Incremental Value of Left Atrial Function Analysis in the Assessment of Left Ventricular Filling Pressures in Patients with ST-Elevation Myocardial Infarction.

Background: Left atrial (LA) reservoir strain provides interesting information about left ventricular (LV) filling pressure. However, the advantages of atrial reservoir strain in comparison with conventional parameters in patients with myocardial infarction are not clear yet. Methods: Fifty patients with ST-elevation myocardial infarction (STEMI) prospectively underwent echocardiographic assessment of LV systolic and diastolic function by conventional parameters and two-dimensional speckle tracking longitudinal strain of left atrium. LV filling pressure was estimated by brain natriuretic peptide (BNP) levels. Results: Systolic and conventional diastolic parameters did not show significant differences between patients with increased and normal BNP values, whereas LA reservoir strain was reduced (33.1 ± 8% vs. 46.5 ± 9.8%; P = 0.001) in patients with higher BNP levels. LA reservoir strain had higher area under curve value (0.880) than the other parameters in identifying patients with elevated BNP and a cut-off value of 40.5% reached sensitivity and specificity values of 93% and 86% and positive and negative predictive values of 92% and 85%. LA reservoir strain reclassified 23 patients with increased BNP values, which were previously estimated to have normal (16 patients) and undeterminable LA pressure (seven patients) by using the recommended algorithm for diastolic function. Conclusions: LA reservoir strain is a useful tool for the evaluation of diastolic function and seems to be more sensitive than conventional parameters in the detection of subtle increase of LV filling pressure in patients with STEMI. It allows physicians to reclassify patients with undeterminable diastolic function according to conventional algorithm.

Takotsubo cardiomyopathy: queries of the current era.

: Takotsubo cardiomyopathy (TTS), also known as left ventricular apical ballooning syndrome, is an acute, usually reversible heart failure syndrome that most often affects postmenopausal women experiencing an emotionally stressful event. It is characterized by sudden left ventricular dysfunction and wall motion abnormalities involving the apical and mid segments. TTS has been increasingly recognized in recent years, and more and more information about the pathophysiology, diagnosis, and treatment of these patients has been reported. However, much is still unknown. TTS has a wide variety of clinical subtypes and has been described in several clinical contexts. Moreover, TTS simulates ST-segment elevation myocardial infarction and acute myocarditis, and it can be difficult to obtain a certain diagnosis. As a result, clinical decisions are challenging, and many patients currently receive an inappropriate management strategy. The aim of this review is to critically analyze the evidence about this disease reported in the literature, with particular focus on the pathophysiological processes, the diagnostic elements that can help the clinician differentiate it from other diseases, and the best management of these patients.

Cardiovascular maladaptation to exercise in young hypertensive patients.

BACKGROUND: Impairment of the adaptive mechanisms that increase cardiac output during exercise can translate to a reduced functional capacity. We investigated cardiovascular adaptation to exertion in asymptomatic hypertensive patients, aiming to identify the early signs of cardiac and vascular dysfunction. METHODS AND RESULTS: We enrolled 54 subjects: 30 patients (45.1±11.9years, 19 males) and 24 age-matched healthy controls (44.4±9.6years, 14 males). Speckle-tracking echocardiography (STE) and echo-tracking were performed at rest and during exertion to assess myocardial deformation and arterial stiffness. RESULTS: E/E' increased from rest to peak exercise more in patients than in controls (peak stage: p=0.024). Global longitudinal strain increased significantly from rest to peak stage in controls (p=0.011) whereas it remained unchanged in patients (p=0.777). Left atrial (LA) reservoir was significantly increased throughout the exercise only in controls (p=0.001) whereas it was almost unchanged in patients (p=0.293). LA stiffness was significantly higher in patients than in controls both at rest (p=0.023) and during exercise (p<0.001). Beta index and pulse wave velocity (PWV) increased during exercise in both groups, showing higher values in patients in each step. CONCLUSIONS: Our study showed a more pronounced maladaptation during exercise, with respect to rest, of the cardiovascular system with impaired cardiac-vessel coupling in hypertensive patients compared to healthy subjects. Exercise echocardiography implemented by STE and echo-tracking is invaluable in the early detection of these cardiovascular abnormalities.

The Diagnostic Challenge of Dipyridamole-atropine Stress Echocardiography in a Patient with Myocardial Bridge.

A 60-year-old male patient was submitted to dipyridamole-atropine stress echocardiography (DSE) for chest pain during exertion. At rest, no electrocardiographic (ECG) and transthoracic echocardiographic (TTE) abnormalities were observed. After dipyridamole infusion, the patient complained a mild chest discomfort, without ECG changes and TTE wall-motion abnormalities. Subsequently, worsening of the anginal symptoms combined with descending ST-depression and T-negative waves occurred after atropine and unexpectedly, aminophylline administration. Coronary angiography was performed showing a myocardial bridge (MB) of the left anterior descending artery. The occurrence, during DSE, of worsening ischemic abnormalities after atropine and aminophylline administration may be a particular diagnostic feature of MB.