Angela Marie Kucia

N-Terminal Pro-Brain Natriuretic Protein Levels in Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is characterized by reversible left ventricular (LV) systolic dysfunction independent of fixed coronary disease or coronary spastic pathogenesis. A number of investigators have documented marked elevation of natriuretic peptide levels at presentation in such patients. We sought to determine the pattern, extent, and determinants of the release of N-terminal pro-B type natriuretic peptide/B type natriuretic peptide (NT-proBNP/BNP) in patients with TTC. We evaluated NT-proBNP/BNP release acutely and during the first 3 months in 56 patients with TTC (96% women, mean age 69 ± 11 years). The peak plasma NT-proBNP levels were compared to the pulmonary capillary wedge pressure and measures of regional and global LV systolic dysfunction (systolic wall stress, wall motion score index, and LV ejection fraction) as potential determinants of NT-proBNP/BNP release. In patients with TTC, the plasma concentrations of NT-proBNP (median 4,382 pg/ml, interquartile range 2,440 to 9,019) and BNP (median 617 pg/ml, interquartile range 426 to 1,026) were substantially elevated and increased significantly during the first 24 hours after the onset of symptoms (p = 0.001), with slow and incomplete resolution during the 3 months thereafter. The peak NT-proBNP levels exhibited no significant correlation with either pulmonary capillary wedge pressure or systolic wall stress. However, the peak NT-proBNP level correlated significantly with the simultaneous plasma normetanephrine concentrations (r = 0.53, p = 0.001) and the extent of impairment of LV systolic function, as measured by the wall motion score index (r = 0.37, p = 0.008) and LV ejection fraction (r = -0.39, p = 0.008). In conclusion, TTC is associated with marked and persistent elevation of NT-proBNP/BNP levels, which correlated with both the extent of catecholamine increase and the severity of LV systolic dysfunction.

Slowly resolving global myocardial inflammation/oedema in Tako-Tsubo cardiomyopathy: evidence from T2-weighted cardiac MRI

Objective Tako-Tsubo cardiomyopathy (TTC) is associated with regional left ventricular dysfunction, independent of the presence of fixed coronary artery disease. Previous studies have used T2-weighted cardiac MRI to demonstrate the presence of periapical oedema. The authors sought to determine the distribution, resolution and correlates of oedema in TTC. Patients 32 patients with TTC were evaluated at a median of 2 days after presentation, along with 10 age-matched female controls. Extent of oedema was quantified both regionally and globally; scanning was repeated in patients with TTC after 3 months. Correlations were sought between oedema and the extent of hypokinesis, catecholamine release, release of N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and markers of systemic inflammatory activation (high-sensitivity C-reactive protein and platelet response to nitric oxide). Results In the acute phase of TTC, T2-weighted signal intensity was greater at the apex than at the base (p<0.0001) but was nevertheless significantly elevated at the base (p<0.0001), relative to control values. Over 3 months, T2-weighted signal decreased substantially, but remained abnormally elevated (p<0.02). The regional extent of oedema correlated inversely with radial myocardial strain (except at the apex). There were also direct correlations between global T2-weighted signal and (1) plasma normetanephrine (r=0.39, p=0.04) and (2) peak NT-proBNP (r=0.39, p=0.03), but not with systemic inflammatory markers. Conclusions TTC is associated with slowly resolving global myocardial oedema, the acute extent of which correlates with regional contractile disturbance and acute release of both catecholamines and NT-proBNP.

Can we make sense of takotsubo cardiomyopathy? An update on pathogenesis, diagnosis and natural history

Takotsubo cardiomyopathy (TTC) is a form of reversible acute cardiac dysfunction of uncertain pathogenesis, which occurs predominantly in postmenopausal women, often with antecedent severe stress. Systolic dysfunction most commonly affects the apex of the left ventricle. There is considerable uncertainty regarding the pathogenesis of TTC and the optimal diagnostic methodology. Acute catecholamine release may play a component role, but the regional hypokinesis is associated with an acute inflammatory process, with resultant early release of brain natriuretic peptide (BNP) and N-terminal pro-BNP. As the diagnosis of TTC has largely been a process of exclusion, there has been considerable underdiagnosis. The combination of demographics, preceding history, ECG appearances and N-terminal pro-BNP elevation may provide the basis for improved early diagnosis. Complete recovery takes at least several months, with a risk of recurrent episodes. Efforts to delineate pathogenesis, expedite diagnosis and evaluate residual disability may assist in the development of appropriate treatment regimens.

