Hyponatremia and takotsubo syndrome: a review of pathogenetic and clinical implications.

Hyponatremia is a common electrolyte abnormality with important prognostic and therapeutic implications. It might exert detrimental effects on various organ systems including the central nervous system (CNS), bone, and heart along with its potential association with poor quality of life. These adverse effects might be largely mediated through a variety of mechanisms including osmotic stress, dysfunctional transmembrane exchangers, and enhanced oxidative stress.Interestingly, hyponatremia might also have an important association with takotsubo syndrome (TTS) that has been universally considered as a reversible form of cardiomyopathy usually emerging in response to various stressors. In this context, severe hyponatremia was previously reported to serve as a direct trigger of TTS evolution largely through its potential impact on CNS and heart. However, pathogenetic and clinical implications of hyponatremia still need to be thoroughly evaluated in patients with TTS. This paper aims to analyze the clinical features of published cases with TTS primarily triggered by hyponatremia and also aims to discuss the association between hyponatremia and TTS from a broader perspective.

Venous leg symptoms, ecchymosis, and coldness in patients with peripheral varicose vein: A multicenter assessment and validation study (VEIN-VIOLET study).

OBJECTIVES: We aimed to evaluate peripheral varicose vein symptoms including ecchymosis and coldness by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire. METHODS: A total of 1120 patients were enrolled to the analysis after the exclusion of 199 patients who did not match the inclusion criteria. Patients were asked to answer the VEINES-Sym questionnaire and questions about ecchymosis and coldness. Scores of ecchymosis and coldness were calculated similar to VEINES-Sym questionnaire. Classifications of peripheral varicose vein were made according to the clinical part of clinical, etiological, anatomical, and pathophysiological classification system and patients with grade 2 or higher were considered as positive for peripheral varicose vein. RESULTS: Frequency of symptoms present in the VEINES-Sym instrument, ecchymosis and coldness were significantly higher in patients with peripheral varicose vein. Mean score of each symptom was significantly lower in peripheral varicose vein patients including scores of ecchymosis and coldness. Logistic regression analysis revealed that presence of hemorrhoids and all symptoms in VEINES-Sym questionnaire except restless leg were significantly and independently associated with peripheral varicose vein. Besides, ecchymosis (odds ratio: 2.04, 95% confidence interval: 1.34-3.08, p = 0.008) but not coldness was significantly and independently associated with peripheral varicose vein. There was also significant correlation of VEINES-Sym score with ecchymosis (r = 0.43, p < 0.001) and coldness (r = 0.47, p < 0.001). CONCLUSIONS: Venous leg symptoms present in VEINES-Sym questionnaire except restless legs, presence of hemorrhoids and ecchymosis are significantly and independently associated with peripheral varicose vein. Not only ecchymosis but also coldness has shown an independent association with total VEINES-Sym score.

Takotsubo syndrome in association with pheochromocytoma: clinical and practical considerations.

In clinical practice, pathophysiology of Takotsubo syndrome (TTS) has been attributed to adrenergic discharge mostly associated with a variety of stressors. Occasionally, organic sources of adrenergic discharge (including pheochromocytoma) might also account for this phenomenon and are not considered as exclusion criteria for the diagnosis of TTS (as opposed to previous suggestions). We read with great interest the recently published article by Maffè et al. that describes a case of fatal TTS due to a ruptured pheochromocytoma in a middle-aged male. In this context, we would like to comment on this interesting case and potential implications of TTS associated with pheochromocytoma....

Cardiac myxoma as a potential trigger of takotsubo cardiomyopathy: A brief review on mechanistic and clinical perspectives.

In clinical practice, cardiac myxomas constitute the majority of benign cardiac neoplasms, and might potentially present with a variety of embolic, obstructive as well as constitutional symptoms. On the other hand, these neoplasms might be potentially associated with the evolution of takotsubo cardiomyopathy (TTC) that is universally considered as a transient form of acute myocardial dysfunction. Accordingly, the present paper primarily aims to focus on potential mechanisms and associated clinical implications of TTC evolution in the setting of cardiac myxomas.

Systemic inflammation in patients with Takotsubo syndrome: a review of mechanistic and clinical implications.

Over recent decades, systemic inflammation  as  quantified  with  inflammation  markers  or  indices has been extensively  investigated  in the setting of  various  cardiovascular  conditions  including heart failure (HF),  acute coronary syndromes (ACS). In contrast, systemic inflammation  in patients with  takotsubo syndrome (TTS) has been an underrated  phenomenon in clinical practice. On the other hand, experimental and clinical data  have been  rapidly  accumulating  in the recent years  regarding   pathogenetic, prognostic as well as therapeutic implications of  systemic inflammation in TTS.  Accordingly, the present article  aims to provide a general perspective  on mechanistic and  clinical aspects of  systemic  inflammation in the setting of  TTS.

