Two-year outcomes after percutaneous coronary intervention with drug-eluting stents or bare-metal stents in elderly patients with coronary artery disease.

OBJECTIVES: Report the results at 2 years of the patients included in the SENIOR trial. BACKGROUND: Patients above 75 years of age represent a fast-growing population in the cathlab. In the SENIOR trial, patients treated by percutaneous coronary intervention (PCI) with drug eluting stent (DES) and a short duration of P2Y12 inhibitor (1 and 6 months for stable and unstable coronary syndromes, respectively) compared with bare metal stents (BMS) was associated with a 29% reduction in the rate of all-cause mortality, myocardial infarction (MI), stroke, and ischaemia-driven target lesion revascularization (ID-TLR) at 1 year. The results at 2 years are reported here. METHODS AND RESULTS: We randomly assigned 1,200 patients (596[50%] to the DES group and 604[50%] to the BMS group). At 2 years, the composite endpoint of all-cause mortality, MI, stroke and ID-TLR had occurred in 116 (20%) patients in the DES group and 131 (22%) patients in the BMS group (RR 0.90 [95%CI 0.72-1.13], p = .37). IDTLR occurred in 14 (2%) patients in the DES group and 41 (7%) patients in the BMS group (RR 0.35 [95%CI 0.16-0.60], p = .0002). Major bleedings (BARC 3-5) occurred in 27(5%) patients in both groups (RR 1.00, [95%CI 0.58-1.75], p = .99). Stent thrombosis rates were low and similar between DES and BMS (0.8 vs 1.3%, (RR 0.52 [95%CI 0.01-1.95], p = .27). CONCLUSION: Among elderly PCI patients, a strategy combining a DES together with a short duration of DAPT is associated with a reduction in revascularization up to 2 years compared with BMS with very few late events and without any increased in bleeding complications or stent thrombosis.

Drug-eluting stents in elderly patients with coronary artery disease (SENIOR): a randomised single-blind trial.

BACKGROUND: Elderly patients regularly receive bare-metal stents (BMS) instead of drug-eluting stents (DES) to shorten the duration of double antiplatelet therapy (DAPT). The aim of this study was to compare outcomes between these two types of stents with a short duration of DAPT in such patients. METHODS: In this randomised single-blind trial, we recruited patients from 44 centres in nine countries. Patients were eligible if they were aged 75 years or older; had stable angina, silent ischaemia, or an acute coronary syndrome; and had at least one coronary artery with a stenosis of at least 70% (≥50% for the left main stem) deemed eligible for percutaneous coronary intervention (PCI). Exclusion criteria were indication for myocardial revascularisation by coronary artery bypass grafting; inability to tolerate, obtain, or comply with DAPT; requirement for additional surgery; non-cardiac comorbidities with a life expectancy of less than 1 year; previous haemorrhagic stroke; allergy to aspirin or P2Y12 inhibitors; contraindication to P2Y12 inhibitors; and silent ischaemia of less than 10% of the left myocardium with a fractional flow reserve of 0·80 or higher. After the intended duration of DAPT was recorded (1 month for patients with stable presentation and 6 months for those with unstable presentation), patients were randomly allocated (1:1) by a central computer system (blocking used with randomly selected block sizes [two, four, eight, or 16]; stratified by site and antiplatelet agent) to either a DES or similar BMS in a single-blind fashion (ie, patients were masked), but those assessing outcomes were masked. The primary outcome was to compare major adverse cardiac and cerebrovascular events (ie, a composite of all-cause mortality, myocardial infarction, stroke, or ischaemia-driven target lesion revascularisation) between groups at 1 year in the intention-to-treat population, assessed at 30 days, 180 days, and 1 year. This trial is registered with ClinicalTrials.gov, number NCT02099617. FINDINGS: Between May 21, 2014, and April 16, 2016, we randomly assigned 1200 patients (596 [50%] to the DES group and 604 [50%] to the BMS group). The primary endpoint occurred in 68 (12%) patients in the DES group and 98 (16%) in the BMS group (relative risk [RR] 0·71 [95% CI 0·52-0·94]; p=0·02). Bleeding complications (26 [5%] in the DES group vs 29 [5%] in the BMS group; RR 0·90 [0·51-1·54]; p=0·68) and stent thrombosis (three [1%] vs eight [1%]; RR 0·38 [0·00-1·48]; p=0·13) at 1 year were infrequent in both groups. INTERPRETATION: Among elderly patients who have PCI, a DES and a short duration of DAPT are better than BMS and a similar duration of DAPT with respect to the occurrence of all-cause mortality, myocardial infarction, stroke, and ischaemia-driven target lesion revascularisation. A strategy of combination of a DES to reduce the risk of subsequent repeat revascularisations with a short BMS-like DAPT regimen to reduce the risk of bleeding event is an attractive option for elderly patients who have PCI. FUNDING: Boston Scientific.

