The brain-heart connection

Ageing, the autonomic nervous system and arrhythmia: From brain to heart

An ageing myocardium possesses significant electrophysiological alterations that predisposes the elderly patient to arrhythmic risk. Whilst these alterations are intrinsic to the cardiac myocytes, they are modulated by the cardiac autonomic nervous system (ANS) and consequently, ageing of the cardiac ANS is fundamental to the development of arrhythmias. A systems-based approach that incorporates the influence of the cardiac ANS could lead to better mechanistic understanding of how arrhythmogenic triggers and substrates interact spatially and temporally to produce sustained arrhythmia and why its incidence increases with age. Despite the existence of physiological oscillations of ANS activity on the heart, pathological oscillations can lead to defective activation and recovery properties of the myocardium. Such changes can be attributable to the decrease in functionality and structural alterations to ANS specific receptors in the myocardium with age. These altered ANS adaptive responses can occur either as a normal ageing process or accelerated in the presence of specific cardiac pathologies, such as genetic mutations or neurodegenerative conditions. Targeted intervention that seek to manipulate the ageing ANS influence on the myocardium may prove to be an efficacious approach for the management of arrhythmia in the ageing population.

Irregular Ventricular Tachycardia as a Mechanism of Stabilization of Mechanoelectrical Processes in Canine Heart under Conditions of Antiorthostatic Hypokinesia

We studied electrophysiological mechanisms of ventricular arrhythmias in dogs (n=7) under conditions of antiorthostatic hypokinesia (head-down tilt 45°). Abnormal transmural heterogeneity of repolarization in the base and apex of the left ventricle and increased dispersion of myocardial repolarization were revealed. By minute 30 of antiorthostatic hypokinesia, an increase in the duration of repolarization was revealed after a period of ventricular arrhythmia in all segments and regions of heart ventricles, which was accompanied by impairment of the pumping function of the heart. A hypothesis on the physiological role of ventricular tachycardia as a mechanism of electromechanical homeostatic stabilization in the heart was proposed. The obtained results suggest that under conditions of antiorthostatic hypokinesia, canine heart after a paroxysm of irregular ventricular tachycardia becomes more resistant to arrhythmia.

Low flow in the left atrial appendage assessed by transesophageal echocardiography is associated with increased stroke severity-Results of a single-center cross-sectional study

BACKGROUND

About 25% of strokes are thought to be cryptogenic. There is growing evidence that most of these cryptogenic strokes are thromboembolic and caused by an undetected atrial fibrillation. Measured slow flow in the left atrial appendage has been proposed to be an indicator for the thromboembolic risk since it is possibly associated with undetected atrial fibrillation.

METHODS

We evaluated all patients (n = 909; mean of 62 years, 39% female) admitted with an ischemic stroke (84%) or transient ischemic attack to our university medical center who underwent transesophageal echocardiography examination 2012-2014. Baseline characteristics, cardio-/neurovascular risk factors, electrocardiogram monitoring data, National Institute of Health Stroke Scale values, the localization of the stroke, as well as transesophageal echocardiography findings were analyzed.

RESULTS

Stroke severity measured by the National Institute of Health Stroke Scale in patients with a low flow in the left atrial appendage was significantly higher than in patients without left atrial appendage low flow (p < 0.001). There was a threshold phenomenon in flow velocity at about 60 cm/s above which no significant change in National Institute of Health Stroke Scale values could be observed. These patients were significantly different concerning incidence of heart failure (10.6% vs. 2.3%; p < 0.001) and atrial fibrillation (32.2% vs. 8.8%; p < 0.001). However, threshold phenomenon of left atrial appendage flow was unchanged when excluding atrial fibrillation and heart failure patients.

CONCLUSIONS

A low flow in the left atrial appendage was associated with clinically elevated stroke severity and could be indicated as an independent stroke risk factor. Further prospective studies are warranted to evaluate beneficial effects of therapeutic options in these patients also in the assumed absence of atrial fibrillation.

Intracerebral Hemorrhage Induces Cardiac Dysfunction in Mice Without Primary Cardiac Disease

Background: Intracerebral hemorrhage (ICH) is a life threatening stroke subtype and a worldwide health problem. In this study, we investigate brain-heart interaction after ICH in mice and test whether ICH induces cardiac dysfunction in the absence of primary cardiac disease. We also investigate underlying mechanisms such as oxidative stress and inflammatory responses in mediating cardiac dysfunction post-ICH in mice.

Methods: Male, adult (3–4 m) C57BL/6J mice were subjected to sham surgery or ICH using an autologous blood injection model (n = 16/group). Cardiac function was evaluated at 7 and 28 days after ICH using echocardiography (n = 8/group per time point). Western blot and immunostaining analysis were employed to assess oxidative stress and inflammatory responses in the heart.

Results: Mice subjected to ICH exhibited significantly decreased cardiac contractile function measured by left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) at 7 and 28 days after ICH compared to sham-control mice (p < 0.05). ICH induced cardiac dysfunction was significantly worse at 28 days than at 7 days after ICH (p < 0.05). ICH in mice significantly increased cardiomyocyte apoptosis, inflammatory factor expression and inflammatory cell infiltration in heart tissue, and induced cardiac oxidative stress at 7 days post-ICH compared to sham-control mice. Compared to sham-control mice, ICH-mice also exhibited significantly increased (p < 0.05) cardiomyocyte hypertrophy and cardiac fibrosis at 28 days after ICH.

