Twenty-five-year trends in incidence, angiographic appearance, and management of spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) has been described as an infrequent cause of acute coronary syndrome (ACS). Knowledge about the disease is still limited and SCAD might still be underdiagnosed.

OBJECTIVES

Trends in incidence, presentation, angiographic appearance, management, and outcomes of SCAD over 25 years were analyzed.

METHODS

Patients with SCAD between 1997 and 2021 at the University Hospital Zurich, Switzerland, were included. Incidences were assessed as total numbers and proportions of ACS cases. Clinical data were collected from medical records and angiographic findings were reviewed. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, cardiac arrest, SCAD recurrence or progression, other myocardial infarction, and stroke.

RESULTS

One hundred fifty-six SCAD cases were included in this study. The incidence increased significantly in total (p < 0.001) and relative to ACS cases (p < 0.001). This was based on an increase of shorter lesions (p = 0.004), SCAD type 2 (p < 0.001), and lesions in side branches (p = 0.014), whereas lesions in the left main coronary artery and proximal segments were decreasing (p-values 0.029 and < 0.001, respectively). There was an increase in conservative therapy (p < 0.001). The rate of MACE (24%) was stable, however, there was a reduced proportion of patients with a need for intensive care treatment (p = 0.017).

CONCLUSIONS

SCAD represents an important entity of ACS that still might be underappreciated. The increasing incidence of SCAD is likely based on better awareness and familiarity with the disease. A lower need for intensive care treatment suggests positive effects of the increasing implementation of conservative management.

Machine learning-based prediction of in-hospital death for patients with takotsubo syndrome: The InterTAK-ML model

AIMS

Takotsubo syndrome (TTS) is associated with a substantial rate of adverse events. We sought to design a machine learning (ML)-based model to predict the risk of in-hospital death and to perform a clustering of TTS patients to identify different risk profiles.

METHODS AND RESULTS

A ridge logistic regression-based ML model for predicting in-hospital death was developed on 3482 TTS patients from the International Takotsubo (InterTAK) Registry, randomly split in a train and an internal validation cohort (75% and 25% of the sample size, respectively) and evaluated in an external validation cohort (1037 patients). Thirty-one clinically relevant variables were included in the prediction model. Model performance represented the primary endpoint and was assessed according to area under the curve (AUC), sensitivity and specificity. As secondary endpoint, a K-medoids clustering algorithm was designed to stratify patients into phenotypic groups based on the 10 most relevant features emerging from the main model. The overall incidence of in-hospital death was 5.2%. The InterTAK-ML model showed an AUC of 0.89 (0.85-0.92), a sensitivity of 0.85 (0.78-0.95) and a specificity of 0.76 (0.74-0.79) in the internal validation cohort and an AUC of 0.82 (0.73-0.91), a sensitivity of 0.74 (0.61-0.87) and a specificity of 0.79 (0.77-0.81) in the external cohort for in-hospital death prediction. By exploiting the 10 variables showing the highest feature importance, TTS patients were clustered into six groups associated with different risks of in-hospital death (28.8% vs. 15.5% vs. 5.4% vs. 1.0.8% vs. 0.5%) which were consistent also in the external cohort.

CONCLUSION

A ML-based approach for the identification of TTS patients at risk of adverse short-term prognosis is feasible and effective. The InterTAK-ML model showed unprecedented discriminative capability for the prediction of in-hospital death.

Coronary microvascular dysfunction in Takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance

BACKGROUND

Coronary microvascular dysfunction (CMD) has been proposed as a crucial factor in the pathophysiology of Takotsubo syndrome (TTS). The angiography-derived index of microcirculatory resistance (caIMR) offers an alternative to conventional hyperemic wire-based IMR to assess CMD. We aimed to evaluate CMD's prevalence, transience, and impact on in-hospital outcomes in TTS.

METHODS

All three coronary arteries of 96 patients with TTS were assessed for their coronary angiography derived Index of microcirculatory Resistance (caIMR) and compared to non-obstructed vessels of matched patients with ST-elevation myocardial infarction. Further, the association between caIMR and the TTS-specific combined in-hospital endpoint of death, cardiac arrest, ventricular arrhythmogenic events and cardiogenic shock was investigated.

