Predictors of in-hospital cardiac complications in patients with Takotsubo syndrome.

Takotsubo syndrome (TTS) has been recognized as a benign condition mainly due to its reversibility. However, recent researches have demonstrated that serious cardiac complications could occur during hospitalization. Thus, the aim of this study is to detect factors associated with in-hospital cardiac complications in patients with TTS. A total of 154 consecutive patients with TTS were enrolled retrospectively. In-hospital cardiac complications were observed in 61 patients (40%), including 44 patients with pulmonary edema (29%) and 25 patients with cardiogenic shock (16%). Multivariate logistic regression analysis identified lower systolic blood pressure on admission (OR 0.97, 95% CI 0.96-0.99, p = 0.001), history of diabetes mellitus (OR 2.92, 95% CI 1.01-8.41, p = 0.04), and ß-blocker use before admission (OR 16.9, 95% CI 1.57-181.7, p = 0.006) as independent predictors of in-hospital cardiac complications, while chest pain at onset was identified as a negative predictor of cardiac complications during hospitalization (OR 0.20, 95% CI 0.07-0.55, p = 0.001). Patients with cardiac complications more often needed hemodynamic support and longer hospital stay than those without (21.2 ± 19.4 vs. 11.8 ± 16.8 days, p = 0.002). TTS should be no longer recognized as a benign disease, but requiring careful management. We should obtain vital signs and patient's medical history carefully as soon as possible after admission to predict in-hospital cardiac complications.

Prevalence and Clinical Features of Focal Takotsubo Cardiomyopathy.

BACKGROUND: Because it is difficult to distinguish between focal takotsubo cardiomyopathy and aborted myocardial infarction, there is little information about the prevalence and clinical features of focal takotsubo cardiomyopathy. METHODS AND RESULTS: Our cardiac catheterization databases were queried to identify patients with focal takotsubo cardiomyopathy and other types of takotsubo cardiomyopathy. We defined focal takotsubo cardiomyopathy as hypo-, a- or dyskinesis in both anterolateral and septal segments without obstructive coronary artery disease explaining the wall motion abnormality. A total of 10 patients were diagnosed with focal takotsubo cardiomyopathy. The control group comprised patients with takotsubo cardiomyopathy with apical, mid-ventricular, or basal ballooning. Clinical features and in-hospital outcomes were compared between patients with focal takotsubo cardiomyopathy and those with other types of takotsubo cardiomyopathy. Among the 144 patients with takotsubo cardiomyopathy, the apical, mid-ventricular, basal, and focal types occurred in 85 (59.0%), 49 (34.0%), 0 (0%), and 10 patients (6.9%), respectively. The left ventricular ejection fraction was significantly higher in the focal group compared with the apical and mid-ventricular group (56±13 vs. 45±13 vs. 46±12%, P=0.03). In-hospital outcome was not significantly different among the 3 groups. CONCLUSIONS: Focal takotsubo cardiomyopathy is not rare. Biplane left ventriculography is useful for its diagnosis. (Circ J 2016; 80: 1824-1829).

Dynamic Trend of Myocardial Edema in Takotsubo Syndrome: A Serial Cardiac Magnetic Resonance Study.

BACKGROUND: The wall motion abnormalities of the left ventricle (LV) in takotsubo syndrome (TTS) are known to be transient and completely recover within a few weeks. However, there is little information about the relationship between functional recovery and tissue characteristics. The aim of this study was to investigate the recovery process of TTS using cardiovascular magnetic resonance (CMR). METHODS: Consecutive patients with TTS were prospectively enrolled. We performed serial CMR in the acute phase (<72 h after admission), the subacute phase (7-10 days after admission) and the chronic phase (3 months later). To assess the degree of myocardial edema quantitatively, we evaluated the signal intensity of myocardium on T2-weighted images and calculated the signal intensity ratio compared with the skeletal muscle. RESULTS: Fifteen patients with TTS were enrolled. CMR demonstrated reduced LV ejection fraction in the acute phase, and it recovered almost completely by the subacute phase. On the other hand, severe myocardial edema was still observed in the subacute phase, associated with increased LV mass. The highest signal intensity ratio in the subacute phase was correlated with the maximum voltage of negative T wave on electrocardiogram (r = 0.57, p = 0.03). CONCLUSIONS: In patients with TTS, myocardial edema associated with increased LV mass still remained in the subacute phase despite functional recovery of the LV. Electrocardiogram may be useful to assess the degree of myocardial edema in the subacute phase. Our study suggests that myocardial ischemia might have a central role in developing TTS.