Platelet function monitoring to adjust antiplatelet therapy in elderly patients stented for an acute coronary syndrome (ANTARCTIC): an open-label, blinded-endpoint, randomised controlled superiority trial.

BACKGROUND: Elderly patients are at high risk of ischaemic and bleeding events. Platelet function monitoring offers the possibility to individualise antiplatelet therapy to improve the therapeutic risk-benefit ratio. We aimed to assess the effect of platelet function monitoring with treatment adjustment in elderly patients stented for an acute coronary syndrome. METHODS: We did this multicentre, open-label, blinded-endpoint, randomised controlled superiority study at 35 centres in France. Patients aged 75 years or older who had undergone coronary stenting for acute coronary syndrome were randomly assigned (1:1), via a central interactive voice-response system based on a computer-generated permuted-block randomisation schedule with randomly selected block sizes, to receive oral prasugrel 5 mg daily with dose or drug adjustment in case of inadequate response (monitoring group) or oral prasugrel 5 mg daily with no monitoring or treatment adjustment (conventional group). Randomisation was stratified by centre. Platelet function testing was done 14 days after randomisation and repeated 14 days after treatment adjustment in patients in the monitoring group. Study investigators and patients were not masked to treatment allocation, but allocation was concealed from an independent clinical events committee responsible for endpoint adjudication. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, urgent revascularisation, and Bleeding Academic Research Consortium-defined bleeding complications (types 2, 3, or 5) at 12 months' follow-up. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01538446. FINDINGS: Between March 27, 2012, and May 19, 2015, we randomly assigned 877 patients to the monitoring group (n=442) or the conventional group (n=435). The primary endpoint occurred in 120 (28%) patients in the monitoring group compared with 123 (28%) patients in the conventional group (hazard ratio [HR], 1·003, 95% CI 0·78-1·29; p=0·98). Rates of bleeding events did not differ significantly between groups. INTERPRETATION: Platelet function monitoring with treatment adjustment did not improve the clinical outcome of elderly patients treated with coronary stenting for an acute coronary syndrome. Platelet function testing is still being used in many centres and international guidelines still recommend platelet function testing in high-risk situations. Our study does not support this practice or these recommendations. FUNDING: Eli Lilly and Company, Daiichi Sankyo, Stentys, Accriva Diagnostics, Medtronic, and Fondation Coeur et Recherche.

Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: design of the randomized antarctic study.

BACKGROUND: Elderly patients are at high risk for both ischemic and bleeding events. Platelet monitoring offers the opportunity to individualized antiplatelet therapy to optimize the therapeutic risk/benefit ratio. STUDY DESIGN: The ANTARCTIC study is designed to demonstrate the superiority of a strategy of platelet function monitoring with dose and drug adjustment in patients initially on prasugrel 5 mg as compared with a more conventional strategy using prasugrel 5 mg without monitoring and without adjustment (Conventional Treatment Arm) to reduce the primary end point evaluated 1 year after stent percutaneous coronary intervention in elderly patients presenting with an acute coronary syndrome (ACS). ANTARCTIC is a multicenter, prospective, open-label study with 2 parallel arms. A total of 852 elderly patients (≥ 75 years) undergoing stent percutaneous coronary intervention for ACS are to be enrolled. The primary end point is the time to first occurrence of cardiovascular death, myocardial infarction, stroke, definite stent thrombosis, urgent revascularization, and bleeding complications (Bleeding Academic Research Consortium definition 2, 3, or 5). Platelet function analyses will be performed 14 days after randomization and repeated 14 days later in patients who require a change in treatment. CONCLUSION: ANTARCTIC is a nationwide, prospective, open-label study testing a strategy of platelet function monitoring with dose and drug adjustment to reduce ischemic and bleeding complications in elderly ACS patients undergoing coronary stenting.

