Novel developments in stress cardiomyopathy: From pathophysiology to prognosis.

Stress cardiomyopathy (SC) is characterized by transient left ventricular (LV) wall motion abnormalities typically involving the apex with preserved basal contractility, chest discomfort, ST-T ischemic changes and elevated cardiac markers with normal or non-flow limiting coronary artery lesions. It represents an important differential diagnosis of Acute Coronary Syndromes caused by atherosclerotic vessel occlusion; most commonly, Tako-tsubo occurs in postmenopausal women after physical or emotional stress. While the exact mechanism of SC remains controversial, various hypotheses have been suggested concerning the vascular, central nervous and endocrine system participation where catecholamines, particularly epinephrine, seem to play a major role. Hormonal, genetic and psychiatric conditions may also define the risk of susceptibility in some groups affected by SC. Long-term survival data are limited with mortality occurring predominantly in the first year after diagnosis usually related to non-cardiac illnesses. Echocardiography promises to become a useful tool to correctly identify SC patients at high risk for complications.

Psychosocial Evaluation in Patients Undergoing Left Ventricular Assist Device Implantation Using the Transplant Evaluation Rating Scale.

BACKGROUND: It has been recommended that all candidates for left ventricular assist device (LVAD) implantation undergo preoperative psychologic evaluation for risk assessment. OBJECTIVE: We used the transplant evaluation rating scale (TERS) that was established for pretransplant evaluation to investigate the psychosocial assessment of patients undergoing LVAD implantation. METHODS: This study retrospectively analyzed data from 125 patients with advanced heart failure who were evaluated by the TERS before LVAD implantation. Postoperative follow-up included survival, total length of hospital stay, readmissions, and post-LVAD out-of-hospital days after discharge. The cohort was stratified according to the TERS scores into low-, moderate-, and high-risk groups. The outcomes were analyzed to evaluate whether the TERS score was associated with post-LVAD adverse events. RESULTS: The TERS, when stratified into 3 risk groups showed significant difference in 8 of the 10 psychosocial domains (p < 0.001). The mean number of outpatient days after discharge was significantly different between the low-, moderate-, and high-risk groups (p < 0.001). All other outcomes were not significantly different. CONCLUSIONS: This study showed that the TERS is successful in stratifying our patients with an LVAD into 3 risk groups, indicating the internal validity of this test. The number of out-of-hospital (outpatient) days after discharge was significantly shorter in the TERS high-risk group, which may affect the quality of life and cost of post-LVAD care.

Predictors of short- and long-term outcomes of Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a reversible cardiomyopathy with a benign short-term prognosis but is associated with recurrence rate of 10%. Clinical variables that predict long-term mortality and recurrence are unknown; 56 consecutive patients presenting to a single urban medical center who fulfilled the Mayo Clinic criteria for the diagnosis of TC were included. Patients were followed with 100% completeness; >60 clinical factors were analyzed, including presentation, treatment, electrocardiogram, and echocardiographic, angiographic, and demographic variables. Survival analysis was performed using the Kaplan-Meier function and Cox proportional hazards regression models. There were 15 deaths during follow-up: 5 in-hospital, 4 before 90 days, and 6 after 90 days. Mean survival was 4.47 years (95% confidence interval 3.81 to 5.13). All short-term survivors had repeat ejection fraction evaluation demonstrating improvement; 45 of 56 patients were women and 96% were postmenopausal. The nonfatal recurrence rate was 1.8%. QTc interval at presentation was the factor most strongly predictive of overall outcome, after intubation. All patients with mortality had QTc intervals between 400 and 550 ms. In conclusion, this study demonstrates the prognostic significance of QTc prolongation at presentation in TC. Because the cause of TC involves intense catecholamine release and hyperadrenergic tone, the QTc may reflect the individual impact on myocardial repolarization and the balance between sympathetic innervation and parasympathetic compensation. In conclusion, in this series, TC was associated with an 8.9% in-hospital mortality, an additional 17.9% mortality after discharge, and a nonfatal recurrence rate of 1.8%. Moreover, the QTc on presentation with TC was predictive of outcome.