Cardiac Biomarkers in the Setting of Asthma Exacerbations: a Review of Clinical Implications and Practical Considerations.

PURPOSE OF REVIEW: The present paper aims to highlight clinical implications of elevated cardiac biomarkers and associated myocardial dysfunction in a variety of cardiac and non-cardiac scenarios in patients with an asthma exacerbation, and to propose a basic algorithm for cardiovascular evaluation and triage (and hence, for further management) of these patients primarily based on evaluation of cardiac biomarkers along with basic diagnostic modalities and specific cardiac symptoms in the hospital setting. RECENT FINDINGS: Elevation of cardiac biomarkers in the setting of an asthma exacerbation mostly signifies a new-onset subclinical myocardial dysfunction/injury generally associated with certain asthma-related factors including acute hypoxemia and bronchodilator therapy, and usually has a limited prognostic value in these patients. On the other hand, elevation of these biomarkers in patients with an asthma exacerbation might also denote a variety of certain life-threatening cardiac or non-cardiac conditions associated with significant myocardial dysfunction (acute coronary syndromes (ACSs), sepsis, etc.) that might be masked by the rampant course of the asthma exacerbation, and hence, might possibly go undetected potentially aggravating the prognosis in a portion of these patients. In patients with an asthma exacerbation, it seems imperative to timely diagnose and manage emerging diverse clinical conditions particularly through the guidance of cardiac biomarkers and associated myocardial dysfunction patterns in an effort to improve overall prognosis in these patients.

Association between atrial septal aneurysm and arrhythmias.

Objective. This study aimed to assess the association of atrial septal aneurysm (ASA) with cardiac arrhythmias by comparing patients with ASA with a control group with non-ASA, matched for age and gender. Methods. 641 patients with ASA who fulfilled the inclusion criteria were enrolled into the study. The control group consisted of 641 patients without ASA. Patients underwent physical, electrocardiographic and transthoracic echocardiographic examinations. Additional examinations such as transesophageal echocardiography, 24-h rhythm Holter monitoring, and electrophysiological study were performed when clinically needed. Results. There were no differences between the groups in respect to baseline demographic, clinical parameters and echocardiographic parameters except ischemic stroke and smoking status. Percentages of patients suffering from atrial premature complex (APC), ventricular premature complex (VPC), supraventricular tachycardia (SVT) and paroxysmal atrial fibrillation (AF) were higher in ASA patients compared to non-ASA patients. In addition, these parameters were independently associated with the presence of ASA in logistic regression analysis. Conclusions. Certain types of arrhythmias such as APC, VPC, SVT and paroxysmal AF have been shown to be independently associated with the presence of ASA.

Takotsubo cardiomyopathy in the setting of multiple sclerosis: a multifaceted phenomenon with important implications.

Dear Editor, Takotsubo cardiomyopathy (TTC) has been universally regarded as a unique form of reversible myocardial dysfunction associated with a variety of emotional and physical stressors. In their recently published elegant article, Dell'Aquila et al. have reported an interesting case of TTC triggered by an exacerbation of relapsing-remitting multiple sclerosis (MS). However, we would like to comment on this interesting case and its particular implications...

Inflammation in Coronary Artery Ectasia Compared to Atherosclerosis.

We have read with great enthusiasm the article recently published by Boles et al. [...].

Diabetes mellitus and female gender are the strongest predictors of poor collateral vessel development in patients with severe coronary artery stenosis.

