The fifth takotsubo variant.

We document the fifth pattern of takotsubo cardiomyopathy, in which the mid-LV is hyperdynamic but the apex and base are akinetic or hypokinetic. This is a reverse mid-ventricular takotsubo. The patient is a 79-year-old woman admitted with chest pain and initially a normal EKG. Her troponin I rose to 5.4 µg/L (0.02-0.03 µg/L) and she developed QT prolongation and widespread T-wave inversion. Coronary angiography showed only very mild atheroma. Follow-up echocardiogram six weeks later showed normal left ventricular function.

Frailty in acute cardiology: comparison of a quick clinical assessment against a validated frailty assessment tool.

BACKGROUND: Increasingly frail patients are being to be referred for invasive cardiac interventions and cardiac surgery. We aimed to evaluate the utility of a quick clinical assessment of frailty against a validated frailty assessment tool in an acute cardiology setting. METHODS: Forty-seven cardiology in-patients ≥70 years were recruited in this prospective study. All patients were first assessed by a senior cardiology registrar as either not-frail or frail. This was based on general observation and brief discussions. Following this, patients were administered the Reported Edmonton Frail Scale (REFS) questionnaire. After a registrar assessment, the foot-of-the bed frailty assessment was independently repeated by one or two consultant cardiologists. RESULTS: None of the three clinicians showed satisfactory similarity to the REFS score. When the two consultants were compared with the registrar, and with each other, the Cohen's kappa was only above 0.7 for the comparison between Consultant 1 and the registrar. Consultant 1 and the registrar were also significantly more likely to disagree at higher REFS score with a mean REFS score of 8.8. CONCLUSION: A quick foot-of-the-bed clinical assessment is not a reliable way to determine frailty.

A case of recurrent earthquake stress cardiomyopathy with a differing wall motion abnormality.

We present the case of a Caucasian woman who survived two major earthquakes, presenting on each occasion with stress cardiomyopathy, but with a different pattern of regional wall motion abnormality on the second occasion. The first Christchurch earthquake struck on September 4, 2010. At 7.1 on the Richter scale, it was larger than the major Haiti quake, but miraculously there were no direct fatalities. In the week following, eight women meeting modified Mayo criteria for stress cardiomyopathy presented to Christchurch Hospital. The second Christchurch earthquake was on February 22, 2011. It measured 6.4 on the Richter scale and caused 180 direct fatalities. In the week following this earthquake, 24 women were admitted with stress cardiomyopathy. One patient presented after both earthquakes. This 76-year-old woman first presented on September 4 with 10 hours of chest pain. Electrocardiogram showed inferolateral deep T-wave inversion and QT prolongation. TnI peaked at 0.81 µg/L. Coronary angiography demonstrated diffuse atheroma with a moderate mid LAD lesion that was stented at the time. Echocardiography showed a classic takotsubo pattern. Her follow-up echocardiogram on September 28 was normal and she was completely well at that point. However, during the second earthquake of February 22, she again developed chest pain and shortness of breath. TnI peaked at 1.3 µg/L. Echocardiogram showed a midwall variant takotsubo with apical sparing. She was discharged from hospital on the 25th, planning to leave Christchurch for a new home in another city, but returned for follow-up echocardiogram on July 27. This was normal.

Successful management of a large air embolus during an extended right hepatectomy with an emergency cardiopulmonary bypass.

BACKGROUND: An air embolus is a recognized but rare complication of a partial hepatectomy. The aim of this report was to describe the diagnosis and management of a large paradoxical air embolus during hepatic resection. METHODS: Case report. RESULTS: A single patient report of a massive paradoxical air embolus during an extended right hepatectomy is described. The diagnosis was confirmed by trans-oesophageal echo (video provided). After failed conservative management an emergency cardiopulmonary bypass was instituted with a successful outcome. CONCLUSION: Surgeons and anaesthetists involved in hepatic surgery should be aware of signs, investigations and management of this life-threatening intra-operative complication.