Clinical Outcomes in Patients Treated With Biodegradable-Polymer Biolimus-Eluting Stents and 6 Months of Dual-Antiplatelet Therapy: The French eBiomatrix 6-Month DAPT Registry.

BACKGROUND: Dual-antiplatelet treatment (DAPT) has conventionally been prescribed for 1 year after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Recent evidence suggests that a duration of only 6 months may be equally safe and effective when using contemporary DES options. OBJECTIVE: The aim of this study was to assess clinical outcomes in patients treated with the BioMatrix biodegradable-polymer coated biolimus-eluting stent (BP-BES; Biosensors International) who received only 6 months of DAPT. METHODS: This prospective "all-comers" registry enrolled 2038 patients in France. Following PCI, DAPT was started for a recommended period of 6 months. Patients were followed up at 6 and 24 months. The primary endpoint of major adverse cardiac and cerebrovascular event (MACCE) was a composite of all-cause death, cerebrovascular accidents, non-fatal myocardial infarction, or clinically driven target-vessel revascularization. Secondary endpoints included stent thrombosis (ST) and major bleeding (MB). RESULTS: The mean age of the study population was 67 ± 10.5 years and 77% of patients were male. Follow-up data were available in 96.9% and 95.3% of patients at 6 and 24 months, respectively. At 6 months, the incidences of MACCE, ST, and MB were 3.1%, 0.3%, and 0.4%, respectively. At 24 months, 21.2% of patients were still on DAPT and the cumulative incidences of MACCE, ST, and MB were 9.7%, 0.54%, and 0.79%, respectively. CONCLUSIONS: In this unselected population of patients undergoing PCI with a BP-BES, a 6-month duration of DAPT after implantation is safe and effective.

Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to ventricular fibrillation.

INTRODUCTION: Since 2003, we have routinely used percutaneous coronary intervention (PCI) and mild therapeutic hypothermia (MTH) to treat patients < 80 years of age after out-of-hospital cardiac arrest (OHCA) related to ventricular fibrillation. The aim of our study was to evaluate the prognostic impact of routine PCI in association with MTH and the potential influence of age. METHODS: We studied 111 consecutive patients resuscitated successfully following OHCA related to shock-sensitive rhythm. They were divided into five groups according to age: < 45 years (n = 22, group 1), 45 to 54 years (n = 27, group 2), 55 to 64 years (n = 22, group 3), 65 to 74 years (n = 23, group 4) and ≥75 years (n = 17, group 5). Emergency coronary angiography was performed in hemodynamically stable patients < 80 years old, regardless of the electrocardiogram pattern. MTH was targeted to a core temperature of 32°C to 34°C for 24 hours. RESULTS: Most patients (73%) had coronary heart disease, although its incidence in group 1 was lower than in other groups (41% versus 81%; P = 0.01). In group 1, all patients but one underwent coronary angiography, and 33% of them underwent associated PCI. In group 5, only 53% of patients underwent a coronary angiography and 44% underwent PCI. Overall in-hospital survival was 54%, ranging between 52% and 64% in groups 1 to 4 and 24% in group 5. Time from collapse to return of spontaneous circulation was associated with mortality (odds ratio (OR) = 1.05 (25th to 75th percentile range, 1.03 to 1.08); P < 0.001), whereas PCI was associated with survival (OR = 0.30 (25th to 75th percentile range, 0.11 to 0.79); P = 0.01). CONCLUSIONS: We suggest that routine coronary angiography with potentially associated PCI may favorably alter the prognosis of resuscitated patients with stable hemodynamics who are treated with MTH after OHCA related to ventricular fibrillation. Although age was not an independent cause of death, the clinical relevance of this therapeutic strategy remains to be determined in older people.

Bleeding in the Elderly: Risk Factors and Impact on Clinical Outcomes After an Acute Coronary Syndrome, a Sub-study of the Randomized ANTARCTIC Trial.