Ethnic comparison in takotsubo syndrome: novel insights from the International Takotsubo Registry.

BACKGROUND: Ethnic disparities have been reported in cardiovascular disease. However, ethnic disparities in takotsubo syndrome (TTS) remain elusive. This study assessed differences in clinical characteristics between Japanese and European TTS patients and determined the impact of ethnicity on in-hospital outcomes. METHODS: TTS patients in Japan were enrolled from 10 hospitals and TTS patients in Europe were enrolled from 32 hospitals participating in the International Takotsubo Registry. Clinical characteristics and in-hospital outcomes were compared between Japanese and European patients. RESULTS: A total of 503 Japanese and 1670 European patients were included. Japanese patients were older (72.6 ± 11.4 years vs. 68.0 ± 12.0 years; p < 0.001) and more likely to be male (18.5 vs. 8.4%; p < 0.001) than European TTS patients. Physical triggering factors were more common (45.5 vs. 32.0%; p < 0.001), and emotional triggers less common (17.5 vs. 31.5%; p < 0.001), in Japanese patients than in European patients. Japanese patients were more likely to experience cardiogenic shock during the acute phase (15.5 vs. 9.0%; p < 0.001) and had a higher in-hospital mortality (8.2 vs. 3.2%; p < 0.001). However, ethnicity itself did not appear to have an impact on in-hospital mortality. Machine learning approach revealed that the presence of physical stressors was the most important prognostic factor in both Japanese and European TTS patients. CONCLUSION: Differences in clinical characteristics and in-hospital outcomes between Japanese and European TTS patients exist. Ethnicity does not impact the outcome in TTS patients. The worse in-hospital outcome in Japanese patients, is mainly driven by the higher prevalence of physical triggers. TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT01947621.

Prognostic Impact of Branch Vessel Involvement on Computed Tomography versus Clinical Presentation of Malperfusion in Patients With Type a Acute Aortic Dissection.

Type A acute aortic dissection (AAD) is a life-threatening disease. The use of contrast-enhanced computed tomography (CT) for diagnosing AAD has increased, and CT can provide pathophysiologic information on dissection such as intramural hematoma (IMH), longitudinal extent of dissection, and branch vessel involvement. However, the prognostic impact of these CT findings is poorly investigated. This multicenter registry included 703 patients with type A AAD. The longitudinal extent of dissection and IMH was determined on CT. Branch vessel involvement was defined as dissection extended into coronary, cerebral, and visceral arteries on CT. The evidence of malperfusion was defined based on clinical presentations. The primary endpoint was in-hospital death. Of 703 patients, 126 (18%) died during hospitalization. Based on contrast-enhanced CT findings, longitudinal extent of dissection was not associated with in-hospital death, while patients with IMH had lower in-hospital mortality than those without (13% vs 22%, p = 0.004). Coronary, cerebral, and visceral artery involvement on CT was found in 6%, 55%, and 32%. In patients with coronary artery involvement, 90% had clinical coronary malperfusion, while only 25% and 21% of patients with cerebral and visceral artery involvement had clinical evidence of corresponding organ malperfusion. Multivariable analysis showed evidence of malperfusion as a significant factor associated with in-hospital mortality. In conclusions, branch vessel involvement on CT was not always associated with end-organ malperfusion in patients with type A AAD, especially in cerebral and visceral arteries. Clinical evidence of malperfusion was significantly associated with in-hospital mortality beyond branch vessel involvement on CT.

Impact of tissue protrusion after coronary stenting in patients with ST-segment elevation myocardial infarction.