Conclusions: ICH induces significant and progressive cardiac dysfunction in mice. ICH increases cardiac oxidative stress and inflammatory factor expression in heart tissue which may play key roles in ICH-induced cardiac dysfunction.

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions.

[Unusual cause of Takotsubo cardiomyopathy after pacemaker implantation]

Since its first description in Japan in 1990, Takotsubo (stress) cardiomyopathy has gained worldwide recognition. The disease is characterized by transient systolic and diastolic left ventricular dysfunction with a variety of wall-motion abnormalities. She predominantly affects elderly women and she is often preceded by an emotional or physical trigger. In the acute phase, the clinical presentation, electrocardiographic findings and biomarker profiles are often similar to those of an acute coronary syndrome. Although, the cause of Takotsubo cardiomyopathy remains unknown, the role of the brain-heart axis in the pathogenesis of the disease has been described. The potential role of catecholamine excess in the pathogenesis of Takotsubo cardiomyopathy has been long debated, and as such beta-blockers have been proposed as a therapeutic strategy. Currently, the treatment is not codified and it adapts according to clinical symptomatology. It seems difficult to summarize all the factors to provoque the cardiomyopathy, we describe a case of Takotsubo after a pacemaker (PM) implantation and to give a recent progress on this heart disease.

Isoprenaline Impairs Contractile Function of Ventricular Myocardium in Common Frog (Rana temporaria)

The contractile function of the heart was studied in adult frogs Rana temporaria under the influence of a toxic dose of isoprenaline under conditions of natural sinoatrial rhythm and during heart pacing. The dynamics of ventricular pressure was recorded with a Prucka MacLab 2000 instrument via a catheter introduced into the ventricle through the ventricular wall. Reduced (p<0.05) parameters of the pump function (HR, maximum ventricular systolic pressure, isovolumic indices dP/dt_max and dP/dt_min) and lengthening of QRS complex and QT interval on ECG attested to impairment of contractile function and electrical processes after exposure to isoprenaline. Electrical stimulation of the right atrium improved myocardial contractility and ECG parameters after the administration of isoprenaline.

A Heartbeat Away From Consciousness: Heart Rate Variability Entropy Can Discriminate Disorders of Consciousness and Is Correlated With Resting-State fMRI Brain Connectivity of the Central Autonomic Network

Background: Disorders of consciousness are challenging to diagnose, with inconsistent behavioral responses, motor and cognitive disabilities, leading to approximately 40% misdiagnoses. Heart rate variability (HRV) reflects the complexity of the heart-brain two-way dynamic interactions. HRV entropy analysis quantifies the unpredictability and complexity of the heart rate beats intervals. We here investigate the complexity index (CI), a score of HRV complexity by aggregating the non-linear multi-scale entropies over a range of time scales, and its discriminative power in chronic patients with unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS), and its relation to brain functional connectivity. Methods: We investigated the CI in short (CIs) and long (CIl) time scales in 14 UWS and 16 MCS sedated. CI for MCS and UWS groups were compared using a Mann-Whitney exact test. Spearman's correlation tests were conducted between the Coma Recovery Scale-revised (CRS-R) and both CI. Discriminative power of both CI was assessed with One-R machine learning model. Correlation between CI and brain connectivity (detected with functional magnetic resonance imagery using seed-based and hypothesis-free intrinsic connectivity) was investigated using a linear regression in a subgroup of 10 UWS and 11 MCS patients with sufficient image quality. Results: Higher CIs and CIl values were observed in MCS compared to UWS. Positive correlations were found between CRS-R and both CI. The One-R classifier selected CIl as the best discriminator between UWS and MCS with 90% accuracy, 7% false positive and 13% false negative rates after a 10-fold cross-validation test. Positive correlations were observed between both CI and the recovery of functional connectivity of brain areas belonging to the central autonomic networks (CAN). Conclusion: CI of MCS compared to UWS patients has high discriminative power and low false negative rate at one third of the estimated human assessors' misdiagnosis, providing an easy, inexpensive and non-invasive diagnostic tool. CI reflects functional connectivity changes in the CAN, suggesting that CI can provide an indirect way to screen and monitor connectivity changes in this neural system. Future studies should assess the extent of CI's predictive power in a larger cohort of patients and prognostic power in acute patients.

Immune Response Mediates Cardiac Dysfunction after Traumatic Brain Injury

Cardiovascular complications are common after traumatic brain injury (TBI) and are associated with increased morbidity and mortality. In this study, we investigated the possible role of the immune system in mediating cardiac dysfunction post-TBI in mice. Adult male C57BL/6J mice were subjected to a TBI model of controlled cortical impact (CCI) with or without splenectomy (n = 20/group). Splenectomy was performed immediately prior to induction of TBI. Cardiac function was measured using echocardiography prior to and after TBI. Neurological and cognitive functional tests and flow cytometry and immunostaining were performed. TBI mice exhibited significant cardiac dysfunction identified by decreased left ventricular ejection fraction and fractional shortening at 3 and 30 days post-TBI. In addition, these mice exhibited significantly increased cardiomyocyte apoptosis, inflammation, and oxidative stress at 3 and 30 days post-TBI, as well as cardiac hypertrophy and fibrosis and ventricular dilatation at 30 days after TBI. TBI mice subjected to splenectomy showed significantly improved cardiac function, and decreased cardiac fibrosis, oxidative stress, cardiomyocyte apoptosis, and infiltration of immune cells and inflammatory factor expression in the heart compared with TBI control mice. TBI mice exhibited severe neurological and cognitive function deficits. However, splenectomy did not improve neurological and cognitive functional outcome after TBI compared with the TBI control group. TBI induces immune cell infiltration and inflammatory factor expression in the heart as well as cardiac dysfunction. Splenectomy decreases heart inflammation and improves cardiac function after TBI. Immune response may contribute to TBI-induced cardiac dysfunction.