RESULTS

Elevated IMR was present in all TTS patients, with significantly elevated caIMR values in all coronary arteries compared to controls. CaIMR did not differ between apical and midventricular TTS types. CaIMR normalized in TTS patients with follow-up angiographies performed at a median of 28 months (median caIMR at event vs follow-up: LAD 34.8 [29.9-41.1] vs 20.3 [16.0-25.3], p < 0.001; LCX: 38.7 [32.9-50.1] vs 23.7 [19.4-30.5], p < 0.001; RCA: 31.7 [25.0-39.1] vs 19.6 [17.1-24.0], p < 0.001). The extent of caIMR elevation significantly correlated with the combined in-hospital endpoint (p = 0.036).

CONCLUSION

TTS patients had evidence of elevated caIMR in at least one coronary artery with a trend towards higher LAD caIMR in apical type TTS and normalization after recovery. Furthermore, extent of caIMR elevation was associated with increased risk of in-hospital MACE of TTS patients.

Effectiveness of radiation protection systems in the cardiac catheterization laboratory: a comparative study

BACKGROUND

As numbers and complexity of percutaneous coronary interventions are constantly increasing, optimal radiation protection is required to ensure operator safety. Suspended radiation protection systems (SRPS) and protective scatter-radiation absorbing drapes (PAD) are novel methods to mitigate fluoroscopic scattered radiation exposure. The aim of the study was to investigate the effectiveness regarding radiation protection of a SRPS and a PAD in comparison with conventional protection.

METHODS

A total of 229 cardiac catheterization procedures with SRPS (N = 73), PAD (N = 82) and standard radiation protection (N = 74) were prospectively included. Real-time dosimeter data were collected from the first operator and the assistant. Endpoints were the cumulative operator exposure relative to the dose area product [standardized operator exposure (SOE)] for the first operator and the assistant.

RESULTS

For the first operator, the SRPS and the PAD significantly decreased the overall SOE compared to conventional shielding by 93.9% and 66.4%, respectively (P < 0.001). The protective effect of the SRPS was significantly higher compared to the PAD (P < 0.001). For the assistant, the SRPS and the PAD provided a not statistically significant reduction compared to conventional shielding in the overall SOE by 38.0% and 30.6%, respectively.

CONCLUSIONS

The SRPS and the PAD enhance radiation protection significantly compared to conventional protection. In most clinical scenarios, the protective effect of SRPS is significantly higher than the additional protection provided by the PAD. Comparison of the additional radiation protection provided by protective scatter-radiation absorbing drapes (PAD) and the suspended radiation protection system (SRPS) system over standard protection with lead aprons.

Cardiac troponin elevation and mortality in takotsubo syndrome: new insights from the International Takotsubo (InterTAK) registry

Background/Introduction

Cardiac biomarker elevations are frequently observed in Takotsubo syndrome (TTS). The clinical relevance of cardiac troponin (cTn) elevations in TTS patients remains uncertain and threshold values indicating clinically relevant myocardial injury are unknown.

Purpose

This study sought to investigate the role of cTn elevations in mortality prediction of patients with TTS.

Methods

A total of 2,938 patients enrolled in the prospective International Takotsubo (InterTAK) Registry from January 2011 to February 2020 and with available data on baseline and peak cTn levels were included in the analysis. The threshold at which myocardial injury drives mortality was identified using restricted cubic spline analysis.

Results

Out of 2,938 patients, 222 (7.6%) patients died during 1-year follow-up. A more than 28.8-fold increase of cTn above the upper reference limit was identified as threshold for clinically relevant myocardial injury. Mortality at 1 year was significantly higher in patients with clinically relevant myocardial injury than in those without (Log Rank p&lt;0.001, Figure 1). The presence of clinically relevant myocardial injury was significantly associated with an increased risk of mortality at 5 years (adjusted HR 1.58, 95% CI 1.18–2.12, p=0.002). Clinically relevant myocardial injury was related to 5-year mortality in patients with apical TTS (adjusted HR 1.57, 95% CI 1.21–2.03, p=0.001), with presence of physical stressors (adjusted HR 1.60, 95% CI 1.22–2.11, p=0.001), and with absence of emotional stressors (adjusted HR 1.49, 95% CI, 1.17–1.89, p=0.001).

Conclusions

This study for the first time determined a troponin threshold for the identification of TTS patients at excess risk of mortality. These findings advance risk stratification in TTS and assist in identifying patients in need for close monitoring and follow-up.

Funding Acknowledgement

Type of funding sources: Foundation.

