Takotsubo syndrome in a breast-feeding young woman: Highlighting the protection of oestrogens?

Takotsubo syndrome (TTS) is currently described as an acute and usually reversible form of systolic dysfunction of the left ventricle, which more frequently affects postmenopausal women after a stressful emotional event. Although TTS is a rare condition in premenopausal women, in recent years, the number of reported cases has increased. This manuscript reports the first case of a TTS several months after delivery in a 22-year-old woman during lactation. It may also emphasize the role of estrogens in the disease pathogenesis.

Creatinine variation improves Zwolle score in selecting low-risk patients after ST-segment elevation myocardial infarction.

BACKGROUND: The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation (Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications. CONCLUSION: Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality / Fibrilação Auricular de Novo no Infarto Agudo do Miocárdio com Supradesnível do Segmento ST: Preditores e Impacto na Terapêutica e Mortalidade

Abstract Backgrund: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance. Objective: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction. Methods: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant. Results: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. Conclusion: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

Resumo Fundamento: A fibrilação auricular de novo no contexto de infarto agudo do miocárdio representa um importante desafio com potencial impacto prognóstico. Objetivo: Determinar a incidência, impacto na terapêutica e mortalidade, e identificar possíveis preditores do aparecimento de fibrilação auricular de novo durante o internamento por infarto agudo do miocárdio com supradesnivelamento do segmento ST. Métodos: Estudamos todos os pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST inseridos consecutivamente de 2010 a 2017 num registro nacional português e comparamos dois grupos: 1 - sem fibrilação auricular; 2- com fibrilação auricular de novo. Efetuamos análise com modelo de regressão logística para avaliar o impacto de fibrilação auricular de novo na mortalidade intra-hospitalar e identificar preditores independentes para o seu aparecimento. Para teste de hipóteses, considerou-se significativo p < 0,05. Resultados: Estudamos 6325 pacientes, dos quais 365 (5.8%) apresentaram fibrilação auricular de novo. Não houve diferença no número de pacientes reperfundidos nem na estratégia de reperfusão. No grupo 2, terapêutica com betabloqueadores e IECA/ARA foi menos frequente, 20.6% tiveram alta sob anticoagulação oral e 16.1% sob terapêutica tripla. A fibrilação auricular de novo associou-se a maior incidência de complicações e mortalidade intra-hospitalar, mas não foi preditor independente de mortalidade intra-hospitalar. Identificamos idade, acidente vascular cerebral prévio, infarto inferior e bloqueio auriculoventricular completo como preditores independentes de fibrilação auricular de novo. Conclusões: A fibrilação auricular de novo continua sendo uma complicação frequente do infarto agudo do miocárdio, estando associada a aumento das complicações e mortalidade intra-hospitalar. Apenas 36.7% desses pacientes teve alta sob anticoagulação.

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality.

BACKGRUND: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance. OBJECTIVE: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction. METHODS: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant. RESULTS: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. CONCLUSION: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

Left main and/or three-vessel disease in patients with non-ST-segment elevation myocardial infarction and low-risk GRACE score: Prevalence, clinical outcomes and predictors.

INTRODUCTION: A low-risk GRACE score identifies patients with a lower incidence of major cardiac events, however it can erroneously classify patients with severe coronary artery disease as low-risk. We assessed the prevalence, clinical outcomes and predictors of left main and/or three-vessel disease (LM/3VD) in non-ST-elevation acute myocardial infarction (NSTEMI) patients with a GRACE score of ≤108 at admission. METHODS: Using data from the Portuguese Registry on Acute Coronary Syndromes, 1196 patients with NSTEMI and a GRACE score of ≤108 who underwent coronary angiography were studied. Independent predictors of LM/3VD and its impact on in-hospital complications and one-year mortality were retrospectively analyzed. RESULTS: LM/3VD was present in 18.2% of patients. Its prevalence was higher in males and associated with hypertension, diabetes, previous myocardial infarction, heart failure and peripheral arterial disease (PAD). Although there were no differences in in-hospital complications, these patients had higher mortality (0.9 vs. 0.0%) and more major adverse cardiac and cerebrovascular events (MACCE) (4.1 vs. 2.5%, p=0.172), and higher one-year mortality (2.4 vs. 0.5%, p=0.005). Independent predictors of LM/3VD were age (OR 1.03; 95% CI 1.01-1.0, p=0.003), male gender (OR 2.56; 95% CI 1.56-4.17, p<0.001), heart rate (1.02; 95% CI 1.01-1.03, p<0.001), PAD (OR 3.21; 95% CI 1.47-7.00, p<0.001) and heart failure (OR 3.38; 95% CI 1.02-11.15, p=0.046). CONCLUSIONS: LM/3VD was found in one in five patients. These patients had a tendency for higher in-hospital mortality and more MACCE, and higher one-year mortality. Simple clinical variables could help predict this severe coronary anatomy.

Prader-Willi syndrome: a nest for premature coronary artery disease?