Histologic Examination of the Heart in the Forensic Autopsy

Histologic examination of the myocardium, valves, and cardiac blood vessels is often as important as the gross examination. The diagnostic features and categories of heart disease are many and varied, possibly more than any other organ. We present a review of the histologic features of forensically important heart disease.

Acute Cardiac Complications in Critical Brain Disease

Acute cardiac complications in critical brain disease should be understood as a clinical condition representing an intense brain-heart crosstalk and might mimic ischemic heart disease. Two main entities (neurogenic stunned myocardium [NSM] and stress cardiomyopathy) have been better characterized in the neurocritically ill patients and they portend worse clinical outcomes in these cases. The pathophysiology of NSM remains elusive. However, significant progress has been made on the early identification of neurocardiac compromise following acute critical brain disease. Effective prevention and treatment interventions are yet to be determined.

Takotsubo Cardiomyopathy-Induced Cardiac Free Wall Rupture: A Case Report and Review of Literature

Takotsubo cardiomyopathy (TCM) is an acquired form of cardiomyopathy that is commonly seen among post-menopausal women. It is characterized by left ventricular apical ballooning, electrocardiographic changes and mild elevation of cardiac enzymes in the absence of significant coronary artery stenosis. TCM usually has benign course. However, on rare instance, it can result in life-threatening and fatal complications including acute cardiogenic shock, ventricular arrhythmias and ventricular wall rupture. We herein report a case of a 77-year-old female who developed TCM complicated with massive pericardial effusion and cardiac arrest. The patient died and autopsy revealed normal coronaries with a slit-like rupture on the antero-apical surface of the heart extending into the papillary muscle. The clinical course, labs and angiographic findings preceding the cardiac rupture will be outlined. A thorough literature review including review of 14 previously reported case reports of TCM complicated with cardiac rupture will be included.

Acute Cardiac Complications in Critical Brain Disease

Acute cardiac complications in critical brain disease should be understood as a clinical condition representing an intense brain-heart crosstalk and might mimic ischemic heart disease. Two main entities (neurogenic stunned myocardium [NSM] and stress cardiomyopathy) have been better characterized in the neurocritically ill patients and they portend worse clinical outcomes in these cases. The pathophysiology of NSM remains elusive. However, significant progress has been made on the early identification of neurocardiac compromise following acute critical brain disease. Effective prevention and treatment interventions are yet to be determined.

Danhong Injection Reversed Cardiac Abnormality in Brain-Heart Syndrome via Local and Remote β-Adrenergic Receptor Signaling

Ischemic brain injury impacts cardiac dysfunction depending on the part of the brain affected, with a manifestation of irregular blood pressure, arrhythmia, and heart failure. Generally called brain–heart syndrome in traditional Chinese medicine, few mechanistic understanding and treatment options are available at present. We hypothesize that considering the established efficacy for both ischemic stroke and myocardial infarction (MI), Danhong injection (DHI), a multicomponent Chinese patent medicine, may have a dual pharmacological potential for treating the brain–heart syndrome caused by cerebral ischemic stroke through its multi-targeted mechanisms. We investigated the role of DHI in the setting of brain–heart syndrome and determined the mechanism by which it regulates this process. We induced Ischemia/Reperfusion in Wistar rats and administered intravenous dose of DHI twice daily for 14 days. We assessed the neurological state, infarct volume, CT scan, arterial blood pressure, heart rhythm, and the hemodynamics. We harvested the brain and heart tissues for immunohistochemistry and western blot analyses. Our data show that DHI exerts potent anti-stroke effects (infarct volume reduction: ^∗∗p < 0.01 and ^∗∗∗p < 0.001 vs. vehicle. Neurological deficit correction: ^∗p < 0.05 and ^∗∗∗p < 0.001 vs. vehicle), and effectively reversed the abnormal arterial pressure (^∗p < 0.05 vs. vehicle) and heart rhythm (^∗∗p < 0.01 vs. vehicle). The phenotype of this brain–heart syndrome is strikingly similar to those of MI model. Quantitative assessment of hemodynamic in cardiac functionality revealed a positive uniformity in the PV-loop after administration with DHI and valsartan in the latter. Immunohistochemistry and western blot results showed the inhibitory effect of DHI on the β-adrenergic pathway as well as protein kinase C epsilon (PKCε) (^∗∗p < 0.01 vs. model). Our data showed the underlying mechanisms of the brain–heart interaction and offer the first evidence that DHI targets the adrenergic pathway to modulate cardiac function in the setting of brain–heart syndrome. This study has made a novel discovery for proper application of the multi-target DHI and could serve as a therapeutic option in the setting of brain–heart syndrome.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

Brain-Heart Interactions in Traumatic Brain Injury

The cardiovascular manifestations associated with nontraumatic head disorders are commonly known. Similar manifestations have been reported in patients with traumatic brain injury (TBI); however, the underlying mechanisms and impact on the patient's clinical outcomes are not well explored. The neurocardiac axis theory and neurogenic stunned myocardium phenomenon could partly explain the brain-heart link and interactions and can thus pave the way to a better understanding and management of TBI. Several observational retrospective studies have shown a promising role for beta-adrenergic blockers in patients with TBI in reducing the overall TBI-related mortality. However, several questions remain to be answered in clinical randomized-controlled trials, including population selection, beta blocker type, dosage, timing, and duration of therapy, while maintaining the optimal mean arterial pressure and cerebral perfusion pressure in patients with TBI.

