The Broken Heart: The Role of Life Events in Takotsubo Syndrome.

The onset of Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is thought to be associated with some life events. This study focuses on clarifying life event characteristics and the role of triggers in the onset of TTS. Participants with TTS (n = 54) were compared to those with acute myocardial infarction (AMI; n = 52) and healthy individuals (n = 54). Using a modified version of the Interview for Recent Life Events, information about general life events perceived as stressful and triggers preceding the onset of a cardiac syndrome was collected. The assessment included the impact of these events as indicated by the participants and estimated by the interviewer; finally, the objective impact was considered. Although the number of events and the objective impact did not differ among the groups, patients with TTS reported a more negative perceived impact. Moreover, 61% of these patients objectively and subjectively reported a more stressful trigger before the onset of the disease (in the 24 h preceding the cardiac event) than those reported by patients with AMI. The dynamic between life events and individual responses could help differentiate TTS from other cardiovascular events, such as AMI. This study suggests that patients' perception of some life events (whether triggers or general life events) could represent a possible marker of TTS.

Prognostic relevance of GRACE risk score in Takotsubo syndrome.

BACKGROUND: Takotsubo syndrome is an increasingly recognised cardiac condition that clinically mimics an acute coronary syndrome, but data regarding its prognosis remain controversial. It is currently unknown whether acute coronary syndrome risk scores could effectively be applied to Takotsubo syndrome patients. This study aims to assess whether the Global Registry of Acute Coronary Events (GRACE) score can predict clinical outcome in Takotsubo syndrome and to compare the prognosis with matched acute coronary syndrome patients. METHODS: A total of 561 Takotsubo syndrome patients was included in this prospective registry. According to the GRACE score, the population was divided into quartiles. The primary endpoint was all-cause mortality and the secondary endpoints were cardiocerebrovascular events (a composite of all-cause mortality, cardiovascular death, recurrence of Takotsubo syndrome and stroke). RESULTS: The median GRACE risk score was 139±27. Takotsubo syndrome patients with a higher GRACE risk score mostly have a higher rate of physical triggers and lower left ventricular ejection fraction on admission. During long-term follow-up, all-cause mortality rates were 5%, 11%, 12% and 22%, respectively, in the first, second, third and fourth quartile (P<0.001). After multivariate analysis, the GRACE risk score was found to be a strong predictor of all-cause mortality (odds ratio (OR) 1.68, 95% confidence interval (CI) 1.28-2.20; P=0.001) and cardiocerebrovascular events (OR 1.63, 95% CI 1.26-2.11; P=0.001). Moreover, all-cause mortality in Takotsubo syndrome patients was comparable with the matched acute coronary syndrome cohort. CONCLUSION: In Takotsubo syndrome, the GRACE risk score allows us to predict all-cause mortality and cardiocerebrovascular events at long-term follow-up.

Admission heart rate and in-hospital course of patients with Takotsubo syndrome.

BACKGROUND: In-hospital course of patients with Takotsubo syndrome (TS) is quite heterogeneous and life-threatening complications are not uncommon in the acute phase. The role of heart rate (HR) as a predictor of prognosis has not been sufficiently investigated in this setting. The study aims to assess the impact of HR at presentation on in-hospital course of patients with TS. METHODS: The study population included 221 patients with TS enrolled in a multicentric registry. HR at admission was evaluated on the first electrocardiogram. According to tertile distribution of HR at presentation, 3 groups were identified: Group A (HR ≤ 76 beats per minute (bpm), n = 76), Group B (HR 77-95 bpm, n = 74) and Group C (HR > 95 bpm, n = 71). Acute in-hospital complications were defined as occurrence of severe pump failure and major arrhythmias. RESULTS: 32 (14.4%) patients experienced complicated in-hospital course. HR on admission was significantly higher (108 bpm vs. 85 bpm; p < 0.001) and ejection fraction (EF) lower (35% vs. 40%; p = 0.009) in patients with complications than in those without. Patients in Group C experienced a 5-fold higher rate of complications compared to group A and B. After multivariate analysis, higher HR (odds ratio 1.34 per 10 bpm increase, 95% confidence interval (CI) 1.12-1.59; p = 0.001) and lower EF (odds ratio 1.24 per 5% decrease, 95% CI 1.01-1.54; p = 0.049) remained independently associated with a worse outcome. CONCLUSION: In a large population with TS, high HR on admission independently predicted complicated in-hospital course.