BACKGROUND: Elderly patients are at high-risk of bleeding, but are under-represented in clinical trials. OBJECTIVES: The aims were to determine the incidence and the predictive factors of bleeding and to assess the impact of bleeding on further ischemic outcomes in elderly patients after acute coronary syndrome (ACS) treated with percutaneous coronary intervention. METHODS: From the 877 patients aged ≥ 75 years included in the ANTARCTIC randomized trial, data on Bleeding Academic Research Consortium (BARC) bleeding complications and major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, myocardial infarction, and stroke, were collected over 1 year. RESULTS: Clinically relevant bleeding events (BARC types 2, 3, or 5) were observed in 20.6% of patients (n = 181) at 1 year, of which, one third occurred in the first month. Anemia (adjusted hazard ratio [adj.HR] 3.98, 95% confidence interval [CI] 1.41-11.22; p = 0.009), severe chronic renal failure (adj.HR 1.83, 95% CI 1.12-2.98; p = 0.015), and femoral access (adj.HR 2.54, 95% CI 1.71-3.77; p < 0.001) were independently associated with clinically relevant bleeding events, while age > 85 years (adj.HR 2.22, 95% CI 1.14-4.30; p = 0.018) was independently associated with major bleeding events (BARC types 3 or 5). Patients with a clinically relevant bleeding event had a higher rate of MACE at 1 year (adj.HR 2.04, 95% CI 1.24-3.38; p = 0.005), with a particularly strong effect on stroke (adj.HR 5.55, 95% CI 2.04-15.06; p < 0.001). CONCLUSIONS: Clinically relevant bleeding events were observed in one out of five elderly patients undergoing stenting for an ACS and were strongly associated with further stroke occurrence. Rather than the antiplatelet therapy, comorbidities and an age > 85 years predicted bleeding outcomes in this elderly population. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01538446. https://www.clinicaltrials.gov .

Home diagnosis of obstructive sleep apnoea in coronary patients: validity of a simplified device automated analysis.

INTRODUCTION: Our aim was to evaluate a type 3 portable simplified device as a screening tool for obstructive sleep apnoea (OSA) in coronary patients. MATERIALS AND METHODS: In 50 patients selected independently from sleep complaints, we compared the number of respiratory events per hour of valid recording time counted automatically by the device and the number counted manually per hour of sleep on polysomnography performed at home during the same night. RESULTS: Five patients were excluded because of technical failures. Estimated OSA prevalences (95% confidence interval) for apnoea/hypopnoea index (AHI) cut-offs > or = 5, > or = 15, and > or = 30 by polysomnography were 0.93 (0.81-0.98), 0.69 (0.53-0.81), and 0.27 (0.15-0.42), respectively. The device would have correctly diagnosed 75% of patients with severe OSA (AHI > or = 30 by polysomnography) and would have classified the remaining 25% as having moderate OSA. DISCUSSION: This ambulatory device may prove valuable in reducing the costs of diagnosing and managing OSA in coronary patients.

Prevalence and characteristics of left ventricular outflow tract obstruction in Tako-Tsubo syndrome.

BACKGROUND AND OBJECTIVE: Tako-Tsubo syndrome is a clinical entity mimicking acute coronary syndrome (ACS). Left ventricular outflow tract (LVOT) obstruction may occur in Tako-Tsubo syndrome. The aim of this study was to determine the prevalence and features of LVOT obstruction in Tako-Tsubo syndrome in a population presenting with ACS. METHODS: This study included consecutive patients admitted to 2 catheterization laboratories for suspected ACS. All patients underwent echocardiography, coronary arteriography, and left ventricular angiography if no significant coronary lesions were found. RESULTS: Among 10,366 patients referred for coronary angiography, the study population consisted of 3,909 patients with suspected ACS. Thirty-two patients (mean age 71 +/- 13 years old) presented with Tako-Tsubo syndrome, resulting in a prevalence of 0.8% in our population of ACS and 5% of patients without significant coronary lesions. Eight women (mean age 81 +/- 4 years old, P = .01) exhibited LVOT obstruction, a prevalence of 25% among Tako-Tsubo syndrome cases. All patients with intraventricular pressure gradient had systolic anterior motion of the mitral valve and septal bulge. Prevalence of septal bulge was 100% in patients with Tako-Tsubo syndrome and LVOT obstruction versus 29% in patients without LVOT obstruction (P = .002). Mean degree of mitral regurgitation was 2.1 +/- 0.7 in cases of LVOT obstruction versus 0.9 +/- 0.7 in patients without LVOT (P = .0003) and significantly decreased during follow-up (1 +/- 0.8, P = .002). Recovery of left ventricular ejection fraction was similar in patients with and without LVOT obstruction (P = .58). CONCLUSIONS: The present study demonstrates that the prevalence of LVOT obstruction in Tako-Tsubo syndrome is high, with specific characteristics as compared with patients without LVOT obstruction. Echocardiography should be systematically performed for all patients presenting with Tako-Tsubo syndrome for the detection of LVOT obstruction.