Association of prolonged QTc interval with Takotsubo cardiomyopathy: A neurocardiac syndrome inside the mystery of the insula of Reil

The Takotsubo cardiomyopathy is often considered autochthonous to the heart, although the primary problem may be not in the heart muscle itself. Instead, similar to several Takotsubo-like cardiac pathologies seen in acute neurological diseases, it may reflect the capacity of the nervous system to injure the heart. Persuasive evidence exists that shocking emotional stress promotes direct heart injuries. Moreover, clinical and laboratory research shows that cardiac structural damage can occur in the presence of a normal heart, especially in the context of seizures, stroke, and traumatic brain injury or under conditions of psychological stress. The aim of this review is to summarize the clinical implications of these observations, several of which focus on the pivotal role of the insula of Reil in the brain-heart connection, to unravel the mystery of Takotsubo cardiomyopathy pathogenesis.

Diabetes mellitus prevalence in patients with takotsubo syndrome: the case of the brain-heart disconnect

BACKGROUND

Hyperactive autonomic nervous system (ANS) is among the postulated pathophysiologic mechanisms of takotsubo syndrome (TTS). Diabetes mellitus (DM) with its associated ANS peripheral neuropathy could exert a "protective" influence for the emergence of TTS.

METHODS

A patient-based meta-analysis of the data obtained from all patients presented individually was carried out, focusing on age, gender, and history of hypertension (HTN) and DM.

RESULTS

The prevalences of HTN and DM for all 2,342 patients, aged 61.1 ± 17.3, 85.1% female, were 37.4% and 9.5%, for patients ≥ 60 years old were 45.8% and 11.7%, and for patients ≥65 years old were 48.2% and 12.3%, correspondingly. The prevalence of DM in patients with TTS is less than half of the world's and USA's elderly populations.

CONCLUSIONS

Prevalence of DM in patients with TTS is lower than in the general population, suggesting that DM, may have a "protective" effect for the emergence of TTS.

Cardiac sympathetic innervation, from a different point of (re)view

The audience of basic and clinical scientists is familiar with the notion that the sympathetic nervous system controls heart function during stresses. However, evidence indicates that the neurogenic control of the heart spans from the maintenance of housekeeping functions in resting conditions to the recruitment of maximal performance, in the fight-or-flight responses, across a whole range of intermediate states. To perform such sophisticated functions, sympathetic ganglia integrate both peripheral and central inputs, and transmit information to the heart via 'motor' neurons, directly interacting with target cardiomyocytes. To date, the dynamics and mode of communication between these two cell types, which determine how neuronal information is adequately translated into the wide spectrum of cardiac responses, are still blurry. By combining the anatomical and structural information brought to light by recent imaging technologies and the functional evidence in cellular systems, we focus on the interface between neurons and cardiomyocytes, and advocate the existence of a specific 'neuro-cardiac junction', where sympathetic neurotransmission occurs in a 'quasi-synaptic' way. The properties of such junctional-type communication fit well with those of the physiological responses elicited by the cardiac sympathetic nervous system, and explain its ability to tune heart function with precision, specificity and elevated temporal resolution.

Adrenergic Blockade Bi-directionally and Asymmetrically Alters Functional Brain-Heart Communication and Prolongs Electrical Activities of the Brain and Heart during Asphyxic Cardiac Arrest

Sudden cardiac arrest is a leading cause of death in the United States. The neurophysiological mechanism underlying sudden death is not well understood. Previously we have shown that the brain is highly stimulated in dying animals and that asphyxia-induced death could be delayed by blocking the intact brain-heart neuronal connection. These studies suggest that the autonomic nervous system plays an important role in mediating sudden cardiac arrest. In this study, we tested the effectiveness of phentolamine and atenolol, individually or combined, in prolonging functionality of the vital organs in CO₂-mediated asphyxic cardiac arrest model. Rats received either saline, phentolamine, atenolol, or phentolamine plus atenolol, 30 min before the onset of asphyxia. Electrocardiogram (ECG) and electroencephalogram (EEG) signals were simultaneously collected from each rat during the entire process and investigated for cardiac and brain functions using a battery of analytic tools. We found that adrenergic blockade significantly suppressed the initial decline of cardiac output, prolonged electrical activities of both brain and heart, asymmetrically altered functional connectivity within the brain, and altered, bi-directionally and asymmetrically, functional, and effective connectivity between the brain and heart. The protective effects of adrenergic blockers paralleled the suppression of brain and heart connectivity, especially in the right hemisphere associated with central regulation of sympathetic function. Collectively, our results demonstrate that blockade of brain-heart connection via alpha- and beta-adrenergic blockers significantly prolonged the detectable activities of both the heart and the brain in asphyxic rat. The beneficial effects of combined alpha and beta blockers may help extend the survival of cardiac arrest patients.

Psychiatric Illness in Takotsubo (Stress) Cardiomyopathy: A Review

BACKGROUND

Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, has been increasingly described in relation to psychiatric illness.

METHODS

We performed a literature review to identify the key findings related to psychiatric illness in TC that may be relevant to the practice of mental health and other health care providers.