Tortuosity, Recurrent Segments, and Bridging of the Epicardial Coronary Arteries in Patients With the Takotsubo Syndrome.

Myocardial bridging (MB) and a long recurrent wraparound left anterior descending artery (wrap-LAD) are coronary anatomic variants that have been recently suggested to be associated with takotsubo syndrome (TS). Until now, coronary artery tortuosity (CAT) has never been investigated in this setting. Our study sought to evaluate the prevalence of the aforementioned anatomic variants in a large population with TS. In this retrospective angiographic study, 109 patients with TS were compared with 109 age- and gender-matched subjects without coronary artery disease, valve heart disease, or cardiomyopathy. CAT was identified by ≥3 consecutive curvatures ≥90° (criteria 1) or by ≥2 consecutive curvatures ≥180° (criteria 2). Wrap-LAD was defined if any part of the vessel outreached the apex of the left ventricle and MB as the presence of a milking effect or a step-up and step-down phenomenon. An anatomic variant was found in 79 patients with TS (72%) and in 48 controls (44%) (p <0.001). CAT in at least 1 vessel (criteria 1: 49% vs 20%, p <0.001; criteria 2: 38% vs 13%, p <0.001), ≥2 vessels (criteria 2: 14% vs 3%, p = 0.005), and wrap-LAD (41% vs 27%, p = 0.02) were significantly more frequent in patients with TS than in controls. The prevalence of MB (9% vs 5%, p = 0.18) did not differ between groups. In conclusion, CAT and wrap-LAD have higher prevalence in patients with TS than in matched controls. These findings could support the hypothesis that anatomic variants might act as potential pathogenic substrates in TS.

Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients.

BACKGROUND: To identify predisposing factors that can result in the onset of takotsubo syndrome, we performed an international, collaborative systematic review focusing on clinical characteristics and comorbidities of patients with takotsubo syndrome. METHODS: We searched and reviewed cited references up to August 2013 to identify relevant studies. Corresponding authors of selected studies were contacted and asked to provide additional quantitative details. Data from each study were extracted by 2 independent reviewers. The cumulative prevalence of presenting features and comorbidities was assessed. Nineteen studies whose authors sent the requested information were included in the systematic review, with a total of 1109 patients (951 women; mean age, 59-76 years). Evaluation of risk factors showed that obesity was present in 17% of patients (range, 2%-48%), hypertension in 54% (range, 27%-83%), dyslipidemia in 32% (range, 7%-59%), diabetes in 17% (range, 4%-34%), and smoking in 22% (range, 6%-49%). Emotional stressors preceded takotsubo syndrome in 39% of patients and physical stressors in 35%. The most common comorbidities were psychological disorders (24%; range, 0-49%), pulmonary diseases (15%; range, 0-22%), and malignancies (10%; range, 4%-29%). Other common associated disorders were neurologic diseases (7%; range, 0-22%), chronic kidney disease (7%; range, 2%-27%), and thyroid diseases (6%; range, 0-37%). CONCLUSIONS: Patients with takotsubo syndrome have a relevant prevalence of cardiovascular risk factors and associated comorbidities. Such of associations needs to be evaluated in further studies.

