Atypical Takotsubo Cardiomyopathy Precipitated by Gastrointestinal Bleeding: Review of the Pathophysiology.

Stress-induced cardiomyopathy, otherwise known as takotsubo cardiomyopathy, typically presents with chest pain and acute left ventricular failure with unobstructed coronary arteries. There is an increase in disease incidence as clinicians are becoming more aware of this clinical entity. An atypical variant exists where there is left ventricular dysfunction with apical sparing. Various precipitants have been described in the literature, however, there has not been any documented case following massive gastrointestinal bleeding. We report an atypical variant of takotsubo cardiomyopathy following a gastrointestinal bleed with review of the pathophysiologic mechanisms behind the disease process.

A randomized trial of intravenous n-acetylcysteine to prevent contrast induced nephropathy in acute coronary syndromes.

BACKGROUND: Pharmacokinetic data suggests that the intravenous form of n-acetylcysteine (NAC) may be more effective than the oral formulation in preventing contrast induced nephropathy (CIN). NAC owing to its anti-oxidant properties might be beneficial for patients with acute coronary syndromes (ACS) who are at increased risk for CIN. The aim of this prospective randomized, single-center, double-blind, placebo controlled trial (NCT00939913) was to assess the effect of high-dose intravenous NAC on CIN in ACS patients undergoing coronary angiography and/or percutaneous coronary intervention (PCI). METHODS: We randomized 398 ACS patients scheduled for diagnostic angiography ± PCI to an intravenous regimen of high-dose NAC (1,200 mg bolus followed by 200 mg/hr for 24 hr; n = 206) or placebo (n = 192). The primary end-point was incidence of CIN defined as an increase in serum creatinine concentration ≥ 25% above the baseline level within 72 hr of the administration of intravenous contrast. RESULTS: There was no difference found for the primary end point with CIN in 16% of the NAC group and in 13% of the placebo group (p = 0.40). Change in serum cystatin-C, a sensitive marker for renal function, was 0.046 ± 0.204 in the NAC group and 0.002 ± 0.260 in the control group (p = 0.07). CONCLUSION: In ACS patients undergoing angiography ± PCI, high-dose intravenous NAC failed to reduce the incidence of CIN.

Factors related to a clinically silent peri-procedural drop in hemoglobin with coronary and peripheral vascular interventions.

Clinically evident and subclinical peri-procedural bleeding following interventional therapies are associated with adverse cardiovascular outcomes. The risk factors for clinically evident bleeding have been well described. Despite the well-documented association of adverse outcomes for patients with a subclinical peri-procedural hemoglobin drop, the clinical predictors have not yet been defined. We identified 1176 consecutive patients with a subclinical drop in hemoglobin (fall of ≥ 1 g/dl in patients without clinical bleeding) following percutaneous coronary interventions (PCI) and peripheral vascular interventions (PVI). Multivariate logistic regression analysis was performed. A subclinical peri-procedural hemoglobin drop ≥ 1 g/dl was identified in 41% (400/972) of PCI and in 49% (213/435) of PVI. More than one access site predicted a higher risk of a subclinical drop in hemoglobin in both groups. A body mass index ≥ 30 predicted a lower risk of a subclinical drop in hemoglobin in both groups. For PCI, creatinine clearance < 60 ml/min was associated with a higher risk of a subclinical drop in hemoglobin. In conclusion, clinically silent peri-procedural hemoglobin fall ≥ 1 g/dl is common in patients undergoing both coronary and peripheral percutaneous intervention. Predictors identified in our study will need prospective validation.

Ultrasound velocity criteria for renal in-stent restenosis.

BACKGROUND: Renal artery stent placement is a recognized treatment for patients with hemodynamically significant renal artery stenosis when medical therapy fails. Duplex ultrasound (DUS) is the primary method used for noninvasive assessment of renal artery patency. Arterial stents alter the compliance of the artery, which could make the standard reference values, based on native renal artery velocities, inaccurate. This study attempted to determine DUS criteria for renal artery in-stent restenosis (ISR). METHODS: We studied 67 consecutive patients with suspected renal artery ISR based on abnormal renal DUS results, defined as peak systolic velocity (PSV) >or=200 cm/s and renal/aortic velocity ratio (RAR) >or=3.5. The ISR patients were compared with 55 consecutive nonstented patients who underwent renal DUS evaluation and renal angiography. Those with >or=50% angiographic narrowing in each group were analyzed, and renal PSV and RAR were compared. RESULTS: In the 67 patients with renal stents and 55 patients without renal stents, a statistically significant correlation was found for both PSV and RAR in detecting renal ISR and renal artery stenosis as defined by quantitative angiography (P = .02). For any level of angiographic stenosis >or=50%, the ISR group had relatively higher PSV and RAR compared with the nonstented group. Receiver operating characteristic curves indicated that PSV >or=395 cm/s or RAR >or=5.1 were the most predictive of angiographically significant ISR >or=70%. CONCLUSION: The current DUS criteria for native renal arteries may overestimate the degree of angiographic ISR due to changes in compliance. We recommend that DUS laboratories make adjustments in PSV and RAR obtained by DUS when monitoring the patency of renal stents for ISR.

Impella 2.5 assisted balloon aortic valvuloplasty and percutaneous coronary intervention as a bridge to heart transplantation.

Percutaneous left ventricular assist device (pLVAD) utilization is increasing as the potential applications expand. We report a case of high-risk balloon aortic valvuloplasty and percutaneous coronary intervention using the Impella 2.5 pLVAD in a patient with severely depressed left ventricular function as a bridge to heart transplantation.

Acute limb ischemia.

Acute limb ischemia is a medical emergency with management options ranging from urgent revascularization to limb amputation. The best patient outcome requires tailoring the treatment to the individual patient. This article describes a step-by-step approach for diagnosis and management of patients presenting with acute limb ischemia.