Body weight and mortality in takotsubo syndrome: insights from the International Takotsubo (InterTAK) registry

Background/Introduction

The obesity paradox has been described in different cardiovascular conditions. Data on the association between obesity and outcomes in patients with Takotsubo syndrome (TTS) are lacking.

Purpose

The aim of this study was to determine the relation of body weight to mortality in TTS patients.

Methods

Patients enrolled in the International Takotsubo (InterTAK) Registry from January 2011 to July 2021 and with available data on BMI were included in the analysis. Patients were stratified according to BMI (underweight, &lt;18.5 kg/m2; normal weight, 18.5–24.9 kg/m2; overweight, 25.0–29.9 kg/m2; obese, 30.0–34.9 kg/m2; and very obese, ≥35.0 kg/m2). The primary endpoint was mortality at 1 year.

Results

Of the 2'707 patients, 222 (8.2%) were underweight, 1340 (49.5%) of normal weight, 759 (28.0%) overweight, 268 (9.9%) obese, and 118 (4.4%) very obese. Mortality at 1 year as a function of BMI with 95% confidence interval is given in Figure 1. Mortality at 1 year was 11.3%, 6.9%, 5.5%, 4.9%, and 9.3% in underweight, normal weight, overweight, obese, and very obese patients (p=0.02, Figure 2). Being overweight or obese was significantly associated with a lower mortality at 1 year (HR 0.70, 95% CI 0.51–0.96, p=0.03), and associations remained significant after multivariable adjustments (adjusted HR 0.67, 95% CI 0.46–0.97, p=0.03). Associations were observed when including patients without emotional stressors (adjusted HR 0.64, 95% CI 0.43–0.94, p=0.02), but not when including those with emotional stressors (adjusted HR 1.14, 95% CI 0.30–4.27, p=0.85).

Conclusion

A U-shaped mortality curve across BMI categories was observed in TTS patients, with lowest mortality rates in obese patients. These observations provide first evidence for the existence of the obesity paradox in TTS.

Funding Acknowledgement

Type of funding sources: Foundation.

Venoarteriolar reflex responses in diabetic patients

The aim of this study was to investigate the venoarteriolar reflex (VAR) responses in type 1 (T1DM) and type 2 (T2DM) diabetes mellitus (DM) with polyneuropathy and to estimate their relationship with age, DM duration, initial cutaneous temperature and body mass index. Four groups of subjects were investigated: 1st group -20 patients with T1DM; 2nd group -50 patients with T2DM; 3rd group of 20 healthy subjects with similar age and body mass index (BMI) to the T1DM group; 4th group (Control2) of 24 healthy subjects adjusted by age and BMI to the T2DM group. The cutaneous perfusions of the big toe pulp were monitored as baseline perfusions at a temperature of 32°C in supine and sitting position with hanging legs and back in supine position. Loss of venoarteriolar reflex responses was established in 75% of T1DM patients, 78% of T2DM patients and in none of the investigated healthy controls. Reduced venoarteriolar perfusion responses were established in both T1DM and T2DM patients with polyneuropathy compared with healthy subjects. Reliable positive associations between VAR responses and the age, DM duration and initial cutaneous temperature were found.

Long-term outcome of treatment for Hodgkin's disease: the University Hospital Sofia experience

BACKGROUND

To establish the efficacy of the combined modality treatment (CMT) including curative extended field radiotherapy (EFRT) and chemotherapy (CHT) by examining the long-term outcome in Hodgkin's disease (HD) patients at the Sofia University Hospital "Queen Giovanna-ISUL", with particular focus on second primary malignancy (SPM), and to establish independent factors correlated with treatment outcome.

METHODS AND MATERIALS

Between 1982 and 2007, 170 patients with HD with median age of 12 years (range 3-40), (68 females, 102 males), were included in this retrospective study. The clinical stage (CS) distribution was CS I in 1 patient (0.6%), CS II in 86 (50.5%), CS III in 77 (45.3%) and CS IV in 6 (3.5%) patients. Histologic subtypes included lymphocyte predominance 7.6%, mixed cellularity 47.1%, nodular sclerosis 42.9% and lymphocyte depletion 0.6%. B symptoms were observed in 57.6% of the patients, hepatosplenomegaly--in 30.6%, anemia--in 27.1% and elevated serum lactat dehydrogenase (LDH)--in 41.2%. The overall treatment consisted of both EFRT and CHT. In 115 patients (67%) supradiaphragmatic irradiation of lymphatic nodes was carried out, in 3 (2%) patients subdiaphragmatic irradiation was performed and in 52 (31%)--irradiation of the supra- and infra-diaphragmatic lymph nodes basically by subtotal 35 (20.6%), and total lymphoid irradiation--in 4 (2.4%) patients. The daily dose was 1.5-2 Gy, the total dose for EFRT was 20-40 Gy. From the analyzed 170 patients 150 were assessable for long-term outcome and 120 for SPM analyses.

