Gurses, L. Sahiner, E. Kaya, K. Aytemir, L. Tokgozoglu, G. Kabakci, A. Oto. Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: Endothelial dysfunction is evidenced by heart beat variation in circulatory dynamics during atrial fibrillation (AF). The aim of the present study is to show endothelial dysfunction in patients with AF and reversibility of endothelial dysfunction after restoration of normal sinus rhythm. Methods: Flow-mediated dilatation (FMD) of the brachial artery were measured using high-resolution ultrasound in 32 patients with persistent AF who underwent electrical cardioversion and in 25 control subjects. In patients who remained in sinus rhythm after cardioversion, these measurements were repeated after 24 hours (n = 30) and 1 month (n = 29). Results: Compared with control subjects, patients (n = 30) showed lower FMD during AF (7.5±3.2% vs. 13.1±2.1%, respectively, p < 0.001). In 29 patients who remained in sinus rhythm, FMD increased at both 24 hours (8.0±3.2% vs. 11.6±4.6%, p = 0.021) and 1 month (8.2±3.2% vs. 12.4±4.7%, p < 0.001). Conclusions: Atrial fibrillation is associated with impairment in endothelial function that improves after sinus rhythm restoration. PP-034 A RARE CAUSE OF ATRIAL FIBRILLATION: EUROPEAN HORNET STING S. Okutucu1 , C. Sabanov1 , E. Abdulhayoglu2 , B. Evranos1 , L. Sahiner1 , E.B. Kaya1 , N.M. Aksu2 , B. Erbil2 , K. Aytemir1 , H. Ozkutlu1 , A. Oto1 . 1 Department of Cardiology, Hacettepe University, Ankara, Turkey; 2 Department of Emergency Medicine, Hacettepe University, Ankara, Turkey Objective: Hornet stings have been associated with a wide variety of local and systemic reactions including anaphylaxis. We briefly describe a 30-years-old man who experienced an atrial fibrillation episode caused by a European hornet (Vespa Crabro Linnaeus) envenomation. Methods: A 30-year-old man was admitted to our Emergency Department (ED) with complaints of palpitations, shortness of breath, dizziness and headache lasting for 2 hours. He had a history of hornet sting on his left shoulder one day before. He had mild pain and tingling sensation at the site of the sting. He did not have any cardiovascular or systemic illnesses and was not taking any medication or herbal products. On arrival to the ED, he had a blood pressure of 111/63 mmHg, respirations 20 breaths/min, oral temperature of 36.7°C, and oxygen saturation of 99% on room air. Cardiovascular examination was unremarkable except for an irregular tachycardic pulse. He had a small erythematous area on his left shoulder with no barb or venom sac. Electrocardiogram revealed atrial fibrillation with a rapid ventricular response. Complete blood count and serum biochemistry were normal. Thyroid function tests and cardiac biomarkers were normal too. Results: He was anticoagulated with low-molecular weight heparin. Intravenous propafenone was initiated for pharmacological cardioversion (loading dose of 1 mg/kg over 10 min+ followed by 2 mg/min for 30 min). At the 25th minute of infusion patient returned to normal sinus rhythm. Transthoracic echocardiography revealed normal left ventricular systolic function and diameters,