Takotsubo syndrome in a breast-feeding young woman: Highlighting the protection of oestrogens?

Takotsubo syndrome (TTS) is currently described as an acute and usually reversible form of systolic dysfunction of the left ventricle, which more frequently affects postmenopausal women after a stressful emotional event. Although TTS is a rare condition in premenopausal women, in recent years, the number of reported cases has increased. This manuscript reports the first case of a TTS several months after delivery in a 22-year-old woman during lactation. It may also emphasize the role of estrogens in the disease pathogenesis.

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality / Fibrilação Auricular de Novo no Infarto Agudo do Miocárdio com Supradesnível do Segmento ST: Preditores e Impacto na Terapêutica e Mortalidade

Abstract Backgrund: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance. Objective: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction. Methods: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant. Results: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. Conclusion: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

Resumo Fundamento: A fibrilação auricular de novo no contexto de infarto agudo do miocárdio representa um importante desafio com potencial impacto prognóstico. Objetivo: Determinar a incidência, impacto na terapêutica e mortalidade, e identificar possíveis preditores do aparecimento de fibrilação auricular de novo durante o internamento por infarto agudo do miocárdio com supradesnivelamento do segmento ST. Métodos: Estudamos todos os pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST inseridos consecutivamente de 2010 a 2017 num registro nacional português e comparamos dois grupos: 1 - sem fibrilação auricular; 2- com fibrilação auricular de novo. Efetuamos análise com modelo de regressão logística para avaliar o impacto de fibrilação auricular de novo na mortalidade intra-hospitalar e identificar preditores independentes para o seu aparecimento. Para teste de hipóteses, considerou-se significativo p < 0,05. Resultados: Estudamos 6325 pacientes, dos quais 365 (5.8%) apresentaram fibrilação auricular de novo. Não houve diferença no número de pacientes reperfundidos nem na estratégia de reperfusão. No grupo 2, terapêutica com betabloqueadores e IECA/ARA foi menos frequente, 20.6% tiveram alta sob anticoagulação oral e 16.1% sob terapêutica tripla. A fibrilação auricular de novo associou-se a maior incidência de complicações e mortalidade intra-hospitalar, mas não foi preditor independente de mortalidade intra-hospitalar. Identificamos idade, acidente vascular cerebral prévio, infarto inferior e bloqueio auriculoventricular completo como preditores independentes de fibrilação auricular de novo. Conclusões: A fibrilação auricular de novo continua sendo uma complicação frequente do infarto agudo do miocárdio, estando associada a aumento das complicações e mortalidade intra-hospitalar. Apenas 36.7% desses pacientes teve alta sob anticoagulação.

Left ventricular basal inferior pseudoaneurysm and left atrial dissection after myocardial infarction: Case report.

Left atrial dissection is a rare entity, mostly occurring after mitral valve surgery, with only a few cases described after myocardial infarction. The authors report a case of a 60-year-old man who presented with an inferior myocardial infarction, complicated with pseudoaneurysm of basal segment of left ventricular inferior wall, which expanded through the mitral ring to left atria, causing left atrial free wall dissection. The left ventriculo-atrial communication through the pseudoaneurysm caused major para-mitral regurgitation and the development of acute heart failure. Good clinical outcome was achieved with stabilization of acute heart failure with high-dose diuretic therapy and delayed cardiac surgery with closure of left ventriculo-atrial communication.

[Right atrial thrombus: a rare presentation of plasminogen activator inhibitor deficiency]. / Trombo na aurícula direita: apresentação rara da deficiência do inibidor do ativador do plaminogénio.

Free-floating right atrial thrombi are rare but associated with high mortality. Although advances in echocardiography have improved diagnosis, their management is still the subject of debate. A 24-year-old woman with a history of smoking, obesity and oral contraceptive use presented to the emergency department with dyspnea, cough and hemoptysis. Transthoracic echocardiography revealed a large free-floating cardiac mass occupying the right atrial chamber and restricting tricuspid valve opening. In view of recurrent pulmonary embolism, she was referred for cardiac surgery and the cardiac mass was excised. Anatomopathological analysis revealed an organized and calcified thrombus. Genetic study showed her to be homozygous for the 4G/4G allelic variant of plasminogen activator inhibitor-1 and heterozygous for the allelic variant A1298C of 5,10-methylenetetrahydrofolate reductase.

Non-cardiac comorbidities in the very elderly with acute myocardial infarction: prevalence and influence on management and in-hospital mortality.

INTRODUCTION: Acute myocardial infarction (AMI) in the very elderly is common and is associated with increased mortality. Despite this, the majority of such patients do not receive the most effective cardiovascular therapies. The presence of non-cardiac comorbidities constitutes an additional challenge to the management of AMI in very elderly patients. OBJECTIVE: To determine the prevalence of non-cardiac comorbidities in the very elderly (age > or = 80 years) with AMI and how it influences their management and in-hospital mortality. METHODS: A total of 132 patients consecutively admitted with a diagnosis of AMI from January 2005 to December 2007 were analyzed retrospectively. Two groups were considered: patients with non-cardiac comorbidities (group 1) and those without non-cardiac comorbidities (group 2). Cardiovascular risk factors and non-cardiac comorbidities (anemia, chronic obstructive pulmonary disease, chronic renal failure, cancer, neurologic or psychiatric disorders, and prostatic hyperplasia in men) were recorded. Use of an invasive strategy and the therapy prescribed at discharge were compared between the groups. RESULTS: Non-cardiac comorbidities were found in 56.8% of patients, with the following prevalences: anemia 18.2%; chronic obstructive pulmonary disease 11.4%; chronic renal failure 25.8%; cancer 3.0%; neurologic or psychiatric disorders 11.4%; and prostatic hyperplasia 20.5%. Patients with comorbidities had longer hospital stay than those without (12.1 +/- 5.5 and 10.1 +/- 3.5 days, respectively; p = 0.014). An invasive strategy, with coronary angiography, was used in 12.1% of patients, with no differences between groups (12.3% in patients without comorbidities and 12.0% in those with, p = 0.82). At discharge, more than 70% of the patients were prescribed aspirin, statins and nitrates. With the exception of non-dihydropyridine calcium antagonists, which were more frequently prescribed in patients with comorbidities (15.9% vs. 2.2%; p = 0.04), no other differences in therapy were observed between the two groups. CONCLUSION: In our population of very elderly patients, the prevalence of non-cardiac comorbidities was high (56.8%), but this did not significantly influence the management of these patients.