Bivalirudin infusion to reduce ventricular infarction: the open-label, randomised Bivalirudin Infusion for Ventricular InfArction Limitation (BIVAL) study.

AIMS: The aim of the study was to investigate whether bivalirudin versus unfractionated heparin (UFH) reduces infarct size (IS) for primary percutaneous coronary intervention (PPCI) in large acute myocardial infarction (AMI). METHODS AND RESULTS: This multicentre open-label trial randomised 78 patients undergoing PPCI for large AMI to bivalirudin or UFH. The primary endpoint was IS, assessed by cardiac magnetic resonance (CMR) five days after PPCI. Secondary endpoints included index of microcirculatory resistance (IMR), CMR-assessed microvascular obstruction (MVO) and ejection fraction, and biomarkers for thrombin activity and cell injury. No difference was observed in mean IS at five days (25.0±19.7 g for bivalirudin vs. 27.1±20.7 g for UFH; p=0.75). Early MVO was numerically lower with bivalirudin (5.3±5.8 g vs. 7.7±6.3 g; p=0.17), with no significant difference in ejection fraction at 90 days (54.6±12.0% vs. 49.1±12.1%; p=0.11). In the biomarkers, thrombin-antithrombin complexes were reduced by 4.8 ug/L over the first day for bivalirudin versus an increase of 1.9 ug/L in the heparin arm (p=0.0003). Acute IMR was lower (43.5±21.6 vs. 68.7±35.8 mmHg×s, respectively; p=0.014). In a planned interim analysis, an approximate 11% reduction in IS was observed with bivalirudin; the trial was discontinued for futility. CONCLUSIONS: This study did not achieve its primary endpoint of significant infarct size reduction in PPCI by prolonged bivalirudin infusion compared to UFH, even though complete thrombin inhibition was achieved in the acute phase, with a lower myocardial microcirculation resistance at the end of the procedure.

Incidence, Characteristics, Risk Factors, and Outcomes of Takotsubo Cardiomyopathy With and Without Ventricular Arrhythmia.

Takotsubo cardiomyopathy (TC) is a medical entity mimicking an acute coronary syndrome (ACS). Ventricular arrhythmia (VA) in TC has been reported in small studies, leading to uncertain knowledge of its incidence. We sought to describe the characteristics, incidence, predictive factors, and outcomes of VA in patients presenting with TC. Over a 12-year period, we reviewed all patients (n = 5,484) referred to our coronary care unit for a suspicion of ACS. TC was diagnosed in 90 patients according to the Mayo Clinic criteria. Incidence of VA among TC was 10%. In multivariate analysis, the factors significantly associated with an increased risk of VA were syncope (p = 0.007), age <55 years (p = 0.008), atypical TC (p = 0.04), a troponin I peak >7 µg/L (p = 0.04), and dobutamine use during hospitalization (p = 0.04). During follow-up, there was no significant difference in mortality rate between patients with or without VA. In conclusion, VA occurred in 10% of patients at the acute phase of TC and independent predictive factors of VA were syncope, atypical pattern of TC, high troponin peak, dobutamine use, and a relatively young age in a female and menopausal population. During the acute phase, identification of high-risk patients with VA allows better management, with electrocardiographic monitoring and therapeutic intervention in the coronary care unit.

Plasma N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in assessment of acute dyspnea.

