Comparison of Left Ventricular Contractile Abnormalities in Stress-Induced Cardiomyopathy versus Obstructive Coronary Artery Disease Using Two-Dimensional Strain Imaging.

BACKGROUND: Data on left ventricular (LV) strain profiles in patients with takotsubo cardiomyopathy (TC) in comparison with obstructive coronary artery disease (CAD) are limited. We sought to investigate regional and global LV longitudinal strain in a cohort of patients with known TC using two-dimensional strain imaging (2DS) in comparison with patients with acute cardiomyopathy (ACM) due to severe obstructive left anterior descending arterial disease or triple-vessel disease and healthy controls. METHODS: Transthoracic echocardiography was performed in 34 patients with established TC, 24 patients with ACM, and 30 healthy subjects. We measured the segmental longitudinal strain in apical views by the use of EchoInsight Epsilon software. Left ventricular global longitudinal strain (GLS) was calculated by averaging segmental wall strains. RESULTS: The TC and ACM groups were comparable for age and demographic characteristics. Systolic and diastolic function were significantly impaired in both groups compared to controls. LV global and segmental systolic strain was also significantly attenuated in patients with TC and ACM compared to controls (P < 0.001). Moreover, LV basal segmental longitudinal strain was higher in the patients with TC compared to ACM (P = 0.02). Global and apical segmental strain appear to be higher in patients with mid-ventricular variant compared to those with apical variant of TC with apical strain cutoff value of -7.85%, offering the best discriminatory value for differentiating these two patterns (P = 0.001). CONCLUSIONS: The results of this hypothesis-generating study indicate that longitudinal LV strain parameters are similarly impaired in patients with TC and ACM due to severe obstructive left anterior descending arterial disease or triple-vessel disease. Assessment of two-dimensional LV strain parameters could help differentiate between different TC patterns.

Role of Proximal Optimization Technique Guided by Intravascular Ultrasound on Stent Expansion, Stent Symmetry Index, and Side-Branch Hemodynamics in Patients With Coronary Bifurcation Lesions.

BACKGROUND: Bench models of coronary bifurcation lesions demonstrated that the proximal optimization technique (POT) expanded the stent and opened the side branch (SB). We investigated the role of POT guided by intravascular ultrasound on the main vessel (MV) stent expansion and SB fractional flow reserve (FFR) in patients with coronary bifurcation lesion. METHODS AND RESULTS: In 40 patients with coronary bifurcation lesion, 120 intravascular ultrasound examinations of the MV were performed at baseline, after MV stenting, and POT followed by 95 FFR measurements of the SB. In the proximal stent segment, stent volume index and minimum stent area were larger after POT versus MV stenting (9.2±3.4 versus 7.40±2.0 mm3/mm and 7.65±1.8 versus 6.38±1.7 mm2, respectively; P<0.01). In the bifurcation segment, minimum stent area was larger after POT versus MV stenting (6.45±2.1 versus 5.9±2.0 mm2, respectively; P<0.05). POT expanded the stent symmetrically. After POT, SB FFR was <0.75 in 12 patients (30%), which improved to >0.75 after SB dilation or SB stenting+final POT. SB FFR was significantly higher after POT+SB dilation or SB stenting+final POT versus after MV stenting and POT. CONCLUSIONS: This is the first study of POT guided by intravascular ultrasound in patients with coronary bifurcation lesion, demonstrating that POT symmetrically expanded the proximal and bifurcation segments of the stent. After POT, SB FFR was <0.75 in a third of patients, which improved to >0.75 after SB dilation or SB stenting+final POT.

Effect of ezetimibe on major atherosclerotic disease events and all-cause mortality.

Despite ezetimibe's ability to reduce serum cholesterol levels, there are concerns over its vascular effects and whether it prevents or ameliorates atherosclerotic disease (AD). The aims of this study were to estimate the effect of ezetimibe use on major AD events and all-cause mortality and to compare these associations to those observed for hydroxymethylglutaryl coenzyme A reductase inhibitor (statin) use. A total of 367 new ezetimibe users were identified from November 1, 2002, to December 31, 2009. These subjects were aged ≥18 years and had no previous statin use. One to 4 statin user matches were identified for each ezetimibe user, resulting in a total of 1,238 closely matched statin users. Pharmacy data and drug dosage information were used to estimate a moving window of ezetimibe and statin exposure for each day of study follow-up. The primary outcome was a composite of major AD events (coronary heart disease, cerebrovascular disease, and peripheral vascular disease events) and all-cause death. Ezetimibe use (odds ratio 0.33, 95% confidence interval 0.13 to 0.86) and statin use (odds ratio 0.61, 95% confidence interval 0.36 to 1.04) were associated with reductions in the likelihood of the composite outcome. These protective associations were most significant for cerebrovascular disease events and all-cause death. Subgroup analyses by gender, race or ethnicity, history of AD, diabetes status, and estimated renal function showed consistent estimates across strata, with no significant differences between ezetimibe and statin use. In conclusion, ezetimibe appeared to have a protective effect on major AD events and all-cause death that was not significantly different from that observed for statin use.