Myocardial ischaemia of non-obstructive origin as a cause of new onset anginal chest pain in the long COVID syndrome

Background

New-onset chest pain occurs in around 20% of patients with long COVID syndrome (LCS). Being the vascular endothelium one of the targets of the SARS-CoV-2 virus, we hypothesized that new onset anginal symptoms in LCS could be due to endothelium dysfunction and other non-obstructive causes of myocardial ischaemia.

Methods

We investigated 11 consecutive patients who developed new onset anginal chest pain, suggestive of myocardial ischaemia, after documented SARS-CoV-2 infection. Intracoronary assessment included endothelium-dependent evaluation with acetylcholine testing (Ach), and endothelium-independent assessment with coronary flow reserve (CFR) and microcirculatory resistance (MR). Criteria for positiveness of these tests and medical treatment recommendation were obtained from 2019 ESC guidelines and 2020 EAPCI consensus document on ischaemia with non-obstructive coronary arteries (INOCA).

Results

Mean patient age was 56 years (SD ± 15); 10 (91%) were female. In the acute COVID-19 phase, 4 patients (36%) had had pulmonary infiltrates and 2 (18%) required hospitalization. Conclusive non-invasive tests were obtained in 7 (64%), showing exercise-related myocardial ischaemia in 6 (86%). Coronary angiography ruled out obstructive epicardial stenoses in all the patients. Ach testing revealed abnormal endothelium-dependent responses in 9 (82%) patients: 5 (56%) had epicardial vessel and 4 (44%) microvascular spasm. Endothelium-independent assessment was abnormal in 6 (54%) cases, with abnormal CFR in 2 (33%), abnormal MR in 2 (33) and both abnormal CFR and MR in 2 (33%) patients. The most frequent endotype was combined endothelium dependent- and independent abnormalities (6/9, 67%). Stratified medical treatment according to endotype led to significant improvement in Seattle Angina Scores for angina frequency (+22 points, p=0.013) and a notable trend towards angina stability (+25 points, p=0.093) at a mean follow-up time of 222 days.

Conclusions

Myocardial ischaemia of non-obstructive origin is common in patients with chest pain and LCS. Vasomotor abnormalities related to endothelial dysfunction occurred in 82% of patients, frequently associated to impaired microvascular vasodilation or high microvascular resistance. Stratified medical treatment led to significant improvement in angina stability and frequency.

Funding Acknowledgement

Type of funding sources: None.

Differences between Takotsubo and the working diagnosis of myocardial infarction with non-obstructive coronary arteries

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the XXXX1 registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centers (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p<0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p<0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p<0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p<0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in global mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

Compared to the rest of MINOCA, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding sources: None. Central Illustration

Long-term prognostic impact of renin-angiotensin system blockade in tako-tsubo syndrome

Introduction

Medical therapy in TakoTsubo Syndrome (TTS) remains mainly empirical, given the lack of randomized studies evaluating different pharmacological strategies.

The prognostic benefit of angiotensin-converting-enzyme inhibitors and angiotensin II receptor blocker (ACEI/ARB) is not well established. The clinical data published so far are often based on small sample registries and offer opposite results, both in terms of survival and TTS recurrence.

Expert recommendations seem favorable to the prescription of ACEI and ARB. Nevertheless, clinical investigation is encouraged for validating the observed results.

Purpose

The aim of our study was to evaluate the long-term prognostic impact of renin-angiotesin blockers (ACEI or ARB) in terms of mortality and TTS recurrence.

Methods

The data analyzed in this study were obtained from the nationwide registry “RETAKO”. It included TTS post-discharge survivors, between January 1, 2003, and July 31, 2018. A total of 1062 patients were included for analysis. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were performed to asses the prognostic benefit of ACEI/ARB. Primary endpoint was a composite outcome of all-cause mortality and TTS recurrence.

