Left ventricular true and false aneurysms identified by cardiovascular magnetic resonance.

Left ventricular aneurysms are uncommon complications of myocardial infarction. However, it is important to identify them because they are associated with increased morbidity and mortality. True aneurysms tend to be managed conservatively whereas false aneurysms, because of the risk of rupture, are usually treated with urgent surgery. Distinguishing these two subtypes is therefore critical and cardiovascular magnetic resonance (MR) is being used more frequently to characterise the type of aneurysm as well as to provide clear three-dimensional images of aneurysm morphology. We present a very rare case of a true and a false aneurysm of the left ventricle in the same patient. MR enabled accurate delineation of both aneurysms and the late gadolinium-enhancement images provided evidence confirming both true and false aneurysms to be present.

Takotsubo (apical ballooning) syndrome in the recovery period following dobutamine stress echocardiography: a first report.

We report a case of Takotsubo syndrome occurring in the recovery phase after a dobutamine stress echocardiogram. Takotsubo syndrome is a widely acknowledged cause of reversible left ventricular systolic dysfunction. It has garnered much attention from the cardiological community since its presentation frequently mimics that of ST-segment elevation myocardial infarction. The exact aetiology remains incompletely defined, although stress is recognized frequently as a precipitating factor. In recent years it has emerged that stress testing, as part of a patient's investigative assessment, can also induce Takotsubo's syndrome. All prior reports of dobutamine-induced Takotsubo's syndrome have described apical ballooning at peak stress. We describe the case of an 85-year-old lady who developed apical ballooning in the recovery period after a dobutamine stress echocardiogram, despite having normal left ventricular wall motion at rest and at peak stress. We believe this to be the first such case reported in the literature. Dobutamine stress testing can precipitate Takotsubo's syndrome not just at peak stress but also during the recovery period. All those performing dobutamine stress tests should be aware of this rare but potentially important complication.

Effect of aggressive risk factor modification on cardiac events and myocardial ischaemia in patients with chronic kidney disease.

OBJECTIVE: To examine whether aggressive risk factor modification in chronic kidney disease (CKD) can limit the development of new ischaemia or reduce cardiac events. METHODS: Patients with CKD were randomly assigned to either an aggressive risk factor modification strategy (targeted treatment of hypertension, dyslipidaemia, homocysteine, haemoglobin and phosphate) or standard care. An intention to treat analysis was performed on 152 patients who had baseline dobutamine stress echocardiography (DSE), including 107 who had follow-up DSE. Biochemical parameters, cardiac risk factors and investigations (ECG, two-dimensional echocardiography) were recorded at baseline. New ischaemia was classed as new or worsening stress wall motion abnormality between follow-up and baseline DSE. Patients were followed up for the development of new ischaemia or cardiac death, acute coronary syndrome and non-fatal myocardial infarction over 1.8 years. RESULTS: The development of new ischaemia was common but not different between the standard and aggressively treated groups (15 (21%) v 18 (23%), p = 0.8). Independent predictors of new ischaemia were older age, abnormal ECG, higher systolic blood pressure and lower serum high density lipoprotein cholesterol, but not treatment arm. The standard and aggressively treated groups did not differ in cardiac event rate (10% v 13%, p = 0.6) or all-cause mortality (10% v 19%, p = 0.2). In patients with an abnormal baseline DSE (non-diagnostic, scar or ischaemia), the event rate was similar (22% v 20%, p = 0.9). CONCLUSION: Aggressive risk factor modification in CKD does not limit the development of new ischaemia or reduce cardiac events in patients with an abnormal DSE.