RESULTS

The association of psychiatric illness with TC in addition to the spectrum of psychiatric illness found in TC, the role of exacerbation or treatment of psychiatric illness in triggering TC, different modes of presentation, prognostic implications, and long-term management of psychiatric illness in TC are discussed. Additionally, we review the limitations of the pre-existing literature and suggest areas of future research.

CONCLUSIONS

There is a strong association between pre-existing psychiatric illness, particularly anxiety and mood spectrum disorders, and TC. Acute exacerbation of psychiatric illness, rapid uptitration or overdose of certain psychotropic agents, and electroconvulsive therapy may trigger TC. Further studies are needed to better evaluate the prognostic significance and long-term management of psychiatric illness in TC.

Electrocardiographic Findings in Patients With Acute Coronary Syndrome Presenting With Out-of-Hospital Cardiac Arrest

We sought to characterize presenting electrocardiographic findings in patients with acute coronary syndromes (ACSs) and out-of-hospital cardiac arrest (OHCA). In the Global Registry of Acute Coronary Events and Canadian ACS Registry I, we examined presenting and 24- to 48-hour follow-up ECGs (electrocardiogram) of ACS patients who survived to hospital admission, stratified by presentation with OHCA. We assessed the prevalence of ST-segment deviation and bundle branch blocks (assessed by an independent ECG core laboratory) and their association with in-hospital and 6-month mortality among those with OHCA. Of the 12,040 ACS patients, 215 (1.8%) survived to hospital admission after OHCA. Those with OHCA had higher presenting rates of ST-segment elevation, ST-segment depression, T-wave inversion, precordial Q-waves, left bundle branch block (LBBB), and right bundle branch block (RBBB) than those without. Among patients with OHCA, those with ST-segment elevation had significantly lower in-hospital mortality (20.9% vs 33.0%, p = 0.044) and a trend toward lower 6-month mortality (27% vs 39%, p = 0.060) compared with those without ST-segment elevation. Conversely, among OCHA patients, LBBB was associated with significantly higher in-hospital and 6-month mortality rates (58% vs 22%, p <0.001, and 65% vs 28%, p <0.001, respectively). ST-segment depression and RBBB were not associated with either outcome. Sixty-three percent of bundle branch blocks (RBBB or LBBB) on the presenting ECG resolved by 24 to 48 hours. In conclusion, compared with ACS patients without cardiac arrest, those with OHCA had higher rates of ST-segment elevation, LBBB, and RBBB on admission. Among OHCA patients, ST-segment elevation was associated with lower in-hospital mortality, whereas LBBB was associated with higher in-hospital and 6-month mortality.

Respiratory sinus arrhythmia as a non-invasive index of 'brain-heart' interaction in stress

Respiratory sinus arrhythmia (RSA) is accepted as a peripheral marker of cardiac-linked parasympathetic regulation. According to polyvagal theory, the RSA is also considered as the index of emotion regulation. The neurovisceral integration model posits that parasympathetic modulation of the heart marked by RSA is related to complex nervous regulation associated with emotional and cognitive processing. From this perspective, high resting RSA amplitude associated with a greater withdrawal during stressors and subsequent recovery could represent a flexible and adaptive physiological response system to a challenge. Conversely, low resting RSA accompanied by an inadequate reactivity to stress might reflect maladaptive regulatory mechanisms. The RSA reactivity is different with various types of stressors: while the RSA decreases to cognitive tasks indicating a vagal withdrawal, the RSA magnitude increases to emotional challenge indicating an effective cognitive processing of emotional stimuli. The RSA reactivity to stress could have important implications for several mental disorders, e.g. depressive or anxiety disorder. It seems that the study of the RSA, as a non-invasive index of ‘brain-heart’ communication, could provide important information on the pathway linked to mental and physical health.

Takotsubo cardiomyopathy in an ultra-centenarian woman

A 101 years-old woman was admitted to our Emergency Department (ED) for acute dyspnea which onset nearly two hours before presentation. She had been on hydrochlorothyazyde-amiloride therapy due to mild hypertension. No other relevant features were present in the clinical history. The old lady had never been admitted to the hospital, and she was still living alone. A few days before hospital admission, one of the daughters became ill, so that a caregiver was paid for assisting her 12/24. This new circumstance was reluctantly accepted by the old lady. At ED presentation the patient was dyspnoic but alert. The electrocardiogram showed a marked elevation of the ST segment in V2-V6 leads. The echocardiogram showed the typical apical ballooning, characteristic of takotsubo cardiomyopathy. Blood test only showed a significant increase of cardiac troponin I. Considering the very good conditions of the patient, a coronary angiography was performed, that demonstrated a coronary tree totally free of lesions, thus confirming the clinical suspicion of takotsubo syndrome. The patient was admitted to the Coronary Care Unit, where she had a very good clinical course, and was discharged on day 6th after presentation. After one month of follow-up the clinical course was uneventful and the lady remained in good clinical and lifestyle conditions as before presenting to the ED. This unique case attests that takotsubo cardiomyopathy can be also observed at extreme ages, and should hence be considered in the differential diagnosis of acute dyspnea and chest pain in extremely elderly patients.