Individuals affected by Prader-Willi syndrome (PWS) may show increased risk for coronary artery disease (CAD), which probably relates, at least, with high burden of cardiovascular risk factors.A 27-year-old man with PWS, obesity, hypertension, diabetes mellitus and dyslipidaemia attended the emergency department with complaints of flu-like condition and chest pain. The ECG revealed a mild ST-segment elevation in inferior leads, followed by positive myocardial necrosis biomarkers. Attending to the high cardiovascular risk profile, ST-segment elevation in inferior territory and wall motion abnormalities, a coronary angiogram was performed. The latter showed a three-vessel CAD, 60% stenosis in midanterior descending artery, total occlusion (100%) of the obtuse marginal artery and 99% stenosis with high thrombi burden in the proximal right coronary artery.The present case report emphasises the plausibility of premature CAD in patients with PWS, a possible underdiagnosed feature of this condition.

Left ventricular basal inferior pseudoaneurysm and left atrial dissection after myocardial infarction: Case report.

Left atrial dissection is a rare entity, mostly occurring after mitral valve surgery, with only a few cases described after myocardial infarction. The authors report a case of a 60-year-old man who presented with an inferior myocardial infarction, complicated with pseudoaneurysm of basal segment of left ventricular inferior wall, which expanded through the mitral ring to left atria, causing left atrial free wall dissection. The left ventriculo-atrial communication through the pseudoaneurysm caused major para-mitral regurgitation and the development of acute heart failure. Good clinical outcome was achieved with stabilization of acute heart failure with high-dose diuretic therapy and delayed cardiac surgery with closure of left ventriculo-atrial communication.

Acute kidney injury in acute coronary syndromes - An important multifactorial consequence.

INTRODUCTION: Acute kidney injury (AKI) is a pathological phenomenon with a negative impact on outcomes in different clinical scenarios. Its mechanism in acute coronary syndrome (ACS) is not completely understood, and measures to prevent it are not uniform. We set out to study the incidence, clinical relevance, predictors and possible implications for patient management of AKI in ACS. METHODS: Using data from a multicenter national registry on ACS, we retrospectively analyzed predictors of AKI and its impact on outcomes (in-hospital complications and one-year mortality). All ACS types were included. AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl (≥26.4 µmol/l) and/or by ≥1.5 times baseline. RESULTS: A total of 7808 ACS patients were included in the analysis, 1369 (17.5%) of whom developed AKI. AKI was shown to be an independent predictor of in-hospital major bleeding (odds ratio [OR] 2.09; 95% confidence interval [CI] 1.19-3.64; p=0.01), mortality (OR 4.72; 95% CI 2.94-7.56; p<0.001) and one-year mortality (hazard ratio 2.01; 95% CI 1.51-2.68; p<0.001). The incidence of AKI was associated with older age, history of hypertension, renal failure and stroke/transient ischemic attack, Killip class >1 on admission and left ventricular ejection fraction <50%. Performance of coronary angiography or angioplasty were not associated with AKI. Diuretics during admission were predictors of AKI only in patients in Killip class 1. CONCLUSIONS: AKI is an important finding in ACS, with a significant impact on hard clinical endpoints such as in-hospital and one-year mortality. It is associated with easily identifiable clinical factors and an invasive strategy does not increase its incidence.

Multivessel approach in ST-elevation myocardial infarction: impact on in-hospital morbidity and mortality.

INTRODUCTION: Multivessel disease in ST-elevation myocardial infarction (STEMI) is associated with a worse prognosis. A multivessel approach at the time of primary percutaneous coronary intervention (PCI) is the subject of debate. OBJECTIVE: To assess the impact of a multivessel approach on in-hospital morbidity and mortality in patients with STEMI undergoing primary PCI. METHODS: We studied patients from the Portuguese Registry of Acute Coronary Syndromes with STEMI and multivessel disease who underwent primary PCI. The 257 patients were divided into two groups: those who underwent PCI of the culprit artery only and those who underwent multivessel PCI. Cardiovascular risk factors, STEMI location, in-hospital treatment, number and type of diseased and treated arteries, type of stent implanted and ejection fraction were recorded. The primary end-point was defined as in-hospital mortality and the secondary end-point as the presence of at least one of the following complications: major bleeding, need for transfusion, invasive ventilation, heart failure and reinfarction. RESULTS: Multivessel disease was found in 43.3% of the study population and a multivessel approach was adopted in 19.2% of these patients. There were no differences between the groups in cardiovascular risk factors or electrocardiographic presentation of STEMI. Patients undergoing multivessel PCI were more likely to be treated with drug-eluting stents and glycoprotein IIb/IIIa inhibitors, and less likely to receive heparin therapy. There were no differences between the groups with regard to in-hospital mortality or the incidence of complications. CONCLUSION: In our population of patients with STEMI, a multivessel approach appears to be safe and not associated with increased in-hospital mortality or morbidity.

Syncope and intermittent Brugada ECG pattern.