BACKGROUND: Coronary collateral vessel development (CVD), i.e., arteriogenesis, is regarded as one of the most important mechanisms­along with angiogenesis­to result in protection of the myocardium. Coronary CVD is associated with a reduction in infarct size, future cardiovascular events and improved survival in patients with occlusive coronary artery disease by enhancing regional perfusion in the chronically ischemic myocardium. In the present study, we aimed to investigate the relation of cardiovascular risk factors and hematological parameters with collateral development in patients with severely stenotic (≥95%) and totally occluded coronary artery disease including at least one major coronary artery. MATERIALS AND METHODS: The study population was selected from the patients who underwent coronary angiography between January 2008 and March 2009. Five hundred and two patients who had at least one coronary artery stenosis ≥95% (368 men; mean age 59 ± 10 years) comprised the study population. Of the 502 patients, 228 had total occlusion in at least one major epicardial coronary artery. Collateral artery grading was performed by using Cohen-Rentrop method to the vessel with coronary artery stenosis of ≥95% and patients with chronic total occlusions (CTO). Patients with grade 0-1 collateral development were regarded as the poor collateral group, and patients with grade 2-3 collateral development were regarded as the good collateral group. RESULTS: Two hundred and fifty-eight (51%) of 502 patients had poor collateral development, and 244 (49%) had good collateral development. Logistic regression analysis revealed that DM was independently associated with poor CVD in patients with ≥95% stenosis (p < 0.001). Additionally, female gender and DM were found to be independently associated with poor CVD in patients with CTO (p = 0.005 and p < 0.001, respectively). Monocyte count was found to be independent of CVD neither in patients with ≥95% stenosis nor in patients with CTO. CONCLUSION: Our data show that DM is an independent factor for poor coronary CVD both in patients with severe coronary artery stenosis and in patients with CTO. Female gender or being in post-menopausal period is another negative risk factor for poor CVD in addition to DM in patients with CTO.

Ignored Role of Paroxysmal Atrial Fibrillation in the Pathophysiology of Cryptogenic Stroke in Patients with Patent Foramen Ovale and Atrial Septal Aneurysm.

The association between cryptogenic stroke (CS) and patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) has been a debate for decades in terms of pathophysiologic processes and clinical courses. This issue has become more interesting and complex, because of the concerns associating the CS with so-called normal variant pathologies of interatrial septum, namely ASA and PFO. While there is an anatomical pathology in the interatrial septum, namely PFO and ASA, the embolic source of stroke is not clearly defined. Moreover, in patients with PFO and CS, the risk of recurrent stroke has also been associated with other PFOunrelated factors, such as hyperlipidemia, body mass index, diabetes mellitus, and hypertension, leading to the difficulty in understanding the pathophysiologic mechanism of CS in patients with PFO and/or ASA. Theoretically, the embolic source of cryptogenic stroke in which PFO and/or ASA has been involved can be categorized into three different anatomical locations, namely PFO tissue and/or ASA tissue itself, right or left atrial chambers, and venous vascular territory distal to the right atrium, i.e., inferior vena cava and lower extremity venous system. However, the possible role of paroxysmal atrial fibrillation associated with PFO and/or ASA as a source of cryptogenic stroke has never been mentioned clearly in the literature. This review aims to explain the association of cryptogenic stroke with PFO and/or ASA in a comprehensive manner, including anatomical, clinical, and mechanistic aspects. The potential role of paroxysmal atrial fibrillation and its contribution to clinical course have been also discussed in a hypothetical manner to elucidate the pathophysiology of CS and support further treatment modalities.

Looking at the Golden Ratio from the Blood Pressure Perspective: Assessing the Hypertensive Patients and Normotensive Subjects.

BACKGROUND: The representatives of mathematical concepts and indices allied to the Golden Ratio (GR) have been shown in the human body in superimposed human hands, phalangeal lengths of the digits, human ears, and the cardiovascular system. Recently, it has been demonstrated that the systolic blood pressure (SBP) to diastolic blood pressure (DBP) ratio measured by ambulatory blood pressure monitoring (ABPM) is close to GR. Accordingly, we aimed to evaluate the ratios between the SBP, DBP, and PP in normotensive and hypertensive patients who were on medical treatment or not, to assess the existence of golden proportions in 24-hour ambulatory blood pressure monitoring results. MATERIAL AND METHOD: Five hundred and twenty-nine patients who underwent ABPM were retrospectively enrolled in the study population. The ABPM was programmed to measure blood pressure every 30 min during the daytime and 60 min night time. Based on the ABPM results, patients were classified as hypertensive (SBP/DBP≥130/80 mmHg) and normotensive (SBP/DBP<130/80 mmHg), depending on ESC/ESH 2018 guidelines. They were also divided into two subgroups: medicated and nonmedicated. Systolic to diastolic blood pressure ratio (SBP/DBP) and diastolic blood pressure to pulse pressure (DBP/PP) were calculated in the usual fashion in all study populations and subgroups. RESULTS: After the exclusion of 133 patients who did not fulfill the inclusion criteria, 396 patients were included in the statistical analysis. Mean SBP/DBP ratios were 1.66±0.15 in all the study population, 1.63±0.11 in normotensive without medication, 1.66±0.13 in normotensive with medications, 1.62±0.15 in hypertensive without medication, and 1.76±0.20 with medications. CONCLUSION: We have documented that SBP to DBP ratios of untreated patients, irrespective of having normal or high blood pressure, run close around the GR. However, SBP to DBP ratios of patients having antihypertensive treatment are far from the GR.