Clinical impact of tissue protrusion (TP) after coronary stenting is still controversial, especially in patients with ST-segment elevation myocardial infarction (STEMI). A total of 104 STEMI patients without previous MI who underwent primary percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS)-guidance were included. Post-stenting grayscale IVUS analysis was performed, and the patients were classified according to the presence or absence of post-stenting TP on IVUS. Coronary angiography and single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) with 99mTc tetrofosmin were analyzed. Major adverse cardiac events were defined as cardiovascular death, myocardial infarction, heart failure hospitalization, and target vessel revascularization. TP on IVUS was detected in 62 patients (60%). Post-PCI coronary flow was more impaired, and peak creatine kinase-myoglobin binding level was higher in patients with TP compared to those without. SPECT MPI was performed in 77 out of 104 patients (74%) at 35.4 ± 7.7 days after primary PCI. In patients with TP, left ventricular ejection fraction was significantly reduced (47.5 ± 12.0% vs. 57.6 ± 11.2%, p < 0.001), and infarct size was larger [17% (8-25) vs. 4% (0-14), p = 0.002] on SPECT MPI. During a median follow-up of 14 months after primary PCI, Kaplan-Meier analysis demonstrated a significantly higher incidence of major adverse cardiac events in patients with TP compared to those without. TP on IVUS after coronary stenting was associated with poor outcomes in patients with STEMI.

Renal Artery Stenting Recovered Renal Function after Spontaneous Renal Artery Dissection.

Spontaneous renal artery dissection (SRAD) is a rare entity and the management of this disease has not been established. A 54-year-old man presented with severe flank pain, and contrast-enhanced computed tomography images suggested SRAD in his left renal artery. After two weeks of conservative treatment, stents were placed in the renal artery. The pre- and post-procedural renal function was independently assessed by renography. After stenting, his left renal function recovered from the renal failure pattern. Renal artery stenting in an acute phase of SRAD may salvage the renal function, even if it appears to be non-functioning.

Impact of myocardial bridging on in-hospital outcome in patients with takotsubo syndrome.

BACKGROUND: Prevalence of myocardial bridging of the left anterior descending coronary artery (LAD) in patients with takotsubo syndrome (TTS) has been demonstrated. However, the impact of myocardial bridging on in-hospital outcome has not been fully evaluated. METHODS: A total of 144 consecutive patients with TTS were enrolled. Coronary angiography and left ventriculography were performed in all patients and absence of obstructive coronary disease explaining the left ventricular contraction abnormality was confirmed. Myocardial bridging was diagnosed when a dynamic compression in systole, so-called "milking effect", was observed in the LAD. We evaluated differences in the clinical characteristics and in-hospital outcome between patients with and without myocardial bridging. Furthermore, multiple logistic regression analysis was performed to predict in-hospital death. RESULTS: Myocardial bridging was observed in 33 patients (23%). In-hospital death was more frequent in patients with myocardial bridging (21% vs. 6%, p=0.02), which was due mainly to a higher non-cardiac death in those patients (15% vs. 5%, p=0.049). Multiple logistic regression analysis demonstrated myocardial bridging (odds ratio=12.0, 95% CI=2.52-78.5, p<0.01) as one of the independent predictors of in-hospital death. CONCLUSION: Myocardial bridging is an independent predictor of in-hospital death in patients with TTS.

Comparison of image characteristics of plaques in culprit coronary arteries by 64 slice CT and intravascular ultrasound in acute coronary syndromes.

