Armando Ferraretti

Lack of Efficacy of Drug Therapy in Preventing Takotsubo Cardiomyopathy Recurrence: A Meta‐analysis

Efficacy of chronic drug therapy in prevention of stress‐induced cardiomyopathy recurrences is not well established. We therefore aimed to evaluate in this meta‐analysis whether pharmacological treatment can effectively prevent takotsubo cardiomyopathy (TTC) recurrences, according to available studies.

Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: In the beginning was basal hyperkinesis?

Tako-Tsubo cardiomyopathy (TTC), also known as stress inducedcardiomyopathy or apical ballooning syndrome, was first describedby Dote in 1991 [1].Itisdefined as a fully reversible acutedeterioration of left-ventricular function, which is mainly found inwomen after an episode of emotional or physical stress (e.g. psycho-social stress, sepsis, surgery) [2]. The underlying mechanisms remainunclear, although increased catecholamine levels were thought asmain responsible [3,4]. Even less known are the mechanismsunderlying the hyper-acute phase of TTC, which precede apicalballooning and are usually missed because they occur during thepre-hospital phase of the disease. We describe in this case thehyper-acute phase of TTC observed during early in-hospital recur-rence of TTC.A 74-year-old woman, with amyotrophic lateral sclerosis (ALS),referred for pneumonia, after a stressful event during hospitalization,complained of chest pain, with evidence at electrocardiogram of STelevation, negative T-waves in anterior leads, intra-ventricular

Potential links between neurological disease and Tako-Tsubo cardiomyopathy: A literature review

Tako-Tsubo cardiomyopathy (TTC), is defined as a fully reversible acute deterioration of left-ventricular (LV) function, which is mainly found in women after an episode of emotional or physical stress (e.g. psychosocial stress, sepsis, surgery). The underlying mechanisms remain unclear. There is evidence suggesting a possible link between neurological disease and TTC. The pathophysiology of the several neurologic diseases has been reviewed searching for possible mechanisms that could lead to TTC in these patients.

Renal impairment and outcome in patients with takotsubo cardiomyopathy

OBJECTIVES The objectives were to ascertain the prevalence of renal impairment among patients with a takotsubo cardiomyopathy (TTC) episode and whether clinical outcomes are related to renal function. METHODS A total of 108 consecutive subjects with TTC were enrolled in a multicenter registry and followed for a mean period of 429 days. Renal function was evaluated during hospitalization in terms of acute kidney injury/failure and estimated glomerular filtration rate (eGFR). Incidence of death, rehospitalization, and recurrence of TTC during follow-up was recorded. RESULTS Raised creatinine levels can be found during hospitalizations for TTC episodes (analysis of variance P<.001). Incidence of acute kidney injury was 10%; that of acute kidney failure was 1%. Admission eGFR levels were proportional to the duration of hospitalization (r = -0.28, P<.01). Estimated GFR nadir values were related to adverse events at follow-up (log-rank P<.001). The hazard ratio of adverse events at follow-up in subjects with severe renal impairment (nadir eGFR <30 mL/[min 1.73 m(2)]) vs those with eGFR >60 mL/(min 1.73 m(2)) was 1.817 (95% confidence interval, 1.097-3.009; P<.05). CONCLUSIONS Raised creatinine levels and impaired renal function may be found in patients with TTC. Lower eGFR values during hospitalization are associated with longer hospitalizations and higher rates of adverse events at follow-up. Renal function during a TTC episode should be carefully evaluated.

Tissue Doppler Time Intervals Predict the Occurrence of Rehospitalization in Chronic Heart Failure: Data from the Daunia Heart Failure Registry

Background: Patients with chronic heart failure (HF) are often rehospitalized; rehospitalization identifies subjects with a poorer quality of life and a worse prognosis. Estimates of the time intervals by tissue Doppler imaging (TDI) in patients with chronic HF has not been fully investigated, despite recent studies having explored the prognostic role of TDI‐derived parameters in major cardiac diseases, such as HF. We, therefore, aimed to assess the prognostic value of time intervals evaluated by TDI in patients with chronic HF. Methods: A total of 249 patients with chronic HF enrolled in the Daunia Heart Failure Registry underwent echocardiography assessment and were followed prospectively for a mean 284 ± 210 days. Conventional echocardiography and TDI parameters were calculated; time intervals were calculated by TDI: ST (systolic time), ET (ejection time), FT (filling time), and ICT (isovolumic contraction time). We also have calculated ICT/ET and tissue myocardial performance index ([ICT+IRT]/ET). Results: At univariate analysis, ET (RR: 0.80, 95% confidence interval [CI] 0.71–0.90, P < 0.001), ST (RR: 0.88, 95% CI 0.78–0.99, P < 0.05), FT (RR: 0.88, 95% CI 0.78–0.99, P < 0.05), ICT/ET (RR: 1.21, 95% CI 1.07–1.37, P < 0.01) were related to the occurrence of rehospitalization during follow‐up. At multivariate Cox regression analysis, correlations remained significant for ET and ST (P < 0.05 and P < 0.01, respectively). Conclusions: Time intervals assessed by TDI may be helpful in predicting the risk of rehospitalization in subjects with chronic HF.

Dynamic changes of QTc interval and prognostic significance in takotsubo (stress) cardiomyopathy

Prolonged QT corrected (QTc) intervals are associated with adverse cardiovascular outcomes both in healthy and high‐risk populations. Our objective was to evaluate the QTc intervals during a takotsubo cardiomyopathy (TTC) episodes and their potential prognostic role.

