Endothelial function and sympathetic nervous system activity in patients with Takotsubo syndrome.

BACKGROUND: Takotsubo syndrome (TTS) is an acute cardiomyopathy associated with intense physical or emotional stress. The precise mechanisms of the disease remain unclear. The aim of this study was to study alterations in endothelial function, vascular compliance and structure and muscle sympathetic activity in the stable phase of the disease. METHODS: In this prospective observational study, patients with TTS and controls matched for age, sex, cardiovascular risk factors and medications were recruited. Flow-mediated vasodilatation (FMD) as a measure of endothelial dysfunction was the primary endpoint. Secondary endpoints included measurements of arterial stiffness, carotid atherosclerosis, quality of life and laboratory parameters. In a subset of patients, muscle sympathetic activity was measured before and after stress tests. RESULTS: The study included 22 TTS patients and 21 matched controls. A significant increase in endothelial dysfunction was seen in TTS compared to controls (FMD 3.4±2.4% vs. 4.8±1.9%, p=0.016). No significant differences in arterial stiffness, intima-media thickness, quality of life and laboratory markers including endothelin-1 were noted. TTS patients showed a reduced carotid total plaque area compared to controls (TPA 17.3±15.1 vs 24.7±12.8mm2, p=0.02). A trend of increased muscle sympathetic activity at rest was observed in TTS patients vs. controls (53.5±28.4 vs. 29.4±16.5 bursts/100 heart beats, p=0.09) with no significant differences in muscle sympathetic activity in response to stress. CONCLUSIONS: Our findings underscore the importance of endothelial dysfunction in patients with TTS which may be involved in the pathophysiology of this syndrome. CLINICALTRIALS. GOV IDENTIFIER: NCT01249599.

[Utility and limitations of the exercise stress test in medical outpatients: an update]. / Apports et limites de l'ECG d'effort dans la pratique médicate quotidienne: un "update".

Exercise testing has remained a widely used test in clinical practice to detect and diagnose coronary artery disease, despite the possibility to use cardiac imaging. The indications and contraindications for exercise testing are well known. However, its limitations have to be kept in mind in order to adequately interpret its results. Although exercise testing allows also deriving prognostic data on cardiovascular morbidity and mortality, consensus papers do not recommend this test as a screening tool in cardiovascular prevention in asymptomatic subjects.

Comparison of 99mTc-sestamibi lung/heart ratio, transient ischaemic dilation and perfusion defect size for the identification of severe and extensive coronary artery disease.

The ability to identify patients with severe coronary artery disease (CAD) by analysis of perfusion defects is limited. The lung/heart ratio (LHR) and transient ischaemic dilatation (TID) have been used for this purpose in thallium-201 scintigraphy. The value of these parameters in technetium-99m sestamibi single-photon emission tomography (SPET) imaging is controversial. In this study, therefore, we determined TID and LHR in a single-day rest/stress 99mTc-sestamibi SPET perfusion protocol and compared these measurements with perfusion defect size (PDS) and angiographic severity of CAD. Severe CAD was defined as >75% left main coronary stenosis and/or >90% proximal left anterior descending artery stenosis and/or >90% proximal stenosis in the left circumflex and right coronary arteries. LHR was determined from a stress anterior planar image recorded < or =6 min after exercise. TID ratio was derived from automatically calculated left ventricular rest/stress volumes, and PDS was measured based on semi-automated computer software (CEqual). Diagnostic accuracy and predictive values were compared between 22 patients with severe and 98 patients without severe CAD. LHRs showed a higher sensitivity (73%) for the assessment of severe CAD as compared to PDS and TID ratio (41% and 23% respectively, P<0.01), whereas specificity was highest for TID ratio [95%, P<0.01 when compared to PDS (84%) and LHR (82%)]. It is concluded that increased LHR in 99mTc-sestamibi myocardial perfusion imaging seems to yield good diagnostic accuracy in the detection of patients with severe CAD and may be derived from a single-day rest/stress study.

No evidence for systolic or diastolic left ventricular dysfunction at rest in selected patients with long-term type I diabetes mellitus.

