Takotsubo cardiomyopathy: reversible stress-induced cardiac insult - a stress protective mechanism.

Takotsubo cardiomyopathy (TCM) is characterized by a typical pattern of wall motion abnormalities (basal hyperkinesis with mid-ventricular and apical hypokinesis) in the absence of obstructive coronary artery disease. The clinical presentation often mimics acute coronary syndrome with anginal and anginal-equivalent symptoms, dynamic ECG changes, and elevated cardiac biomarkers. Patients are predominantly postmenopausal women. In the vast majority of cases an extremely stressful inciting event can be identified. The catecholamine surge occurring in response to stress has been implicated as the trigger for this peculiar myocardial response. It appears the specific type of beta-adrenergic receptor activation, relative epinephrine to norepinephrine activity, and a genetic predisposition all play a role. This apparently paradoxical response to stress may, in fact, be an important evolutionary safety net preventing catecholamine induced myocardial collapse.

Carotid artery stenting in a community hospital: a success story.

BACKGROUND: Carotid endarterectomy (CEA) is an effective procedure for reducing the risk of stroke in patients with carotid artery atherosclerosis. The evolution of carotid artery stenting (CAS) has made this a viable alternative to CEA in appropriate patient populations. We sought to evaluate the safety and efficacy of CAS in a high-risk population, in an effort to report such results in a medium-size community hospital. The data were then compared with the results published in the CREST and SAPPHIRE trials. METHODS: The records of 280 consecutive patients undergoing carotid artery stenting between January 2005 and December 2011 were reviewed. A total of 271 patients were included in the final analysis. The clinical endpoints included cerebrovascular accident, myocardial infarction, and death in the perioperative period. RESULTS: A total of 155 men (57.2%) and 116 women (42.8%) underwent CAS. A total of 259 carotid interventions (95.6%) were successful. Two of 271 patients (0.7%) experienced a minor neurologic event post procedure, with 1 patient death (0.35%) recorded. No perioperative myocardial infarctions were encountered. CONCLUSION: Our findings indicate that our institution has been able to safely and effectively introduce and carry out CAS as a substitute to CEA in patients that are at high risk for surgery with results comparable to those published in large-scale clinical trials. Further studies are needed to verify whether these results can be generalized to other community hospitals, as well as to refine qualification criteria for performing physicians. Furthermore, the applicability of these results to normal-risk patients is currently being investigated.

"Register and Roll": A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction.

Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the "Register and Roll" initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. "Register and Roll" streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.

Myocardial infarction in a young female with palindromic rheumatism: a consequence of negative remodeling.

Palindromic rheumatism is a rare disease associated with systemic inflammation. Negative or constrictive coronary artery remodeling is typically not seen until the 7th or 8th decade of life. We report a case of a young female with palindromic rheumatism who suffered a non-ST segment elevation myocardial infarction secondary to a flow-limiting lesion that demonstrated negative remodeling by intravascular ultrasound (IVUS).