ST/T wave changes during acute coronary syndrome presentation in patients with the coronary slow flow phenomenon

Article history:Received 20 October 2010Accepted 23 October 2010Available online 3 December 2010Keywords:Coronary slow flow phenomenonECG abnormalitiesAcute coronary syndromeMyocardial ischaemia⁎ Corresponding author. Cardiology Unit, The Queen Elizabeth Hospital, 28 Wood-ville Road, Woodville, SA 5011, Australia. Tel.: +61 8222 6740; fax: +61 8222 6042.E-mail address: john.beltrame@adelaide.edu.au (J.F. Beltrame).Table 1Baseline characteristics.CSFP ControlsNumber 37 20Age (Mean±SD) 49±14.6*years 54.8±13.5 yearsCV risk factorsMales 27 (73%)* 9 (45%)Smoking History 19 (51%) 5 (25%)Hypertension 19 (51%)** 0 (0%)Cholesterol 20 (54%)* 6 (30%)Diabetes 9 (24%) 1 (5%)Pain-free Resting ECGSinus Rhythm 33 (100%) 20 (100%)Heart Rate 65±10 bpm 60±7 bpmResting ST changes 13 (39%)** 0 (0%)Inferior ST Elevation 9 (27%)* 0 (0%)Anterior ST Elevation 1 (3%) 0 (0%)Resting T wave changes 5 (15%) 1 (5%)Inferior T wave change 2 (6%) 1 (3%)Anterior T wave change 2 (6%) 0 (0%)QTc Interval 426±33 msec 410±10 msec*pb0.05 or **pb0.01; significant difference between CSFPs and healthy controls.

Unstructured cardiac rehabilitation and secondary prevention in rural South Australia: does it meet best practice guidelines?

Abstract Comprehensive cardiac rehabilitation programs that address risk factors, psychological problems, and physical activity are essential in optimizing health and reducing the risk of further cardiac events. Behavioural and lifestyle modification support offered through these programs is predicated on initial identification of risk. Many rural populations in Australia do not have access to structured cardiac rehabilitation (CR) programs, and the level of support available to them in the form of unstructured CR is unclear. A retrospective analysis of medical records of patients presenting to hospital with myocardial infarction in rural South Australia over a 12-month period was undertaken to identify documented evidence of assessment of and intervention for lifestyle and behavioural risk factors in-hospital and at follow up in general practice (GP) clinics. Of 77 eligible participants, permission was received to access the medical records of 55 patients in the hospital setting, and 34 of these 55 patients in GP clinic follow up. Documented evidence of assessment of modifiable risk factors was inadequate for the majority of participants, with the exception of smoking status, hypertension and diabetes. This suggests that the majority of these participants did not receive lifestyle and behavioural interventions in line with current National Heart Foundation Recommendations for Cardiac Rehabilitation. Barriers to comprehensive CR and secondary prevention services in Australia must be addressed, particularly in high risk rural and remote populations. Future research must focus on the ongoing monitoring and evaluation of rural health care services to analyse existing levels of CR and secondary prevention to ensure current guidelines are being implemented, to support the further development and resourcing of CR services and to evaluate the subsequent impact on patient outcomes.

The role of ST-segment monitoring in assessment of acute myocardial infarction.

Continuous ST-segment analysis is an accurate and noninvasive tool for monitoring coronary artery patency in patients with acute myocardial infarction. This type of monitoring also is easy to use and cost-effective. The critical care nurse plays a pivotal role in initiating ST-segment monitoring, promptly detecting ST-segment changes, and rapidly intervening to achieve myocardial reperfusion.

Continuous ST-segment monitoring: a non-invasive method of assessing myocardial perfusion in acute myocardial infarction

c 1. Background A number of therapeutic strategies have contributed to improved survival rates in patients with acute myo- cardial infarction (AMI) who survive sufficiently long enough to receive hospital treatment w1x. The initial assessment of patients with chest pain, potentially due to AMI, includes a history and physical assessment, 12-lead electrocardiograph (ECG) and measurement of biochemical markers such as CK, CK- MB, troponins, and myoglobin. The primary therapeutic goals of management for patients with AMI are to promptly restore perfusion to the myocardium and to prevent or limit myocardial cell death. Continuous mon- itoring of myocardial perfusion status is, therefore, an essential component of ongoing management for patients with AMI. Critical care nurses can have an important role in recognising and monitoring ischaemia. Traditionally, the 12-lead electrocardiograph (ECG) has been used diagnostically to detect myocardial ischae- mia or infarction, manifested by changes in the ST-seg- ment andy or T-wave. Q-wave development and R-wave loss may also be present. The 12-lead ECG is the single- most important source of data in the assessment of patients with potential AMI. However, ECG changes indicating AMI may not be immediately apparent at the point of hospital admission. Furthermore, in the early stages of myocardial ischaemia and infarction, the ST- segment and T-wave undergo dynamic changes, which may not be captured by single or intermittent serial ECGs w2x. Obtaining serial standard ECGs can be time-

Early detection and management of right ventricular infarction: the role of the critical care nurse.

Patients with acute inferior myocardial infarction (IMI), complicated by a more extensive right ventricular infarction (RVI), have an increased risk of both complications and mortality. The critical care nurse plays an important role in 1) the early detection of RVI and 2) the management of the common hemodynamic and conduction disturbances that can typically arise.

PERIPARTUM TAKOTSUBO CARDIOMYOPATHY

Takotsubo Cardiomyopathy (TCM) is a rarely identified cause of acute heart failure in pregnancy. We describe the demographic characteristics, clinical features and outcomes in reported cases of peripartum TCM. We searched four databases (EMBASE, OVID Medline, PubMed and Google Scholar) from Jan