RESULTS

Follow-up extended from a minimum of 0,3 years to maximum 25,7 years, with a median observation time 12 years.The 5-, 10-, 15-, and 25-year overall survival (OS) in the whole group was 93% : 86% : 82% : 82%, respectively. A tendency for better survival was found for patients with age < or = 15 than for those with > 15 years, with 5-, 10-, and 15- year OS of 95% : 87% : 84% vs 84% : 84% : 56%, p = 0.09. There was a trend for better survival in males compared with females with 5-, 10- and 15-year OS of 96%: 93%: 91% vs 88% : 73% : 65%, p = 0.001. The OS difference between CS IIB and IIIA turned out to be significant in favor of the patients in CS IIIA with 5- and 10-year OS of 89%: 76% vs 95%: 90%, respectively, p = 0.03. The following factors were analyzed for their prognostic influence: age, gender, stage, histologic subtype at first diagnosis, sites of involvement, number of involved lymph node areas, B symptoms, hepatosplenomegaly, anemia, elevated serum LDH, daily dose, total dose, boost and technique used in EFRT. In univariate analysis, independent risk factors were gender (p < 0.001), stage (IIB: IIIA) (p = 0.03), mediastinal involvement (p = 0.03), daily dose (p = 0.01) and total dose (p = 0.02). In multivariate analysis, independent risk factors age < or = 15 years (p < 0.001), male gender (p = 0.005), daily dose < or = 1.5 Gy (p = 0.009), and total dose 26-30 Gy (p = 0.048) were found to positively affect OS. We investigated a prognostic model, identifying groups of HD patients with particularly responsive disease, combining prognostic factors as age < or = 15 years (p = 0.001), male gender (p = 0.011), and total dose 26-30 Gy (p = 0.012). In the observed 25-year period SPM development was not established in any of the 120 patients subjected to follow-up.

CONCLUSION

The performed first Bulgarian study on CMT including EFRT and CHT exhibited a certain therapeutic potential in the treatment of HD patients, expressed in the achievement of high long term outcome and low SPM frequency.

Desmoid-type fibromatosis in childhood: report of 3 cases with review of the literature

During the last 20 years we observed 3 cases with the rare condition of desmoid fibromatosis in childhood. This benign tumor with infiltrating potential has therapeutic difficulties for the achievement of a stable local tumor control (LTC). In this paper we present our experience with the therapeutic manipulations applied to our patients and go through the relevant literature on desmoids tumors.

[Factors influencing the cosmetic outcome in early breast cancer patients following salvage surgery and radioisotope teletherapy]

It is the purpose of the report to analyze the factors exerting effect on the cosmetic outcome in breast cancer patients (I-II clinical stage), following organ-salvaging operation in conjunction with telegammatherapy. Assessment of the cosmetic results in 100 female patients with early mammary gland cancer is done 5 years after complex treatment (conservative surgery, postoperative radiotherapy, and chemo- and/or hormonotherapy when indicated). The influence of eight factors on the cosmetic outcome attained is evaluated through correlative statistical analysis, namely: breast size, scope of the surgical intervention, number of lymph nodes dissected, type of operative cicatrix, dose exposure of the entire mamma, homogeneity of radiation dose distribution in tre entire mammary gland, dose exposure of the tumor bed and adjuvant therapy. The analysis performed points to the important practical implications of three of the factors: size of operative intervention (axillary dissection range), breast volume and homogeneity of the irradiation dose in the entire breast.

[Gynecological interventions and cesarean section without suturing of the peritoneum (visceral and parietal)]

The authors reveal advantages of sewing off technics of parietal and visceral peritoneum in gynaecologic operations and Caesarean sections compared with common routine technics of sewing up. This study is prospective, controlled and includes two years period. 170 cases of gynaecologic operations and 45 Caesarean sections are investigated. It is confirmed the role of preoperative microbiologic investigations of cervical secret and vaginal secret. On the base of results similar to world experience in this field authors recommend described technics to gynaecologists and obstetricians.