We examined the analytical correlation between non-radioimmunometric plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) and evaluated whether NT-proBNP or BNP was superior in the emergency diagnosis of heart failure and whether this was influenced by age, gender, body mass index (BMI) and renal function. Data were collected prospectively from patients admitted to the emergency department for acute dyspnea. Plasma BNP (Triage, Biosite) and NT-proBNP (Elecsys, Roche diagnostic(R)) were measured at admission in addition to other standard biological parameters and clinical variables. Reference diagnosis was adjudicated by two independent cardiologists using the European society of cardiology guidelines. We evaluated the influence of creatinine clearance, age, gender and BMI on plasma BNP and NT-proBNP levels. One hundred and sixty consecutive patients were included: 84 females and 76 males, mean age 80.1 + 13.5 (16-98). The analytical correlation between the automated electro-chemiluminescence immunoassay for NT-proBNP and the single use fluorescence immunoassay for BNP was satisfactory using the equation: NT-proBNP = 1.1 BNP + 0.57 and a correlation r = 0.93. This was established over a wide range of concentration (5-6400 pg/ml for BNP). Areas under receiver operating characteristic (ROC) curve for BNP and NT-proBNP as a diagnostic marker for heart failure were 0.82 and 0.84, respectively and a BNP level of 150 pg/ml has similar sensitivity and specificity that NT-proBNP level of 1000 pg/ml. The correlation was not influenced by age, gender and BMI of patients. Renal dysfunction did not affect significantly this correlation (r = 0.93). We conclude that NT-proBNP, as assayed in the present study, correlates closely with BNP. This correlation is only slightly modulated by creatinine clearance values. The NT-proBNP appears as accurate as BNP according to area under ROC curve. Used in conjunction with other clinical information, rapid measurement of BNP or NT-proBNP is useful in establishing or excluding the diagnosis of congestive heart failure in patients with acute dyspnea.

Analytical correlation between plasma N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in patients presenting with dyspnea.

OBJECTIVES: We examined the analytical correlation N-terminal pro-brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP). DESIGN AND METHODS: Electrochemiluminescence and fluorescence immunoassays were used to measure NT-proBNP and BNP levels, respectively. RESULTS: The analytical correlation was satisfactory using the equation: NT-proBNP = 8.56 x BNP + 91.7 and a correlation r = 0.85. The correlation was not influenced by age, gender and BMI of patients. CONCLUSIONS: We conclude that NT-proBNP correlates with BNP.

Prospective assessment of incidence of Tako-Tsubo cardiomyopathy in a very large urban agglomeration.

BACKGROUND: Tako-Tsubo cardiomyopathy (TTC) is a recently described medical entity and the incidence of TTC in a global population is still uncertain. We sought to prospectively assess the incidence of TTC in a large urban area. METHODS AND RESULTS: We included all consecutive patients referred for coronary angiography in three hospitals located in Paris and its suburbs. We prospectively estimated the percentage of TTC among patients referred for coronary angiography and extrapolated the number of cases of TTC in the greater Paris area (11,598,866 inhabitants) according to the CARDIO-ARHIF registry (government agency). Among 2547 patients (2972 coronary angiographies) including 815 acute coronary syndromes, 20 patients presented with TTC (19 women, mean age 66 ± 13 years). The percentage of TTC among suspected acute coronary syndromes was 2.5% (8.2% in women versus 0.2% in men, p<0.001). In the CARDIO-ARHIF registry, we individualized 51,403 coronary angiographies performed in all catheterization laboratories in one year (13,820 women and 10,246 women ≥ 60 years). In this region, the yearly number of TTC cases is estimated to be 346 (95% CI: 216-520). The annual incidence of TTC is estimated to be 29.8 per 1,000,000 inhabitants (95% CI: 18.6-44.9), 48.2 per 1,000,000 inhabitants (95% CI: 29.7-73.0) among women and 187.4 per 1,000,000 inhabitants (95% CI: 103.3-307.2) among women ≥ 60 years. CONCLUSIONS: Within a large urban agglomeration, the incidence of TTC is high in women ≥ 60 years. The current rate of this recently described cardiomyopathy has been underestimated in previous retrospective studies and will probably rise with the increase of life expectancy.

Prevalence of coronary artery spasm during dobutamine stress echocardiography.

The aim of this study was to assess the prevalence of coronary artery spasm during dobutamine stress echocardiography (DSE). Over a 9-year period (from November 2001 to October 2010) we reviewed all patients (n = 2,224) referred for DSE. Criteria for selection included patients > 18 years old who underwent DSE. We systematically analyzed all electrocardiograms obtained during DSE to detect ST-segment elevation during the examination. All patients with ST-segment elevation underwent coronary angiography. DSE was performed in 2,179 patients. ST-segment elevation was observed in 21 patients, all of whom underwent emergency coronary angiography. In 13 of these 21 patients (62%) significant coronary stenosis was observed: 6 patients with critical coronary stenosis and 7 patients with chronic coronary occlusion. The remaining 8 patients (38% of patients presenting with ST-segment elevation during DSE, 7 men, mean age 67 ± 11 years) had no significant coronary stenosis. Prevalence of coronary artery spasm during DSE was 0.4%. In conclusion, physicians should be aware that, although rare, coronary artery spasm may occur during DSE.

