Characteristics of coronary microcirculatory function in patients with Takotsubo syndrome

BACKGROUND

Takotsubo syndrome (TS) is a recently described cardiac syndrome whose pathogenesis is still unclear. We investigated the characteristics of coronary microcirculatory function in patients with TS through the analysis of the TIMI frame count (TFC) compared to normal subjects and with to subjects with microvascular angina (MA).

METHODS

We enrolled 71 TS patients (F:M =69:2, mean age of 65.27±9.53 years), 70 controls (F:M =34:36, mean age of 56.63±13.5 years) and 71 patients with MA, (F:M =69:2, mean age of 65.9±9.2 years). The assessment of the microcirculation was carried out through the TFC.

RESULTS

microcirculation was significantly altered in patients with TS compared with healthy controls [left anterior descending coronary artery (LAD) 25.16±6.91 vs. 17.30±3.76, P<0.001; circumflex artery (CX) 25.48±6.10 vs. 17.05±4.60, P<0.001; right coronary artery (RCA) 26.43±8.95 vs. 15.74±4.27, P<0.001, average TFC in TS 25.70±5.34 vs. 16,70±3.26, P<0.001). A TFC >20 frames was able to discriminate TS patients from controls with a specificity of 88.57% and sensitivity of 85.92% (AUC 0.927, P<0.0001). Microvascular dysfunction was diffuse in TS as well as in MA and slightly more severe in this last (mean TFC in MA 28.25±9.3 vs. 25.7±5.34 in TS, P<0.046).

CONCLUSIONS

Coronary microcirculation in TS patients is diffuse and milder compared to MA patients. Cut-off values >20 frames discriminate between patients with normal microcirculation and patients with TS.

Climatic variables in Takotsubo cardiomyopathy: role of temperature

BACKGROUND

Recent studies documented a seasonal (summer) and circadian (morning) temporal distribution of takotsubo cardiomyopathy (TTC).

AIM

The aim of our study was to investigate whether there is a relationship among season, temperature and the occurrence of TTC. A second aim of our study was the comparison of climatic variables in Takotsubo cardiomyopathy versus acute myocardial infarction (AMI).

METHODS

We enrolled consecutive patients with TTC in three Italian centres and, for comparison consecutive patients with AMI. The frequency of TTC and AMI patients according to month, season and quartiles of temperature (I quartile: 9.8-15°, II quartile: 15-19°, III quartile: 19-25° and IV quartile: 25-38°C) was reported. Climatic variables of TTC and AMI patients were compared.

RESULTS

We included in the study 85 patients with TTC and 900 patients with AMI. It was not observed a significant peak in the occurrence of TTC during summer time; however, when compared with AMI, TTC was more frequent in summer. We found an absolute higher frequency of TTC cases with warmer temperatures. TTC cases occurred during warmer temperatures than AMI.

CONCLUSION

Our study does not confirm a summer preference for TTC occurrence, as reported by previous studies, even if, compared with AMI, TTC is more frequent in summer. During warmest days, it was recorded the highest incidence of TTC.

Left ventricular non compaction: epidemiology, clinical findings, diagnosis and therapy

Left ventricular non compaction (LVNC) is a cardiomyopathy due to an arrest of the normal development of myocardium which determines the persistence of fetal myocardium in postnatal life in at least 2/3 of the wall (criterion known as non compacted/ compacted ratio greater than 2). Although in absence of a confirmed prevalence of LVNC, reviewing literature shows an increasing number of reports over the years, though diagnosed cases represent just the tip of a realistically far wider phenomenon. Clinical manifestations are variable, ranging from the absence of any symptom to congestive heart failure, arrhythmias and systemic thromboembolism. Echocardiography is the gold standard for the diagnosis. Tissue Doppler and three-dimensional echocardiography may give further information in the evaluation of patients affected by LVNC. Magnetic resonance could refine diagnosis particularly in those patients with not conclusive echocardiogram: it may help in differential diagnosis and give prognostic information. There is no specific therapy for patients with LVNC but the treatment is aimed at treating heart failure, or other complications such as arrhythmias and thromboembolic events.