[Anomalous origin of the right coronary artery from the left sinus of Valsalva: essential role of computed tomography to clarify the coronary artery course and literature review on diagnostic and therapeutic management in 215 cases]. / Origine anomala della coronaria destra dal seno di Valsalva sinistro: ruolo essenziale della tomografia computerizzata nello studio del decorso arterioso coronarico e revisione della letteratura sull'approccio diagnostico-terapeutico in 215 casi.

Coronary artery anomalies are among the most confusing topics in cardiology. Although the medical community is increasingly aware that coronary anomalies can be fatal, the reasons for a sudden fatal event and the frequency with which it occurs are generally unclear. In addition, coronary anomalies are usually compatible with normal prenatal myocardial development and postnatal growth and function, even permitting intense athletic activity. Nevertheless, coronary anomalies may lead to a pathological state, which usually originates suddenly, and the diagnostic and therapeutic management remains controversial, as outlined in our review of 215 cases in the literature. We report the case of a 53-year-old female who presented with effort/stress angina. She underwent coronary angiography, which demonstrated no significant parietal lesions but an anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva: the RCA showed an anomalous course between the aorta and the pulmonary artery with systolic compression and potential myocardial ischemia. The patient was then referred for surgical treatment and, according to the surgeons, she underwent isolated coronary artery bypass with the right internal mammary artery on the RCA and ligature of the native RCA to prevent competitive flow.

Observational study on Takotsubo-like cardiomyopathy: clinical features, diagnosis, prognosis and follow-up.

OBJECTIVES: The present study attempts to identify appropriate elements that may contribute to clarify the broad clinical features (diagnosis, care, complication and prognosis) of Takotsubo-like cardiomyopathy for improving its management. DESIGN STUDY: Observational study. SETTING: Primary level of care referred to the emergency department of Vannini Hospital, Rome, Italy. PARTICIPANTS: The study population consisted of 75 patients, 72 of the them were women and 3 were men with a mean age of 71.9±9.6 years. METHODS: From February 2004 to November 2010, prospectively included 84 consecutive patients diagnosed for suspected Takotsubo-like cardiomyopathy. To be eligible, patients had to meet all the Mayo clinic criteria in the absence of neurological trauma or intracranial haemorrhage. Moreover, those patients that at follow-up still presented alteration of acute phase at ECG and echocardiogram were excluded. Thus, 75 patients comprised the study population. To follow-up 19 patients were lost. RESULTS: None of 75 patients died in acute phase. All patients were promptly discharged (8.4±4.4 days), since they recovered their normal functional status without symptoms. Follow-up information was available for 56 patients. At a mean follow-up time of 2.2±2 years (range, 0.1-6.8 years) two octogenarian patients (2.6%) died because of sudden cardiac death and pulmonary embolism, respectively. The Takotsubo-like cardiomyopathy recurred in one patient. CONCLUSIONS: The results of this study support the previous reports about the good prognosis, also in critically ill patients, of Takotsubo-like cardiomyopathy. Further assessment will be needed to determine a careful and sustained follow-up for choosing the best care and foreseeing the recurrences of this emerging condition.

Management of Atrial Fibrillation in Pregnancy.

Pregnancy is accompanied by a variety of cardiovascular changes in normal women; all of these changes are thought to promote arrhythmogenesis. Atrial fibrillation is unusual during pregnancy and it can represent a benign, self-limited lone atrial fibrillation or can be hemodynamically significant in parturient with or without structural heart disease. Management of atrial fibrillation should be the same as in non-pregnant women, but requires faster intervention, even in patients with a normal heart function, and cautious use of medication to avoid harm to the fetus. We might remember that synchronized electrical cardioversion has been performed safely during all stages of pregnancy.

Short-term evolution (9 months) of aortic atheroma in patients with or without embolic events: a follow-up transoesophageal echocardiographic study.