Clinical characteristics of stress cardiomyopathy in patients with acute poisoning

Patients who attempt intentional suicide suffer from physical or emotional stress. This situation might be an important factor that causes takotsubo cardiomyopathy. We retrospectively investigated the clinical features of Takotsubo cardiomyopathy in patients with acute poisoning. This study included patients who were admitted from January 2010 to December 2015 because of intentional poisoning by ingestion. Among these patients, we selectively collected data of patients who underwent an echocardiogram. We divided the patients into three groups according to the echocardiogram; the non-cardiomyopathy group, the global hypokinesia group, and the takotsubo cardiomyopathy group. One hundred forty-seven patients were analyzed in this study. One hundred thirty-one patients had normal cardiac function without regional wall motion abnormality. Global hypokinesia was observed in five patients. The overall incidence of takotsubo cardiomyopathy was 7.5% (11/147). Levels of cardiac enzymes including CK-MB, Troponin T, a marker of cardiac muscle ischemia, were higher in the global hypokinesia group and the takotsubo cardiomyopathy group compared with the non-cardiomyopathy group. The most commonly consumed poison was organophosphate in the takotsubo cardiomyopathy group. In conclusion, takotsubo cardiomyopathy may be one of the cardiac complications in patients who attempt suicide by consuming a poison.

Seizure-Associated ST Elevation Myocardial Infarction in Absence of Plaque Rupture

Acute coronary syndrome (ACS) is a very common cause of morbidity and mortality in the U.S. Here, we present a case of acute ST elevation myocardial infarction (STEMI) in the setting of seizure activity. In this rare case, we have data from optical coherence tomography (OCT) that showed no plaque disruption, showing the role of OCT in understanding the pathophysiology of STEMI and providing some ideas for the mechanism of this seizure-induced STEMI.

Hemorrhagic infarct of basal ganglia in cardiac arrest. CT and MRI findings. 2 cases

We report the CT and MRI findings in two cases of hemorrhagic infarct of the basal ganglia (BG), following out-of-hospital cardiac arrest (CA). In case 1, Brain-CT realized at day 2 showed bilateral and almost symmetric hemorrhagic infarct of the BG and infarct of the tectum of the mesencephalon. In case 2, MRI realized at day 6 showed hemorrhagic infarct of both lenticular nuclei on T2 GE images. In both cases there was no medical history and the cardiovascular and the coagulation profile were normal. In these cases, the lesions are observed earlier than reported in a few previous radiological cases. Similar lesions have been reported in pathological studies. These lesions seem occur early after CA. Reperfusion is probably responsible for the hemorrhagic transformation. The reason why some patients present either BG or brainstem infarct or both remains unclear. Bilateral and symmetric hemorrhagic infarct of the BG, especially of the Lenticular nuclei, and infarct of the dorsal pons and mesencephalic tegmentum seem to be a characteristic feature of profound and prolonged hypotension or of CA.

Network pharmacology exploration reveals endothelial inflammation as a common mechanism for stroke and coronary artery disease treatment of Danhong injection

Although Danhong injection (DHI) is the most widely prescribed Chinese medicine for both stroke and coronary artery disease (CAD), its underlying common molecular mechanisms remain unclear. An integrated network pharmacology and experimental verification approach was used to decipher common pharmacological mechanisms of DHI on stroke and CAD treatment. A compound-target-disease & function-pathway network was constructed and analyzed, indicating that 37 ingredients derived from DH (Salvia miltiorrhiza Bge., Flos Carthami tinctorii and DHI) modulated 68 common targets shared by stroke and CAD. In-depth network analysis results of the top diseases, functions, pathways and upstream regulators implied that a common underlying mechanism linking DHI’s role in stroke and CAD treatment was inflammatory response in the process of atherosclerosis. Experimentally, DHI exerted comprehensive anti-inflammatory effects on LPS, ox-LDL or cholesterol crystal-induced NF-κB, c-jun and p38 activation, as well as IL-1β, TNF-α, and IL-10 secretion in vascular endothelial cells. Ten of 14 predicted ingredients were verified to have significant anti-inflammatory activities on LPS-induced endothelial inflammation. DHI exerts pharmacological efficacies on both stroke and CAD through multi-ingredient, multi-target, multi-function and multi-pathway mode. Anti-endothelial inflammation therapy serves as a common underlying mechanism. This study provides a new understanding of DHI in clinical application on cardiovascular and cerebrovascular diseases.

Stroke-induced chronic systolic dysfunction driven by sympathetic overactivity

Objective

Cardiac diseases are established risk factors for ischemic stroke incidence and severity. Conversely, there is increasing evidence that brain ischemia can cause cardiac dysfunction. The mechanisms underlying this neurogenic heart disease are incompletely understood. Although it is established that ischemic stroke is associated with cardiac arrhythmias, myocardial damage, elevated cardiac enzymes, and plasma catecholamines in the acute phase, nothing is known about the delayed consequences of ischemic stroke on cardiovascular function.

Methods

To determine the long‐term cardiac consequences of a focal cerebral ischemia, we subjected young and aged mice to a 30‐minute transient middle cerebral artery occlusion and analyzed cardiac function by serial transthoracic echocardiography and hemodynamic measurements up to week 8 after surgery. Finally, animals were treated with metoprolol to evaluate a pharmacologic treatment option to prevent the development of heart failure.

Results

Focal cerebral ischemia induced a long‐term cardiac dysfunction with a reduction in left ventricular ejection fraction and an increase in left ventricular volumes; this development was associated with higher peripheral sympathetic activity. Metoprolol treatment prevented the development of chronic cardiac dysfunction by decelerating extracellular cardiac remodeling and inhibiting sympathetic signaling relevant to chronic autonomic dysfunction.