Assessment of No-Reflow Phenomenon by Myocardial Blush Grade and Pulsed Wave Tissue Doppler Imaging in Patients with Acute Coronary Syndrome

Background:

No-reflow phenomenon is a complication of myocardial revascularization and it is associated with a worse prognosis.

Materials and Methods:

A prospective study was carried out enrolling patients with acute myocardial infarction (64 patients, 49 male and 15 female, median age 64.9 ± 10.61 years), both STEMI and NSTEMI, who underwent myocardial revascularization with percutaneous coronary intervention (PCI). TIMI flow and Myocardial Blush Grade (MBG) were assessed at baseline (T0), in addition to tissue Doppler imaging (TDI) and electrocardiogram. Cardiological evaluation was also performed at T1 (one month after PCI) and T2 (every year after revascularization for a mean follow-up of 24.9 months ± 6.93 months). Patients were divided into two groups on the basis of MBG.

Results:

In the present study, we found at T1 a significant association between MBG and dyslipidemia (P = 0,038) and NYHA class and MBG (P = 0,040), among clinical variables and cardiovascular risk factors. Moreover, a statistically significant relationship was observed between MBG and a new echocardiographic index of systolic and diastolic dysfunction, the EAS index measured with tissue Doppler imaging (P = 0,013). At T2, the EAS parameter was also significantly impaired in patients with reduced MBG, compared to patients with normal MBG (P = 0,003).

Conclusions:

This study demonstrates that the combined evaluation of systolic and diastolic dysfunction by EAS index, according to the literature, could detect a subclinical ventricular dysfunction due to a perfusion defect. Therefore, EAS index could be a useful parameter to be measured in the follow-up of patients undergoing revascularization.

Troponin I release after intravenous treatment with high furosemide doses plus hypertonic saline solution in decompensated heart failure trial (Tra-HSS-Fur)

BACKGROUND

High values of cardiac troponin in acute decompensated congestive heart failure (ADHF) identify patients at higher risk and worsened prognosis. A cardiac troponin increase during therapy indicates the need for more appropriate intervention, aimed at compensating cardiac disease and effectively minimizing myocardial wall stress and subsequent cytolysis. This study evaluated the effects of an intravenous high dose of furosemide with (group A) or without small volume hypertonic saline solution (HSS) (group B) on myocardial cytolysis in patients with ADHF.

METHODS

A total of 248 consecutive patients with ADHF (148 men, mean age 74.9 ± 10.9 years) were randomly assigned to group A or B. Plasma levels of cardiac troponin-I, brain natriuretic peptide, glomerular filtration rate by Modification of Diet in Renal Disease formula, bioelectrical impedance analysis measurements, and delta pressure/delta time (dP/dt) rate were observed on admission and discharge for all patients.

RESULTS

We observed a significant reduction of cardiac troponin in both groups and a significant improvement in renal function, hydration state, pulmonary capillary wedge pressure (P < .0001), end diastolic volume (P < .01), ejection fraction (P < .01), and dP/dt (P < .004) in group A. We also observed a significant reduction in body weight (64.4 vs 75.8 kg) (P < .001), cardiac troponin I (0.02 vs 0.31 ng/mL) (P < .0001) and brain natriuretic peptide (542 vs 1,284 pg/mL) (P < .0001), and hospitalization time (6.25 vs 10.2 days) (P < .0001) in the HSS group.

CONCLUSIONS

These data demonstrate that intravenous high doses of furosemide do not increase myocardial injury and, in addition, when associated to HSS, significantly reduce cardiac troponin I release. This behavior is mirrored by the achievement of improved hemodynamic compensation at echocardiography and body hydration normalization.