Relationship between pattern of Tako-Tsubo cardiomyopathy and age: from midventricular to apical ballooning syndrome.

Several patterns of Tako-Tsubo cardiomyopathy (TTC) have been recently published. However, its physiopathology is still unclear. We report the case of a 63-year-old woman who had a previous history of transient midventricular ballooning and was admitted 11 years after the first TTC, for a recurrence of typical pattern of TTC. Our report suggests that age could affect the left ventricular pattern of TTC and should be taken into account for a correct diagnosis of TTC.

Diagnostic value of contrast echocardiography in Tako-Tsubo cardiomyopathy.

BACKGROUND: Tako-Tsubo cardiomyopathy is a clinical entity mimicking acute coronary syndrome. Assessment of left ventricular function may be difficult using conventional echocardiography. AIMS: to characterize left ventricular systolic function using contrast echocardiography in Tako-Tsubo cardiomyopathy. METHODS: We prospectively studied 63 consecutive women admitted for suspected acute coronary syndrome who underwent coronary arteriography, biplane left ventricular angiography and conventional and contrast echocardiography; 25 women had Tako-Tsubo cardiomyopathy (group 1), 25 women had proven coronary artery disease (group 2) and 13 women had no significant coronary lesion (group 3). Echocardiographic interpretation was performed by two observers: a physician trainee (observer 1) and an experienced investigator (observer 2). RESULTS: Left ventricular segments were assessed for wall motion abnormalities, which were present in 70 and 88% (observer 1) and in 91 and 99% (observer 2), using conventional and contrast echocardiography, respectively (P<0.0001). Accuracy for the diagnosis of Tako-Tsubo cardiomyopathy was improved significantly for both observers using contrast echocardiography: for observer 1, sensitivity was 56 and 88%, respectively, using conventional and contrast echocardiography (P=0.01), whereas for observer 2, sensitivity was 72 and 96%, respectively (P=0.04). Interobserver agreement was excellent using contrast agent (kappa=0.85 vs 0.34 using conventional echocardiography). The blinded review of left ventriculograms distinguished Tako-Tsubo cardiomyopathy from coronary artery disease correctly in 96% of cases. CONCLUSIONS: Contrast echocardiography could be used in routine practice to replace left ventricular angiography in Tako-Tsubo cardiomyopathy.

Apical-sparing variant of Tako-Tsubo cardiomyopathy: prevalence and characteristics.

BACKGROUND: Several patterns of Tako-Tsubo cardiomyopathy (TTC) have been described recently. AIMS: To assess the prevalence and characteristics of an apical-sparing variant of TTC. METHODS: This study included consecutive patients admitted to our catheterization laboratory for suspected acute coronary syndrome (ACS). All patients underwent coronary and left ventricular angiography systematically if no significant coronary lesions were found. RESULTS: Among 2893 patients with a suspected ACS, 38 had confirmed TTC. Nine patients presented with the apical-sparing variant, resulting in a 24% prevalence in our TTC population. At admission, mean left ventricular ejection fraction (LVEF) was significantly higher in patients with apical-sparing TTC (45+/-4% vs 35+/-7%, p=0.01). Patients with classic TTC were significantly older (74+/-10 years vs 63+/-14 years, p=0.01) and had a significantly higher mean heart rate and New York Heart Association functional class (p=0.04 and p=0.002, respectively). Surgical or disease-related stress was found more frequently among patients with the apical-sparing variant (p=0.02). At day 7, mean LVEF was significantly higher in patients with apical-sparing TTC (55+/-6% vs 48+/-6%, p=0.04). At 1-month and 1-year follow-up, no significant difference in LVEF was observed between the two patterns of TTC (p=0.60 and p=0.46, respectively). CONCLUSIONS: The apical-sparing variant of TTC is not rare and differs in several ways from the classic pattern of TTC. Physicians should be aware of and recognize this partial pattern of TTC.