Interpretation

Focal cerebral ischemia in mice leads to the development of chronic systolic dysfunction driven by increased sympathetic activity. If these results can be confirmed in a clinical setting, treating physicians should be attentive to clinical signs of heart failure in every patient after ischemic stroke. Therapeutically, the successful β‐blockade with metoprolol in mice could also have future clinical implications. Ann Neurol 2017;82:729–743

Sudden cardiac arrest in hypertrophic cardiomyopathy with dynamic cavity obstruction: The case for a decatecholaminisation strategy

Catecholamines are entrenched in the management of shock states. A paradigm shift has pervaded the critical care arena in recent years acknowledging their propensity to cause harm and fuel a 'death-spiral'. We present the case of a 21-year-old male following a witnessed out-of-hospital cardiac arrest who received high-quality cardiopulmonary resuscitation and standard advanced life support for refractory ventricular fibrillation until return of spontaneous circulation after 70 min. Early post-admission echocardiography revealed severe diffuse sub-basal left ventricular hypertrophy with dynamic mid-cavity obstruction and akinetic apical pouching. Within this context, a decatecholaminised strategy comprising a beta-blocker was used to augment the left ventricular end-diastolic volume and attain cardiovascular stability.

Hypertension After Severe Traumatic Brain Injury: Friend or Foe?

Traumatic brain injury (TBI) is a major public health problem, with severe TBI contributing to a large number of deaths and disability worldwide. Early hypotension has been linked with poor outcomes following severe TBI, and guidelines suggest early and aggressive management of hypotension after TBI. Despite these recommendations, no guidelines exist for the management of hypertension after severe TBI, although observational data suggests that early hypertension is also associated with an increased risk of mortality after severe TBI. The purpose of this review is to discuss the underlying pathophysiology of hypertension after TBI, provide an overview of the current clinical data on early hypertension after TBI, and discuss future research that should test the benefits and harms of treating high blood pressure in TBI patients.

The Role of Post-Resuscitation Electrocardiogram in Patients With ST-Segment Changes in the Immediate Post-Cardiac Arrest Period

OBJECTIVES

The authors aimed to evaluate the role of post-resuscitation electrocardiogram (ECG) in patients showing significant ST-segment changes on the initial ECG and to provide useful diagnostic indicators for physicians to determine in which out-of-hospital cardiac arrest (OHCA) patients brain computed tomography (CT) should be performed before emergency coronary angiography.

BACKGROUND

The usefulness of immediate brain CT and ECG for all resuscitated patients with nontraumatic OHCA remains controversial.

METHODS

Between January 2010 and December 2014, 1,088 consecutive adult nontraumatic patients with return of spontaneous circulation who visited the emergency department of 3 tertiary care hospitals were enrolled. After excluding 245 patients with obvious extracardiac causes, 200 patients were finally included.

RESULTS

The patients were categorized into 2 groups: those with ST-segment changes with spontaneous subarachnoid hemorrhage (SAH) (n = 50) and those with OHCA of suspected cardiac origin group (n = 150). The combination of 4 ECG characteristics including narrow QRS (<120 ms), atrial fibrillation, prolonged QTc interval (≥460 ms), and ≥4 ST-segment depressions had a 66.0% sensitivity, 80.0% specificity, 52.4% positive predictive value, and 87.6% negative predictive value for predicting SAH. The area under the receiver-operating characteristic curves in the post-resuscitation ECG findings was 0.816 for SAH.

CONCLUSIONS

SAH was observed in a substantial number of OHCA survivors (25.0%) with significant ST-segment changes on post-resuscitation ECG. Resuscitated patients with narrow QRS complex and any 2 ECG findings of atrial fibrillation, QTc interval prolongation, or ≥4 ST-segment depressions may help identify patients who need brain CT as the next diagnostic work-up.

Epidemiology, pathogenesis, and management of takotsubo syndrome

Takotsubo syndrome is a recently recognized acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome. The typical takotsubo syndrome patient has a unique circumferential left (bi-) ventricular contraction abnormality profile that extends beyond a coronary artery supply territory and appears to follow the anatomical cardiac sympathetic innervation. The syndrome predominantly affects postmenopausal women and is often preceded by emotional or physical stress. Patients with predisposing factors such as malignancy and other chronic comorbidities are more prone to suffer from takotsubo syndrome. The pathogenesis of takotsubo syndrome is elusive. Several pathophysiological mechanisms involving myocardial ischemia (multivessel coronary artery spasm, microvascular dysfunction, aborted myocardial infarction), left ventricular outlet tract obstruction, blood-borne catecholamine myocardial toxicity, epinephrine-induced switch in signal trafficking, and autonomic nervous system dysfunction have been proposed. The syndrome is usually reversible; nevertheless, during the acute stage, a substantial number of patients develop severe complications such as arrhythmias, heart failure including pulmonary edema and cardiogenic shock, thromboembolism, cardiac arrest, and rupture. Treatment of precipitating factors, predisposing diseases, and complications is fundamental during the acute stage of the disease. The epidemiology, pathogenesis, and management of takotsubo syndrome are reviewed in this paper.