AIMS: The influence of clinical risk factors and therapeutic options on aortic plaque changes is unknown. In this study, we have evaluated aortic atheroma (AA) evolution in patients with and without embolic events. METHODS AND RESULTS: We enrolled 83 patients (mean age 67.9+/-8.6 years). All patients were studied with transoesophageal echocardiography at baseline and 9 months after enrolment. Baseline atherosclerotic plaques were defined as uncomplicated (between 1 and 3.9 mm) and complicated aortic plaques (>or=4 mm). To minimize sub-millimetre errors in plaque evolution, AA progression was defined as an increase in maximal plaque thickness>or=1 mm. Similarly, regression was defined as a decrease in maximal thickness of atheromatous plaque>or=1 mm. Aortic plaques were classified as uncomplicated in 20.5% and complicated in 79.5% of patients. Fifty-five plaques (47.8%), both complicated and uncomplicated, remained unchanged. Conversely, 16 plaques (13.9%) increased (mean plaque thickness from 3.94+/-1.39 to 5.56+/-1.41 mm, P<0.001) and 44 (38.3%) decreased (mean plaque thickness from 5.25+/-1.52 to 3.79+/-1.53 mm, P<0.001). Multinomial logistic regression procedure suggests that statins increase the probability of plaque thickness reduction (OR 5.92, 95% CI 1.27-27.7, P=0.024) and decrease the probability of plaque progression (OR 0.03, 95% CI 0.01-0.28, P=0.002). CONCLUSION: This study suggests that statins may reduce the risk of AA progression.

2- and 3-dimensional echocardiographic analysis of an unusual transient apical ballooning.

We report the clinical case of a 60-year-old woman who referred to our hospital for the occurrence of typical chest pain during mild effort. At admission, the electrocardiogram showed S-T segment elevation from V(3) to V(6), and an increase in troponin I level (11.4 ng/mL). Echocardiogram showed midapical segment akinesia with depressed ejection fraction (30%). Basal segments were hypercontractile and there was evidence of dynamic obstruction of the left ventricle with an end-systolic peak gradient of 65 mm Hg. Results of emergency coronary arteriography were normal and left ventricular angiography confirmed the midapical akinesia and hypercontractility of the basal segments. Serial 2- and 3-dimensional Doppler echocardiographic examinations were performed. Regression of left ventricular outflow tract obstruction was soon detected (day 3). Fifteen days after admission, 2- and 3-dimensional echocardiography showed a complete regression of both apical ballooning and wall-motion abnormalities with an improvement in overall systolic function. Segmental volumetric analysis allowed accurate assessment of regional volumes and ejection fraction, which were indicative for a progressive reverse remodeling. Regression of wall-motion abnormalities was expressed by a normalization in regional ejection fraction curves at 15 days.

Distribution of potential cardiac sources of embolism in young and older stroke patients: implications for recurrent vascular events.

BACKGROUND: Transesophageal echocardiography (TEE) has improved the diagnostic evaluation of ischemic stroke patients, permitting detection of potential cardiac sources of embolism. The present study aimed to evaluate the distribution of potential cardioembolic sources in young versus older stroke patients and their clinical implication for recurrent vascular events. Two hundred and twenty-eight patients with undetermined ischemic stroke were enrolled in the study. METHODS: All patients were submitted to transthoracic and to TEE examination. The mean follow-up period was 43 +/- 19 months. RESULTS: The overall detection of cardiac sources of embolism was significantly higher in younger than in older patients (P = 0.006). Atrial septal abnormalities were more prevalent in the younger than in the older population (P = 0.006), whereas complicated aortic plaques were detected more often in older patients. During the follow-up period of 4-5 years, we identified 40 recurrent stroke episodes or vascular deaths. As expected, there was a significant difference in recurrent vascular events and death of older patients compared to the younger ones (P = 0.025). CONCLUSIONS: The present study demonstrates that atrial septal abnormalities and aortic atheromas are the most prevalent echocardiographic findings in young and elderly stroke patients, respectively. Complicated aortic atheroma is strictly correlated with recurrent cerebral vascular events or death.