Brugada syndrome is a rare syndrome, with an estimated prevalence in Europe of 1-5/10 000 population, whose initial clinical presentation can be sudden death. Although it has a characteristic electrocardiographic pattern, this can be intermittent. The authors present the case of a 32-year-old man, with no family history of syncope or sudden death, who went to the emergency department for syncope without prodromes. The initial electrocardiogram (ECG) in sinus rhythm documented an isolated and non-specific ST-segment elevation in V2. During further diagnostic studies, a repeat ECG revealed type 1 Brugada pattern. This pattern was later seen in a more marked form during a respiratory infection. The patient subsequently underwent electrophysiological study, followed by implantation of an implantable cardioverter-defibrillator (ICD), with an episode of ventricular fibrillation converted via ICD shock two months after implantation.

[Right atrial thrombus: a rare presentation of plasminogen activator inhibitor deficiency]. / Trombo na aurícula direita: apresentação rara da deficiência do inibidor do ativador do plaminogénio.

Free-floating right atrial thrombi are rare but associated with high mortality. Although advances in echocardiography have improved diagnosis, their management is still the subject of debate. A 24-year-old woman with a history of smoking, obesity and oral contraceptive use presented to the emergency department with dyspnea, cough and hemoptysis. Transthoracic echocardiography revealed a large free-floating cardiac mass occupying the right atrial chamber and restricting tricuspid valve opening. In view of recurrent pulmonary embolism, she was referred for cardiac surgery and the cardiac mass was excised. Anatomopathological analysis revealed an organized and calcified thrombus. Genetic study showed her to be homozygous for the 4G/4G allelic variant of plasminogen activator inhibitor-1 and heterozygous for the allelic variant A1298C of 5,10-methylenetetrahydrofolate reductase.

[Dyspnea in aortic stenosis: appearances can be deceptive]. / Dispneia na estenose aórtica: nem tudo o que parece é.

Valvular aortic stenosis is the most common valvular disorder in Europe. Although recommended, stress exams are still underused in its evaluation. We report the case of a 60-year-old man who, following a routine electrocardiogram with abnormal ventricular repolarization, underwent stress testing, which was positive for myocardial ischemia, and an echocardiogram that revealed moderate aortic stenosis. Cardiac catheterization showed no angiographic coronary lesions and an intraventricular gradient of 45 mmHg. In view of the latter, stress echocardiography was performed, which documented an increase in the intraventricular gradient from 30 mmHg to 131 mmHg. Repeat stress echocardiography under treatment with bisoprolol showed an increase in test duration and a maximum intraventricular gradient at peak exercise of 36 mmHg. Stress exams may have an important role in the diagnostic and therapeutic management of patients with aortic stenosis.

Non-cardiac comorbidities in the very elderly with acute myocardial infarction: prevalence and influence on management and in-hospital mortality.

INTRODUCTION: Acute myocardial infarction (AMI) in the very elderly is common and is associated with increased mortality. Despite this, the majority of such patients do not receive the most effective cardiovascular therapies. The presence of non-cardiac comorbidities constitutes an additional challenge to the management of AMI in very elderly patients. OBJECTIVE: To determine the prevalence of non-cardiac comorbidities in the very elderly (age > or = 80 years) with AMI and how it influences their management and in-hospital mortality. METHODS: A total of 132 patients consecutively admitted with a diagnosis of AMI from January 2005 to December 2007 were analyzed retrospectively. Two groups were considered: patients with non-cardiac comorbidities (group 1) and those without non-cardiac comorbidities (group 2). Cardiovascular risk factors and non-cardiac comorbidities (anemia, chronic obstructive pulmonary disease, chronic renal failure, cancer, neurologic or psychiatric disorders, and prostatic hyperplasia in men) were recorded. Use of an invasive strategy and the therapy prescribed at discharge were compared between the groups. RESULTS: Non-cardiac comorbidities were found in 56.8% of patients, with the following prevalences: anemia 18.2%; chronic obstructive pulmonary disease 11.4%; chronic renal failure 25.8%; cancer 3.0%; neurologic or psychiatric disorders 11.4%; and prostatic hyperplasia 20.5%. Patients with comorbidities had longer hospital stay than those without (12.1 +/- 5.5 and 10.1 +/- 3.5 days, respectively; p = 0.014). An invasive strategy, with coronary angiography, was used in 12.1% of patients, with no differences between groups (12.3% in patients without comorbidities and 12.0% in those with, p = 0.82). At discharge, more than 70% of the patients were prescribed aspirin, statins and nitrates. With the exception of non-dihydropyridine calcium antagonists, which were more frequently prescribed in patients with comorbidities (15.9% vs. 2.2%; p = 0.04), no other differences in therapy were observed between the two groups. CONCLUSION: In our population of very elderly patients, the prevalence of non-cardiac comorbidities was high (56.8%), but this did not significantly influence the management of these patients.

The role of antidiuretic hormone in the pathophysiology and treatment of heart failure.

Heart failure (HF) is still one of the most important causes of morbidity and mortality worldwide. Neurohormonal changes appear to play an important role in the development and continuation of HF. Among the mediators responsible for these changes, antidiuretic hormone (ADH) is probably the least known. However, elevated concentrations of ADH are frequently found in this syndrome and have prognostic value in addition to known biomarkers. Recent experimental studies and clinical trials have aroused interest in the possible benefits of ADH receptor antagonists. This article reviews the pathophysiological mechanisms of ADH in HF and the latest advances in ADH antagonism in the therapeutic management of HF.