Takotsubo cardiomyopathy: real life management in the intensive coronary care unit.

AIM: Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular dysfunction, ischemic changes on electrocardiogram, elevation of cardiac biomarkers, absence of obstructive coronary artery disease in the setting of various stressing conditions. To date, little is known on best clinical management of this syndrome in coronary care units. Whe thus aimed to present our experience in a real life takotsubo population. METHODS: We identified all patients with Takotsubo cardiomyopathy at our center Maria Vittoria Hospital, Turin, between October 2006 and February 2012. Patients where considered to have Takotsubo syndrome if they presented chest pain on admission, new elettrocardiographic changes suggestive of myocardial ischemia, evidence of apical balloning with hyperkinesis of basal segments on echocardiography, rise in troponin I and, after coronary angiography, no coronary artery disease. We adjudicated the following clinical events: death and recurrence of ischemic events; we also made a detailed analysis of the stressing conditions leading to clinical syndrome. RESULTS: A total of 26 patients were included, 4 (15%) males and 22 (85%) females; mean age was 71±13. After more than 1 year median follow-up the incidence of death was 7.7% (2 deaths), with all deaths, due to cardiogenic shock, occurring in the first 10 days of hospitalization; 2 patients (8%) experienced recurrence of ischemic event. Leading cause of Takostubo was major depressive episode (16%), followed by mourning (12%), falling down with difficulties in standing up (12%), vomiting (8%) and pulmonary infection (8%). In the coronary care unit major complications of patients with Takotsubo syndrome were acute hearth failure (62%), cardiogenic shock (27%), sepsis (31%), pulmonary aedema (27%) and anemia (12%). Two patients needed non-invasive ventilation support and one intra-aortic balloon conterpulasation. In addition one patient developed rabdomyolysis and one left heart thrombus. Cornerstone drug therapy was as follows: 96% of patients took aspirin, 58% beta blockers, 54% nitroglicerine, 46% intravenous heparin, 27% dopamine. CONCLUSION: Takotsubo syndrome is an important safety issue occurring predominantly in post-menopausal women undergoing specific stressing condition. Heart failure and cardiogenic shock are the most serious clinical complication and leading cause of death in the short period, good prognosis is seen thereafter.

Inaccuracy of four coronary surgery risk-adjusted models to predict mortality in individual patients.

OBJECTIVES: This study was undertaken to evaluate the accuracy of four different risk-adjusted models in predicting mortality in individual patients who are undergoing coronary artery by-pass graft surgery. In the last decade several models to stratify patients before open heart surgery, according to factors affecting mortality, were developed with the aim of retrospectively comparing outcomes of open heart surgery, based on reliable stratification of case-mix, and of prospectively identifying high risk patients as a basis for a meaningful informed consent for patients counseling. METHODS: The pre-operative risk of death was calculated with four different models in 418 consecutive patients who underwent coronary artery by-pass surgery and then compared with the actual outcome. To discriminate patients with favorable and unfavorable outcome, the logistic regression analysis and the areas under the receiver-operating-characteristic curves were applied. The accuracy score was used to evaluate the reliability of each score to predict the individual outcome. RESULTS: Seven deaths (1.7%) were observed within 30 days from the operation, and the overall incidence was similar to that predicted by all models. Only the NBI score was not able to discriminate survivors from patients who will die, and the areas under the curves were 0.596 for the Parsonnet score, 0.861 for the Cleveland Clinic Foundation score, 0.823 for the French score, and 0.806 for the EuroSCORE. The four models were highly accurate (between 0.97 and 0.98) to predict the overall mortality. In seven patients who died the mean predictive scores were very low and ranged between 2.1 and 4.6, but were significantly higher than those of patients who survived (between 1.1 and 2.2). CONCLUSIONS: The four pre-surgical predictive models were similarly able to discriminate favorable vs. unfavorable outcomes and highly accurate to predict overall mortality, but very inaccurate to predict mortality in individual patients.

[Models of preoperative risk stratification in cardiac surgery: the prediction of mortality or of survival?]. / Modelli di stratificazione del rischio preoperatorio in cardiochirurgia: predizione di mortalità o di sopravvivenza?

BACKGROUND: The need to assess the quality of heart surgery outcomes stimulated the development of pre-surgical risk stratification models in order to predict outcome on the basis of patient characteristics. The aim of the study was to compare the predictive accuracy of hospital mortality according to the following three models: Parsonnet (NBI Score), Higgins (CCF Score) and Roques (French Score), in a setting totally independent from the one in which the models were derived. METHODS: For each of the 516 patients undergoing heart surgery at our institution between January 1992 and December 1993, we calculated the pre-surgical risk according to the three models. Then we compared the predicted mortality against the observed mortality by means of the Shannon accuracy index, the ROC curve analysis and the overestimation histogram. RESULTS: Overall observed mortality (1.5%) was similar to the predicted mortality by the NBI Score (1.5 +/- 2.1%, p = ns), the CCF Score (1.7 +/- 2.0%, p = ns) and the French Score (1.9 +/- 2.5%, p = ns). The predictive accuracy of global mortality is very high and equal with the three models, and it is very low in the 8 patients who died (NBI Score = 0.06 +/- 0.06; CCF Score = 0.125 +/- 0.067; French Score = 0.102 +/- 0.07, p = ns). The area under the ROC curve is identical in the 3 models. CONCLUSIONS: The predicted mortality obtained by the three models is not significantly different from the observed mortality and therefore, the global accuracy is similar and very high, while it is very low for patients who will die. The models for pre-surgical risk stratification are useful for comparing the results among different institutions or different surgeons, or for monitoring the results over time in the same institution, but they cannot be used to accurately predict the individual risk of hospital mortality.

