Mortal consequences of a cooperative action between Takotsubo syndrome and increased intracranial pressure.

An elderly patient with head injury was registered to the emergency room. Because the patient arrived to the hospital unconscious, her cranial, cerebrovascular, and cardiac function was studied. The cardiac function measurements were (i) heart rate, (ii) blood pressure, (iii) oxygen saturation level, (iv) electrocardiogram (ECG), (v) coronary angiogram, (vi) chest computerized tomography (CT), and (vii) echocardiogram. The head damage was studied by cerebral CT and magnetic resonance imaging (MRI). The serum ischemia and inflammatory biomarkers were analysed. For the immediate treatment, the patient received cardiovascular system supporting medication. The cardiac diagnostic results were (i) the ECG suggested an elevation in the left ventricular systolic function, (ii) the blood test showed neutrophilia, increased creatine and increased troponin I kinase values, and (iii) the coronary angiogram and ECG analysis demonstrated a lack of a myocardial infarction but identified apical akinesia. The patient did not have previous symptoms of cardiovascular disease. The brain imaging demonstrated (iv) an acute ischemia in the left occipital area and (v) increased intracranial pressure. Brain MRI indicated (vi) aqueductal stenosis and (vii) multiple gliomatotic foci demonstrating hydrocephalus caused by gliomatosis cerebri. A chest CT indicated (viii) chronic obstructive pulmonary disease (COPD). One week later, the patient died because of cardiac arrest. The diagnosis was Takotsubo syndrome enforced by gliomatosis cerebri and COPD. To our knowledge, this is the first reported case in which the cardiac dysfunction of the patient is associated with gliomatosis cerebri-derived hydrocephalus and increased intracranial pressure that together with COPD may have enhanced the negative clinical outcome.

Should thiazide diuretics be given as first line antihypertensive therapy or in addition to other medications?

INTRODUCTION: The recommendation to start antihypertensive therapy with diuretics (D) might produce delay in blood pressure (BP) control and, possibly, increase cost/benefit ratio. AIM: We evaluate the effects of D in relation to the administration of other anti-hypertensive medications, in clinical practice. METHODS: General practitioners recruited 2,409 hypertensive patients with indication to antihypertensive therapy, who were randomized to start treatment with chlorthalidone (12.5-25  mg daily, group D) or any other single medications (excluding thiazides, group A). The patients have been followed for at least 2 years. RESULT: Among the 2,409 patients recruited (42.5 % women), 1,205 were randomized in group D and 1,204 in group A, of which 1,051 (or 87 %) and 1026 (or 85 %) respectively, completed the study. The number of patients in optimal BP control was similar in the two groups (65.0 vs 64.0 %; p = NS). During follow-up, the group D had prescribed a slightly greater number of medications compared to the group A who added D as second line (2.3 vs 2.1; p < 0.0001). In particular group D took more ß-blockers (27.1 vs 14.9 %; p < 0.0001) with a similar number of patients in optimal BP control (64.35 vs 63.9 %; p = NS). CONCLUSION: The beginning of antihypertensive therapy with diuretics is more often subject to the addition of one or more medications to obtain an effective blood pressure control, since the diuretic administered at the beginning of the antihypertensive regimen is only rarely associated with optimal blood pressure control.

Mitral annular calcification and incident ischemic stroke in treated hypertensive patients: the LIFE study.

Background Fibro-calcification of the mitral annulus (MAC) has been associated with increased risk of ischemic stroke in general populations. This study was performed to assess whether MAC predicts incidence of ischemic stroke in treated hypertensive patients with left ventricular hypertrophy (LVH). Methods Baseline and follow-up clinical and echocardiographic parameters were assessed in 939 hypertensive patients with electrocardiogram (ECG) LVH participating in the Losartan Intervention for Endpoint reduction in hypertension (LIFE) echocardiography substudy (66±7 years; 42% women; 11% with diabetes) who did not have aortic or mitral valve stenosis or prosthesis. Results MAC was found in 458 patients (49%). Patients with MAC were older (68±7 vs. 65±7 years); were more often women (47% vs. 37%); had higher baseline systolic blood pressure (BP) (175±14 vs. 172±15mm Hg), left atrial diameter (4.0±0.5 vs. 3.8±0.6cm), and left ventricular mass index (58±13 vs. 55±12g/m(2.7)) and included more patients with proteinuria (30% vs. 21%; all P < 0.01). During a mean follow-up of 4.8 years, 58 participants had an ischemic stroke. Risk of incident ischemic stroke was significantly related to presence of MAC (log rank = 9; P < 0.01). In multivariable Cox regression analysis models, MAC was associated with increased risk of ischemic stroke (hazard ratio = 1.78-2.35), independent of age, baseline or time-varying systolic BP, prevalence or incidence of atrial fibrillation, history of previous cerebrovascular disease, and other well-recognized confounders, such as sex, time-varying left ventricular mass, left atrial diameter, and urinary albumin/creatinine ratio (all P < 0.05). Conclusions MAC is common in treated hypertensive patients with ECG LVH and is an independent predictor of incident ischemic stroke.

Prognostic significance of left atrial volume dilatation in patients with hypertrophic cardiomyopathy.

To evaluate the prognostic role of left atrial (LA) volume in hypertrophic cardiomyopathy (HCM), LA volume was measured at baseline and during follow-up in 140 patients with HCM. Unfavorable outcome, defined as occurrence of sudden death, heart transplantation, or invasive reduction of obstruction, developed in 16 patients. In patients with enlarged LA volume (>27 mL/m(2)), there was an increased risk for unfavorable outcome (P = .0152). Patients with normal LA volume at baseline in whom volume increased more than 3 mL per year (fast dilating LA volume) had a worse prognosis than patients with normal and stable volume (P < .001) and similar to patients with dilated LA volume at baseline (P = not significant). LA volume dilated at baseline, fast dilating LA volume, and New York Heart Association functional class were independent predictors of unfavorable outcome development (odds ratio: 11.453; P = .021, P = 2.019, P = .020, respectively). The assessment of LA volume at baseline and during follow-up adds information regarding prognosis in patients with HCM.