PURPOSE: To evaluate plaque image characteristics in coronary artery culprit-lesions in subjects with acute coronary syndromes (ACS), we retrospectively compared coronary arterial images by 64-slice CT before conventional-coronary-angiogram with those by intravascular ultrasound (IVUS). MATERIALS-AND-METHODS: Retrospective analysis of coronary arterial images from thirty-one subjects (26-males, mean age 59.3 ± 12.0 years) exhibiting acute symptoms with suspicion of ACS, where either (1) ECG was un-interpretable or (2) ECG was non diagnostic/cardiac biomarkers was equivocal; with significant stenosis on emergent 64 slice CT and subjects were finally diagnosed as having ACS confirmed by conventional-coronary-angiogram, followed by IVUS before coronary-intervention. After principal culprit-lesion components were classified into 1) thrombus, 2) soft plaques, and 3) fibrotic plaques by IVUS, corresponding culprit-lesion CT values were measured (two-observers). RESULTS: Nineteen and 12 of 31 subjects were finally diagnosed as unstable angina pectoris and non-ST elevation acute myocardial infarction respectively. Main culprit-lesion components of ACS were identified on MSCT in all subjects. Culprit-lesion CT values diagnosed as soft plaques by IVUS (n=6, 32.9 ± 8.7 HU) were not lower than those of thrombi (n=18, 43.2 ± 10.7 HU, p=0.268); both values were significantly lower than those of fibrotic plaques (n=7, 82.5 ± 22.6 HU) (both p<0.01). Calcification, spotty calcification, and positive arterial remodeling were observed in 67.7%, 61.3%, 58.1% (IVUS) and 58.1%, 51.6%, 74.2% (MSCT), respectively (all p=NS). CT value reproducibilities and culprit-lesion areas, were 0.87 and 0.86, respectively (two analyzers). CONCLUSIONS: 64-slice CT can non-invasively evaluate image characteristics in coronary artery culprit-lesions in ACS subjects accurately; this may help to differentiate soft plaques or thrombi generated by plaque rupture from fibrotic plaques.

Feasibility and safety of granulocyte colony-stimulating factor treatment in patients with acute myocardial infarction.

BACKGROUND: This study examined feasibility and safety of granulocyte colony-stimulating factor (G-CSF) treatment for patients with acute myocardial infarction (AMI). METHODS: Forty patients with AMI related with the left anterior descending coronary artery, who underwent successful percutaneous coronary intervention (PCI), were randomized into G-CSF group (n=18) or Control group (n=22). G-CSF treatment was started within 24 h after PCI. 99mTc-tetrofosmin single-photon emission computed tomography (SPECT) was performed at 4 days and 6 months after AMI. SPECT data was analyzed for LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF) and myocardial perfusion. RESULTS: LVEF at 6 months was significantly better than that at 4 days in G-CSF group (p=0.013), but not changed in Control group (p=0.245). Although no significant difference was observed for LVEDV between the two groups, LVESV tended to be decreased only in G-CSF group. In G-CSF group, defect score (DS) was significantly decreased from 4 days to 6 months after AMI. Restenosis rate at 6 months after AMI was not significantly different between the two groups. CONCLUSIONS: G-CSF treatment for patients with AMI was effective and did not have any clinical and angiographic adverse effects.

Comparison between nicorandil and magnesium as an adjunct cardioprotective agent to percutaneous coronary intervention in acute anterior myocardial infarction.

BACKGROUND: It has been reported that both nicorandil and magnesium have a cardioprotective effect in experimental ischemia - reperfusion models. In the present study, the cardioprotective effects of nicorandil and magnesium as an adjunct to reperfusion therapy in patients with acute myocardial infarction (AMI) were compared. METHODS AND RESULTS: Forty consecutive patients with AMI caused by occlusion of anterior descending coronary artery were randomized into 3 groups: (1) Group N: nicorandil was given as 4 mg iv and 4 mg ic before reperfusion, followed by continuous infusion at 4 mg/h for 24 h; (2) Group M: magnesium was administered at 10 mmol iv before reperfusion, followed by continuous infusion at 0.4 mmol/h for 24 h; and (3) Group C: neither nicorandil nor magnesium was given. Left ventriculography was performed immediately after reperfusion and 3 months later. There was no significant change in regional wall motion (RWM) in either Group C or M, whereas that of group N improved significantly. The change in RWM in Group N was significantly greater than in Group C (Group N: 0.92+/-0.92, Group M: 0.44+/-0.80, Group C: -0.01+/-0.65, p<0.05). CONCLUSIONS: The early administration of nicorandil as an adjunct to reperfusion is useful for cardioprotection in AMI, but magnesium is not.