Brain-Heart Interaction: Cardiac Complications After Stroke

Neurocardiology is an emerging specialty that addresses the interaction between the brain and the heart, that is, the effects of cardiac injury on the brain and the effects of brain injury on the heart. This review article focuses on cardiac dysfunction in the setting of stroke such as ischemic stroke, brain hemorrhage, and subarachnoid hemorrhage. The majority of post-stroke deaths are attributed to neurological damage, and cardiovascular complications are the second leading cause of post-stroke mortality. Accumulating clinical and experimental evidence suggests a causal relationship between brain damage and heart dysfunction. Thus, it is important to determine whether cardiac dysfunction is triggered by stroke, is an unrelated complication, or is the underlying cause of stroke. Stroke-induced cardiac damage may lead to fatality or potentially lifelong cardiac problems (such as heart failure), or to mild and recoverable damage such as neurogenic stress cardiomyopathy and Takotsubo cardiomyopathy. The role of location and lateralization of brain lesions after stroke in brain-heart interaction; clinical biomarkers and manifestations of cardiac complications; and underlying mechanisms of brain-heart interaction after stroke, such as the hypothalamic-pituitary-adrenal axis; catecholamine surge; sympathetic and parasympathetic regulation; microvesicles; microRNAs; gut microbiome, immunoresponse, and systemic inflammation, are discussed.

Dynamic changes of QTc interval and prognostic significance in takotsubo (stress) cardiomyopathy

BACKGROUND

Prolonged QT corrected (QTc) intervals are associated with adverse cardiovascular outcomes both in healthy and high-risk populations. Our objective was to evaluate the QTc intervals during a takotsubo cardiomyopathy (TTC) episodes and their potential prognostic role.

HYPOTHESIS

Dynamic changes of QTc interval during hospitalization for TTC could be associated with outcome at follow-up.

METHODS

Fifty-two consecutive patients hospitalized for TTC were enrolled. Twelve-lead electrocardiogram (ECG) was performed within 3 h after admission and repeated after 3, 5, and 7 days. Patients were classified in 2 groups: group 1 presented the maximal QTc interval length at admission and group 2 developed maximal QTc interval length after admission.

RESULTS

Mean admission QTc interval was 493 ± 71 ms and mean QTc peak interval was 550 ± 76 ms (P < 0.001). Seventeen (33%) patients were included in group 1 and 35 (67%) patients in group 2. There were no differences for cardiovascular risk factors and in terms of ECG findings such as ST elevation, ST depression, and inverted T waves. Rates of adverse events during hospitalization among patients of group 1 and 2 were different although not significantly (20% vs 6%, P = 0.22). After 647 days follow-up, patients of group 1 presented higher risk of cardiovascular rehospitalization (31% vs 6%, P = 0.013; log-rank, P < 0.01). At multivariate analysis, including age and gender, a prolonged QTc interval at admission was significantly associated with higher risk of rehospitalization at follow-up (hazard ratio: 1.07 every 10 ms, 95% confidence interval: 1.003-1.14, P = 0.04).

CONCLUSIONS

Prolonged QTc intervals at admission during a TTC episode could be associated with a higher risk of cardiovascular rehospitalization at follow-up. Dynamic increase of QTc intervals after admission are characterized by a trend toward a better prognosis.

Chromogranins: from discovery to current times

The discovery in 1953 of the chromaffin granules as co-storage of catecholamines and ATP was soon followed by identification of a range of uniquely acidic proteins making up the isotonic vesicular storage complex within elements of the diffuse sympathoadrenal system. In the mid-1960s, the enzymatically inactive, major core protein, chromogranin A was shown to be exocytotically discharged from the stimulated adrenal gland in parallel with the co-stored catecholamines and ATP. A prohormone concept was introduced when one of the main storage proteins collectively named granins was identified as the insulin release inhibitory polypeptide pancreastatin. A wide range of granin-derived biologically active peptides have subsequently been identified. Both chromogranin A and chromogranin B give rise to antimicrobial peptides of relevance for combat of pathogens. While two of the chromogranin A-derived peptides, vasostatin-I and pancreastatin, are involved in modulation of calcium and glucose homeostasis, respectively, vasostatin-I and catestatin are important modulators of endothelial permeability, angiogenesis, myocardial contractility, and innate immunity. A physiological role is now evident for the full-length chromogranin A and vasostatin-I as circulating stabilizers of endothelial integrity and in protection against myocardial injury. The high circulating levels of chromogranin A and its fragments in patients suffering from various inflammatory diseases have emerged as challenges for future research and clinical applications.

Neuroprotective effect of kinin B1 receptor activation in acute cerebral ischemia in diabetic mice

Activation of the kallikrein-kinin system enhances cardiac and renal tolerance to ischemia. Here we investigated the effects of selective agonists of kinin B1 or B2 receptor (R) in brain ischemia-reperfusion in diabetic and non-diabetic mice. The role of endogenous kinins was assessed in tissue kallikrein deficient mice (TK^−/−). Mice underwent 60min-middle cerebral artery occlusion (MCAO), eight weeks after type 1-diabetes induction. Treatment with B1R-, B2R-agonist or saline was started at reperfusion. Neurological deficit (ND), infarct size (IS), brain water content (BWC) were measured at day 0, 1 and 2 after injury. MCAO induced exaggerated ND, mortality and IS in diabetic mice. B2R-agonist increased ND and mortality to 60% and 80% in non-diabetic and diabetic mice respectively, by mechanisms involving hemodynamic failure and renal insufficiency. TK^−/− mice displayed reduced ND and IS compared to wild-type littermate, consistent with suppression of B2R activity. B1R mRNA level increased in ischemic brain but B1R-agonist had no effect on ND, mortality or IS in non-diabetic mice. In contrast, in diabetic mice, B1R-agonist tested at two doses significantly reduced ND by 42–52% and IS by 66–71%, without effect on BWC or renal function. This suggests potential therapeutic interest of B1R agonism for cerebral protection in diabetes.

A Review of Neurogenic Stunned Myocardium

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician's awareness of NSM and its features to help tailor management according to the patient's clinical profile.