We assessed left ventricular systolic and diastolic function using pulsed-waved Doppler echocardiography in a selected group of 20 patients with insulin-dependent diabetes mellitus (IDDM) (mean age, 35 +/- 8 years; mean diabetes duration, 17 + 7 years). Our patients were free of autonomic neuropathy and major micro- or macrovascular complications and had no evidence of ischemic heart disease or hypertension. The results were compared with those of 20 age- and sex-matched control subjects. We found that left ventricular geometry and mass, systolic function by M-mode and 2D-echocardiography, isovolumetric relaxation time, deceleration time and the PEP/LVET ratio were not significantly different between patients and control subjects. Hemodynamic parameters were also not significantly different except for a slightly higher heart rate in the patient group (75 +/- 11 vs. 68 + 6 bpm, P = 0.019). After correction of A-peak velocities for differences in heart rate, there was no significant difference of Doppler indices of diastolic left ventricular function between patients and control subjects. The absence of significant left ventricular systolic and diastolic dysfunction by Doppler echocardiography in our study patients may be explained by our patient selection. Left ventricular dysfunction in diabetic patients without concomitant hypertensive or ischemic heart disease may only occur in conjunction with microvascular disease in other organ systems, with autonomic neuropathy or with poor metabolic control.

[Aortic valve stenosis in the old age: clinical and echocardiographic aspects]. / Die valvuläre Aortenstenose im Alter: Klinische und echokardiographische Aspekte.

Among 380 consecutive patients > 70 years of age, patients with a systolic heart murmur were investigated both clinically and by doppler echocardiography. The aim of the study was to compare the validity of the clinical diagnosis of valvular aortic stenosis in elderly patients with the results of doppler echocardiography. 138/380 patients (36%) had a systolic heart murmur. 130 were investigated by doppler echocardiography. 23/130 patients with systolic murmur (18%) had moderate or severe aortic stenosis. Clinically, patients with moderate or severe aortic stenosis had a pulsus parvus et tardus of the carotid artery more often than patients with only slight or no evidence of aortic stenosis (61% vs 16%; p < 0.0001). In patients with moderate or severe aortic stenosis, the murmur radiated more often to the carotid vessels (65% vs 19%; p < 0.0001). Systolic blood pressures and pressure amplitudes were lower in patients with moderate or severe aortic stenosis (132 vs 141 mm Hg; p < 0.01; 61 vs 68 mm Hg; p < 0.001). Electrocardiography showed left ventricular hypertrophy or bundle branch block more often in patients with moderate or severe aortic stenosis (57% vs 15%; p < 0.01). We conclude that moderate or severe aortic stenosis is a frequent finding in elderly patients. Diagnosis by clinical examination may be difficult. For this reason, doppler echocardiography should be performed, especially when therapeutic consequences are to be expected from the diagnosis, such as aortic valve replacement or vasodilator treatment in the case of congestive heart failure.

[Acute left heart insufficiency: possible leading symptom of a pheochromocytoma]. / Akute Linksherzinsuffizienz: mögliches Leitsymptom eines Phäochromozytoms.

A 42-year-old patient with acute left-ventricular failure is described in whom pheochromocytoma was diagnosed only after prolonged and fruitless efforts. Pheochromocytoma may present without the typical features of paroxysmal or sustained hypertension, headache, increased sweating, and palpitations. Therefore, in cases of acute left-sided cardiac failure of primarily undetermined origin, pheochromocytoma should be considered in differential diagnosis.

[Epidemiology of fatal abnormalities in Switzerland]. / Epidemiologie der letalen Missbildungen in der Schweiz.

Official certificates of stillbirth and infant death are analysed in the birth cohort of 1979-81. Congenital malformations account for approx. 40% of infant mortality. Cantonal differences in malformation rates are not explained by different incidence of such malformations only, but also by differences in lethality. Incidence of Anencephaly is examined in detail.

[Nursing care cases and acute-care hospital beds: results of a one-day census]. / Pflegefälle und Akutbetten: Ergebnisse eines Tageszensus.

For the purposes of an analysis of the hospital capacities of the canton of Basel-Stadt, a one-day census was conducted on April 20, 1983. On that day, the physicians in charge identified every fifth patient out of 2920 hospitalized patients as misplaced. "Misplaced" means that, from a medical point of view, mostly elderly patients could be treated and cared for as well (and cheaper) in other institutions (e.g., nursing homes) or in community settings if adequate home care services were available.

[Drug consumption by students in Basel]. / Medikamentenkonsum bei Basler Schülern.

A survey on drug consumption of school children of Basle (age 13-18) was conducted by anonymous questionnaire and involved 50% of the adolescents concerned. Analgesic drugs were taken by almost 60% of pupils, this proportion increased with age and demands of school. Psychosomatic complaints like headache were the most frequent reasons given for the consumption of drugs; alternative treatments for such complaints were unknown to the pupils.