A randomised cross-over trial of QT response to hyperventilation-induced anxiety and diaphragmatic breathing in patients with stress cardiomyopathy and in control patients.

OBJECTIVES: The most perfect example of the mind-body interaction in all of medicine is provided by stress cardiomyopathy. In stress cardiomyopathy, what is initially a purely emotional event may become rapidly fatal. Prolongation of the QT interval is a cardinal feature of the condition, but the mechanism of the prolongation is unknown. We undertook a randomised controlled trial of stress with a cross-over design, comparing the cardiac response of women with a history of stress cardiomyopathy to age-matched controls to explore the mind-body interaction. Our hypothesis is that the hearts of women with a history of stress cardiomyopathy will respond differently to emotional stress than those of the controls. METHOD: This is a randomised cross-over study. Each patient underwent two separate 24-hour Holter monitors performed at least 5 days apart. Baseline recording was followed by either the stress intervention (hyperventilation) or control (diaphragmatic breathing). Our primary endpoint is change in QTc interval over the first hour. Secondary endpoints were change in QTc over 24 hours, and change in SDNN, a measure of heart rate variability. As a secondary stressor, each participant was telephoned four times during their stressed recording and asked to complete a questionnaire. RESULTS: Twelve stress cardiomyopathy patients and twelve control patients were recruited. Baseline characteristics did not differ between cases and controls. With hyperventilation, there was a significant initial difference in anxiety (p<0.001), heart rate response (p<0.0001), and QTc (p<0.0002) compared to diaphragmatic breathing, but no differences between the cases and controls. Only first phone call caused an increase in QTc in cases and controls (p = 0.0098). SDNN increased with hyperventilation (p<0.0001) but did not differ between cases and controls. CONCLUSIONS: QTc response in women with a history of stress cardiomyopathy does not differ from controls. The relevance of QT prolongation and sensitivity in the autonomic response to the pathogenesis of stress cardiomyopathy remains uncertain.

Transforming growth factor-beta blockade down-regulates the renin-angiotensin system and modifies cardiac remodeling after myocardial infarction.

After myocardial infarction (MI), the heart may undergo progressive ventricular remodeling, resulting in a deterioration of cardiac function. TGF-beta is a key cytokine that both initiates and terminates tissue repair, and its sustained production underlies the development of tissue fibrosis, particularly after MI. We investigated the effects of a novel orally active specific inhibitor of the TGF-beta receptor 1 (SD-208) in an experimental model of MI. Mice underwent ligation of the left coronary artery to induce MI and were subsequently treated for 30 d after infarction with either SD-208 or a vehicle control. Blockade of TGF-beta signaling reduced mean arterial pressure in all groups. SD-208 treatment after MI resulted in a trend for reduced ventricular and renal gene expression of TGF-beta-activated kinase-1 (a downstream modulator of TGF-beta signaling) and a significant decrease in collagen 1, in association with a marked decrease in cardiac mass. Post-MI SD-208 treatment significantly reduced circulating levels of plasma renin activity as well as down-regulating the components of the cardiac and renal renin-angiotensin system (angiotensinogen, angiotensin converting enzyme, and angiotensin II type I receptor). Our findings indicate that blockade of the TGF-beta signaling pathway results in significant amelioration of deleterious cardiac remodeling after infarction.

Copy number variants implicate cardiac function and development pathways in earthquake-induced stress cardiomyopathy.