Diffuse ST-elevation following J-wave presentation as an uncommon electrocardiogram pattern of Tako-Tsubo cardiomyopathy

BACKGROUND Tako-Tsubo cardiomyopathy (TTC) is characterized by symptoms, ECG changes with elevated cardiac markers mimicking acute myocardial infarction, left ventricular (LV) wall motion abnormalities in the apical region with preserved function of base, and normal coronary arteries. Usual ECG anomalies heralding TTC are ST-elevation in anterior leads, QT prolongation and negative T-waves. METHODS We report the unusual case of TTC with an uncommon ECG presentation: J wave in inferior leads followed by diffuse ST-elevation. RESULTS An 82-year-old woman was admitted for dyspnea and chest pain following exacerbation of chronic obstructive pulmonary disease. ECG showed J-wave in inferior leads followed by diffuse ST-elevation. The patient was monitored in intensive care unit and treated with diuretics. Both ECG and echocardiography anomalies gradually recovered. CONCLUSIONS Diffuse ST-elevation following J-waves may be considered as a possible ECG pattern of presentation in case of TTC.

Peak myocardial acceleration during isovolumic relaxation time predicts the occurrence of rehospitalization in chronic heart failure: data from the Daunia heart failure registry.

Tissue Doppler imaging (TDI) may be useful in identifying subjects at higher risk among patients with chronic heart failure (CHF). The clinical role of new developed TDI parameters, however, still needs to be documented.

Recurrent Tako-Tsubo cardiomyopathy apparently induced by opposite triggers

We report the case of a 78-year-old woman, who was hypertensive, diabetic, and with a previous episode of Tako-Tsubo-syndrome (TTs) 4 years earlier, whowas referred for weakness with dyspnea appearing after a week. Arterial blood pressure at admission was 145/50 mm Hg, and physical examination was unremarkable. Resting ECG showed low ventricular rate (40 bpm) atrial fibrillation, right bundle branch block and left anterior hemi-block (Fig. 1a). Blood tests revealed higher digoxin levels (2.8 ng/ml, n.v. 0.9–2), acute renal failure (creatinine 5.92 mg/dl, n.v. 0.44–1), hyperkalemia (8.2 mEq/l, n.v. 3.5–5.3) and hyponatremia (131 mEq/l, n.v. 136–146); cardiac troponin-I levels were normal (0.02 ng/ml, n.v. 0–0.10). At echocardiographic examination, left ventricular ejection fraction (LVEF) was normal. The patient underwent temporary pacing and electrolyte level correction, with restored sinus rhythm (Fig. 1b). Aweek later, digoxin, potassiumand sodium levelswere normal, and creatinine levels were 1.66 mg/dl; however, troponin levels rose to 3.44 ng/ml. Resting ECG now showed negative T-waves in anterior leads and long QT (Fig. 1c). At echocardiographic examination, a severe systolic dysfunction was found (LVEF 35%) with apical dyskinesis and basal hyperkinesis resembling apical ballooning typical of TTs was unexpectedly found (Video 1). Coronary angiography did not show any sign of significant coronary atherosclerosis. The patient gradually recovered, and was discharged a week later, when intra-ventricular conduction delay disappeared (Fig.1d). Echocardiographic examination before discharge showed full recovery of left ventricular systolic function. We report a case of a recurrent TTs probably triggered by increased catecholamine levels consequent to a brady-arrhythmia induced by digoxin toxicity and hyperkalemia. Recurrences of TTs are rare, with a reported incidence of 2.9% per year over the first 4 years, decreasing to 1.3% per year thereafter [1]. Cases of recurrent TTs with different morphologic patterns [2] and stressors [3], however, were reported. Digoxin toxicity may have played an important role in this patient in triggering TTs; Plunkett et al. previously showed that a continuous digoxin infusion produces significant increases in cerebro-spinal fluid norepinephrine [4], and catecholamine levels are commonly considered as the leading mechanism underlying TTs. Bradycardias and complete atrio-ventricular block, however, are also known to be characterized by an excess in internal adrenergic activation, presumably representing a finalized compensative mechanism [5]. We therefore hypothesize that presumable increased levels of catecholamines induced by both bradycardia and higher digoxin levels may be responsible for the clinical onset of left ventricular apical ballooning. As matter of fact, we previously showed a case of TTs in a patient with complete atrio-ventricular block [6]. The patient, however, presented with the same clinical features of TTs 4 years earlier, even though with a different triggering condition, then a hypokalemia consequent to several episodes of diarrhea. Also hypokalemia was reported as a possible trigger for TTs [7]. In this patient recurrent episodes of transient left ventricular apical ballooning were presumably triggered by apparently opposite conditions. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2012.08.020.

Tissue Doppler imaging in coronary artery diseases and heart failure.

Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as coronary artery disease (CAD) and heart failure (HF). In these conditions, myocardial mitral annular systolic (S’) and early diastolic (E’) velocities have been shown to predict mortality or cardiovascular events. In heart failure non invasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/E’) is a strong prognosticator, especially when E/E’ is > or =15. Moreover, other parameters derived by TDI, as cardiac time intervals and Myocardial Performance Index, might play a role in the prognostic stratification in CAD and HF. Recently, a three-dimensional (3-D) TDI imaging modality, triplane TDI, has become available, and this allows calculation of 3-Dvolumes and LV ejection fraction. We present a brief update of TDI.