Risk stratification for open heart operations: comparison of centers regardless of the influence of the surgical team.

BACKGROUND: Risk-adjusted mortality was previously used to compare institutions as a whole or surgeons. Because the same surgical team is working in two different hospitals, the aim of our study was to assess whether the institution can make a difference in surgical mortality. METHODS: Preoperative data of 554 patients in institution A and 500 in institution B were prospectively collected during the same period of time. All patients were operated on by the same surgeon with the same first assistant and anesthesiology staff in both institutions. Patient population was stratified according to Parsonnet's predictive model, in five risk groups, and mortality was adjusted by the direct standardization method. RESULTS: At institution A it was observed that in-hospital mortality was 2.3% (95% confidence interval, 1.3% to 4.0%), and in institution B 4.0% (95% confidence interval, 2.5% to 6.1%). The difference between the two mortality rates (1.7%; 95% confidence interval, -0.5% to 3.8%) is not statistically significant (p = 0.16), nor is the difference within each class. The standardized mortality ratio was 3.6% (95% confidence interval, 2.7% to 4.8%) and 5.8% (95% confidence interval, 4.6% to 7.2%), respectively. The difference of 2.2% (95% confidence interval, 0.5% to 3.8%) is statistically significant (p = 0.01). CONCLUSIONS: The institution can affect mortality of patients undergoing open heart operations, regardless of the influence of the surgical team.

Clinical outcome and emotional-behavioural status after isolated coronary surgery.

In order to evaluate clinical and psychosocial results of isolated coronary artery by-pass graft (CABG) we studied 626 consecutive patients, mean age 61 +/- 8 years (86% men), in a follow-up (median: 58 months) with a complete questionnaire about cardiosurgical problems (post-operative vital status, angina relapse, infarction, heart failure, PTCA, redo, PM) and psychosocial variables (mood, irritableness, job satisfaction, hobby satisfaction, family relations, sexual activity, general well-being and work status). Global evaluation improvement of psychosocial variables was found in 71% of patients without cardiac events (group A) and 11% of patients with cardiac events (group B); worsening was found in 2% of group A and 1% of group B; no referred variations in 13% and 2% respectively (p < or = 0.05. Interests (in work, hobbies and sexual activities) demonstrate an improvement in 20% (group A) and 2% (group B); worsening in 12% (group A) and 4% (group B); no variations in 51% (group A) and 11% (group B) (p < or = 0.005). Patients reported a well-being evaluation improvement about 66% in the group returning to work without restriction, 13% in those with limitation, 6% no further working; worse or unchanged well-being evaluation was found in 9% of patients returning to work without restriction, 3% with limitation, 3% no further working (p < or = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of gallopamil on myocardial perfusion in angina of effort]. / Influenza del gallopamil sulla perfusione miocardica nell'angina da sforzo.

To value stress tolerance and stress myocardial perfusion before and after a week of oral therapy with gallopamil 150 mg daily, we studied 10 patients suffering from stable effort angina. We performed bicycle exercise stress testing and thallium scintigraphy (Tl) with planar technique in 3 projections (anterior-posterior and oblique left anterior at 45 and 70 degrees) according to the current standards. We valued systolic and diastolic blood pressure (SBP-DBP), heart rate (HR) and HR-SBP product at rest, at symptoms stress-induced and at the end of the procedure. Moreover we valued work threshold of chest discomfort and ischemia, the maximal work capacity and the perfusion defects according to a Tl score obtained dividing the 3 projections in 5 segments and fixing a value according to the observed perfusion from 0 = normal perfusion to 3 absent perfusion. We observed a significant reduction of basal HR (77 vs 71, p = 0.05), SBP (147 +/- 15 vs 131 +/- 15 mmHg, p = 0.001), DBP (91 +/- 6 vs 83 +/- 6 mmHg, p = 0.002). Work threshold of chest discomfort and ischemia significantly arose (8 +/- 3 vs 11 +/- 4 min., p = 0.002; 6 +/- 3 vs 10 +/- 4 min., p = 0.001). The HR-SBP product at the maximal work capacity and the Tl score significant decreased (31650 +/- 6239 vs 29406 +/- 5418, p = 0.003; 8 +/- 2 vs 5 +/- 1, p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

A quality control method in cardiac surgical outcome: experience in 462 patients.

The aim of our study is to verify the reliability, reproductiveness and simplicity of a method to control cardiac surgical results. We divided 462 adult patients, operated on for acquired heart disease from October 1989 to January 1991, into five classes according to an individual score which was predictive for their operative mortality risk. The score resulted from 15 different risk factors tested with univariate and multivariate analysis against one event: operative death. The total number of deaths was 12: 2, 2, 1, 2, 5 for each class respectively. When comparing the predicted versus our observed mortality, we found no statistically significant difference, using the chi-squared test. The method we used is highly predictive for surgical mortality risk: it makes the results objectively comparable among different institutions; it is useful as a self-controlled quality method for cardiac surgical activity in any single institution.