The pathophysiology of stress cardiomyopathy (SCM), also known as takotsubo syndrome, is poorly understood. SCM usually occurs sporadically, often in association with a stressful event, but clusters of cases are reported after major natural disasters. There is some evidence that this is a familial condition. We have examined three possible models for an underlying genetic predisposition to SCM. Our primary study cohort consists of 28 women who suffered SCM as a result of two devastating earthquakes that struck the city of Christchurch, New Zealand, in 2010 and 2011. To seek possible underlying genetic factors we carried out exome analysis, genotyping array analysis, and array comparative genomic hybridization on these subjects. The most striking finding was the observation of a markedly elevated rate of rare, heterogeneous copy number variants (CNV) of uncertain clinical significance (in 12/28 subjects). Several of these CNVs impacted on genes of cardiac relevance including RBFOX1, GPC5, KCNRG, CHODL, and GPBP1L1. There is no physical overlap between the CNVs, and the genes they impact do not appear to be functionally related. The recognition that SCM predisposition may be associated with a high rate of rare CNVs offers a novel perspective on this enigmatic condition.

Prediction of cardiac rhythm 1 year following cardioversion for atrial fibrillation.

BACKGROUND: There is little recent information regarding outcome and its determinants following cardioversion (CV) for atrial fibrillation (AF) or flutter. This study aims to help improve prediction of cardiac rhythm outcome following CV for AF. METHODS: Cardiac rhythm at 6 weeks and 12 months was documented following elective (EC; n=496) or immediate (IC; n=52) cardioversion for AF or atrial flutter in a single referral centre. RESULTS: 65 and 58% of IC patients remained in sinus rhythm (SR) 6 weeks and 1 year after CV (respectively) compared with 43% and 30% in EC patients (P<0.001). Independent positive predictors of SR 6 weeks after cardioversion included amiodarone therapy (OR 2.04 [1.28-3.33], P<0.01) and atrial flutter (OR 1.85 [1.09-3.13], P<0.05). Negative predictors included the need for >1 shock to achieve SR (OR 1.61 [1.12-2.37], P=0.011) and arrhythmia duration, (OR 0.96 [0.95-0.97], P<0.001). At 1 year, amiodarone, duration of arrhythmia and the need for >1 shock remained independent predictors of rhythm. CONCLUSIONS: The number of shocks required to achieve SR is a newly demonstrated independent predictor of rhythm outcome after elective CV.

Survey of clinical echocardiography in New Zealand (SCANZ).

AIMS: In New Zealand, we have neither guidelines nor data regarding the provision of echocardiography and disparities between regional echocardiography are believed to exist. The purpose of this study was to provide a cross-sectional snapshot of clinical use of echocardiography within New Zealand (NZ). METHODS: Over a 1-week period (5/12/2005-11/12/2005) echocardiography laboratories around NZ (tertiary, secondary hospitals, and private practices) sent copies of their echo reports and referral forms (with patient identifiers removed) to a central site. Demographic information, clinical indication, measurements performed, and interpretation were collated, recorded, reviewed, tabulated, and entered into a Microsoft Access database. RESULTS: 1498 echoes were performed, 92% were transthoracic examinations. Adult examinations comprised 83% of the echocardiograms performed: median age was 61.7 years (interquartile range 47.3 to 74.1) and 56% were male. The three most common primary clinical indications were: left ventricular (LV) function (43%), valve disease (14%), and murmur (7.5%). Seventy-five percent reported abnormal findings. There was wide disparity in the population adjusted rates of echoes performed across NZ's district health boards. CONCLUSION: This prospective survey provides a contemporary overview of echocardiography in NZ and highlights the inherent geographical disparity in echocardiography utilisation throughout the country.

Late presentation of a cardiomyopathy provoked by sudden emotional stress.

This case report describes a Caucasian woman with an acute and reversible cardiomyopathy provoked by sudden emotional stress. Notable features of the case are the lack of neurohumoral activation, a 1-week delay between the identified emotional stressor and presentation, and the development of torsades de pointes with amiodarone therapy. Amiodarone should be viewed as contraindicated in this condition.

Asymmetric myocardial thickening during acute myocarditis.

The case of a young man presenting with an acute myocarditis is described. Transthoracic echocardiography showed severe asymmetric thickening of the posterolateral left ventricle with associated hypokinesis. These abnormalities resolved following the patient's recovery from the acute illness. Asymmetric posterolateral myocardial thickening has not previously been reported in acute myocarditis.