Results

A total of 1062 TTS patients were included. ACEI or ARB were used in 639 patients (60.2%). During a mean follow-up of 2.7±3.5 years, there were 101 deaths (3.9 per 100 patients/year) and 34 recurrences of TTS (1.3 per 100 patients/year). We found no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox regression analysis (Hazard Ratio [HR] 0.69, 95% Confidence Interval [CI] 0.47–1.02) between patients treated and untreated with ACEI/ARB. After performing propensity score matching, differences in long term prognosis (all-cause mortality or recurrence) remained no statistically significant (HR 0.73, 95% CI 0.45–1.18).

Conclusions

In this observational study, we found that ACEI and ARB therapy was not significantly associated with improved long term survival free of recurrence in post-discharged TTS patients.

Funding Acknowledgement

Type of funding sources: None. Incidence of primary endpoint

Shall be takotsubo tear apart from working diagnosis of myocardial infarction with non-obstructive coronary arteries?

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work is to evaluate main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the RETAKO registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centres (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p<0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p<0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p<0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p<0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in total mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

TTS has a different patient's profile and a more aggressive acute phase than the rest of MINOCA. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a distinct entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding source: None

Long-term prognostic benefit of beta-blockers use after discharge in patients with Tako-Tsubo syndrome

Background

Tako-tsubo Syndrome (TS) seems to be associated with a catecholamine-mediated mechanism. However, the impact of beta-blockers (BB) in-hospital and after discharge still remain uncertain. Objectives: The purpose of the study was to examine whether BB use after discharge in patients with TS, was associated with lower long-term mortality and recurrence.

Methods

Using a national multicentre large-scale inpatient database (RETAKO Registry), we analysed patients with a definitive TS diagnosis.

Results

A total of 970 patients were analysed (568 with BB therapy and 402 no-BB therapy). After discharge and over a median of follow-up of 1.1 years, treatment with BB have no shown prognostic effectiveness in terms of mortality and TS recurrence in unadjusted and adjusted Cox analysis (HR 0.86; 95% CI: 0.59 to 1.27; and 0.95; 95% CI: 0.57–1.13, respectively).

Conclusions

This data suggests that use of beta-blockers after hospital discharge has not shown long-term prognostic benefit in patients with Tako-tsubo Syndrome.

Prognostic impact of BB in TS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Retako webpage was funded by a non-conditioned Astrazeneca scholarship.

Electrocardiographic characteristics and associated outcomes in patients with Takotsubo syndrome. Insights from the RETAKO registry

Background

Our aim was to describe the prevalence and prognostic significance of electrocardiographic features in patients with Takotsubo syndrome (TTS).

Methods

Our data come from the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO). All patients with complete electrocardiogram were included.

Results

246 patients were studied, mean age was 71.3±11.5 and 215 (87.4%) were women. ST-segment elevation was seen in 143 patients (59.1%) and was present in ≥2 wall leads in 97 (39.8%). Exclusive elevation in inferior leads was infrequent (5 - 2.0%). After 48 hours, 198 patients (88.0%) developed negative T-waves in a median of 8 leads with a mean amplitude of 0.7±0.5 mV. Mean corrected QT interval was 520±72 ms and it was independently associated with the primary endpoint of all-cause death and nonfatal cardiovascular events (p=0.002) and all-cause death (p=0.008). A higher heart rate at admission was also an independent predictor of the primary endpoint (p=0.001) and of developing acute pulmonary edema (p=0.04). ST-segment elevation with reciprocal depression was an independent predictor of all-cause death (p=0.04). Absence of ST-segment deviation was a protective factor (p=0.005) for the primary endpoint. Arrhythmias were independently associated with cardiogenic shock (p<0.001).

Conclusion

Prolonged corrected QT interval, arrhythmia, heart rate at admission and broader repolarization alterations are associated with a poor outcome in TTS.

Typical ECG at admission and after 48h.

Funding Acknowledgement

Type of funding source: None