Comparison and outcome analysis of patients with apical and non-apical takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC. METHODS AND RESULTS: Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n = 82, 72%) or absence (n = 32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1 ± 8.9 years vs. 69.5 ± 11.2; P < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8 ± 57 ms vs. 464 ± 34.1 ms; P = 0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P = 0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P = 0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (36 ± 9% vs. 42.4 ± 9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P = 0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison. CONCLUSIONS: The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis.

Residual platelet activity is increased in clopidogrel- and ASA-treated patients with coronary stenting for acute coronary syndromes compared with stable coronary artery disease.

OBJECTIVE: To evaluate residual platelet activity in a consecutive cohort of patients treated with dual antiplatelet therapy after coronary stent implantation DESIGN: Prospective single-centre cohort study. SETTING: University hospital in Germany. PATIENTS: 480 patients with symptomatic coronary artery disease (n = 221 (46%) or acute coronary syndrome (ACS; n = 259 (54%) stable angina) were studied. Platelet activity was measured by collagen- (5 microg/ml) and adenosine diphosphate- (ADP; 20 micromol/l) induced platelet aggregation to assess post-treatment activity in patients treated with acetylsalicylic acid (500 mg bolus intravenously followed by 100 mg once a day) and clopidogrel (600 mg loading dose followed by 75 mg once a day) MAIN OUTCOME MEASURES: Increased residual platelet activity (IRPA) was defined if platelet aggregation was in the upper tertile of values in the patient collective. Association of epidemiological factors with IRPA was evaluated in a multivariate logistic regression analysis. RESULTS: IRPA-ADP was found in 53 patients (11.0%) and IRPA-collagen in 42 patients (8.8%). ACS was associated with IRPA independently from other factors (for IRPA-collagen: odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.2 to 4.5, p<0.05; for IRPA-ADP: OR = 2.4; 95% CI 1.3 to 4.4, p<0.01; for IRPA-ADP/collagen: OR = 4.5, 95% CI 1.2 to 16.9, p<0.05). CONCLUSIONS: The data suggest that ACS is independently associated with IRPA despite conventional antiplatelet therapy. Further studies are warranted to demonstrate the effects of intensified antiplatelet therapy for patients with acute coronary events.

[The QT-interval during "pressure-autotransfusion" with heparin and citrate (author's transl)]. / Das QT-Intervall unter der "Druckautotransfusion" mit Heparin und Citrat.

Nine anaesthetized, splenectomized dogs, heparinized with 300 IU/kg heparin i.v. had one tenth of their blood volume returned to them by autotransfusion under pressure. The blood was mixed with 1:5 0,9% NaCl for the "Heparin-Autotransfusion", and with 1:5 ACD-B or CPD-stabilisor for the "Citrate-Autotransfusion". The blood was removed from an opening made in the left renal artery, and autotransfused with the Bentley-System. A Stathem-Element was used to monitor the aortic pressure and the tracing obtained was divided into four phases: V is at the end of the blood loss before autotransfusion, G is at the peak, S is at the trough and ST is at the phase when the aortic pressure becomes stable. In these four phases the heart rate was also measured in the normal way using needle electrodes in the extremities. Following the method of Colletti the QT intervals of the ECG (RR, QoTc, QTc, SaTc, SoTc) were measured. Immediately after the blood loss (phase V) we found no alteration in the heart rate, depolarisation, isoelectric phase or repolarisation of myocardium. In phase G during the increase in blood volume, the heart rate slowed slightly, but the QT interval was unchanged. In the following phase S, during Heparin-Autotransfusion the heart rate was slightly reduced whilst the ECG remained unchanged. During Citrate-Autotransfusion there was a reduction in heart rate, and a corresponding prolongation of the QTc and QoTc, significantly, without any relationship to the infused dose of citrate. The prolongation of the SaTc and especially of the SoTc correlated directly with the infused dose of citrate. In phase ST using CPD only SaTc and SoTc were prolonged.