Cesare de Gregorio

Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: A systematic review

BACKGROUND Though a severe left ventricular systolic dysfunction has been described in most patients with Takotsubo-like (or Apical Ballooning) syndrome, the occurrence of intra-cavitary thrombus formation seems to be such an exceptional finding. However, no large studies but single case descriptions of this complication are available over the last decade in the literature. METHODS By searching for the PubMed-Medline database we selected 14 studies that met our eligibility criteria. RESULTS Demographic, clinical and morphofunctional characteristics of 15 patients who where described to have left ventricular thrombosis as a complication of the Takotsubo-like syndrome are comprehensively described in this review. Cardioembolic complications (stroke in 3 cases, renal infarction or popliteal artery thrombosis in other two) occurred in 33.3% out of them. The incidence of thrombus formation and related systemic embolisms in the general population with this syndrome were established on the basis of such available historical data and reviews on this subject. CONCLUSION Left ventricular thrombus formation has been reported in at least 14 studies (15 patients) over the last decade until the end of 2007. This approximately results in about 2.5% of all the patients with documented Takotsubo-like syndrome. Cardioembolic complications occurred in 5/15 cases, corresponding to 0.8% of the whole known population.

Genistein in the Metabolic Syndrome: Results of a Randomized Clinical Trial

CONTEXT This study was performed to evaluate the effects of genistein on metabolic and cardiovascular risk factors in Caucasian postmenopausal subjects with metabolic syndrome (MetS). OBJECTIVE Our objective was to assess the effects of genistein on surrogate endpoints associated with diabetes and cardiovascular disease. DESIGN AND SETTING This was a randomized, double-blind, placebo-controlled trial at 3 university medical centers in Italy. PATIENTS Patients included 120 postmenopausal women with MetS according to modified Third Report of the National Cholesterol Education Program (NCEP), Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) criteria. INTERVENTION After a 4-week stabilization period, postmenopausal women with MetS were randomly assigned to receive placebo (n = 60) or 54 mg genistein daily (n = 60) for 1 year. MAIN OUTCOME MEASURES The primary outcome was homeostasis model assessment for insulin resistance (HOMA-IR) at 1 year. Secondary outcomes were fasting glucose, fasting insulin, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, visfatin, adiponectin, and homocysteine levels. Data on adverse events were also recorded. RESULTS At 1 year in genistein recipients, fasting glucose, fasting insulin, and HOMA-IR (mean from 4.5 to 2.7; P < .001) decreased and were unchanged in placebo recipients. Genistein statistically increased HDL-C (mean from 46.4 to 56.8 mg/dL) and adiponectin and decreased total cholesterol, LDL-C (mean from 108.8 to 78.7 mg/dL), triglycerides, visfatin, and homocysteine (mean from 14.3 to 11.7 μmol/L) blood levels. Systolic and diastolic blood pressure was also reduced in genistein recipients. Genistein recipients neither experienced more side adverse effects than placebo nor discontinued the study. CONCLUSION One year of treatment with genistein improves surrogate endpoints associated with risk for diabetes and cardiovascular disease in postmenopausal women with MetS.

Age, glomerular filtration rate, ejection fraction, and the AGEF score predict contrast-induced nephropathy in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.

In patients undergoing primary percutaneous coronary interventions (PCI) for ST‐segment elevation myocardial infarction (STEMI), the occurrence of Contrast‐Induced Nephropathy (CIN) has a pronounced impact both on morbidity and mortality. We investigated the variables associated with CIN development in 481 consecutive patients with STEMI undergoing primary PCI and evaluated the predictive value of a 3‐variable clinical risk score (the AGEF score) based on age, left ventricular ejection fraction (EF), and estimated glomerular filtration rate (eGFR).

Cardioembolic outcomes in stress-related cardiomyopathy complicated by ventricular thrombus: A systematic review of 26 clinical studies

BACKGROUND The stress-related cardiomyopathy (SRC) is a relatively novel cardiac syndrome characterized by peculiar transient left ventricular dysfunction, which accounts for approximately 1-3% of patients with symptoms that initially appear to be an acute coronary syndrome. To date, the true incidence and clinical significance of left ventricular thrombus and related embolic outcomes in these patients have not been fully established. METHODS The present systematic review aimed to report updated case series of SRC patients with left ventricular thrombus and/or cardioembolic events complicating the course of syndrome, in an attempt to summarize their demographic and clinical characteristics. RESULTS Overall, 33 eligible studies (44 patients) were selected through the PubMed-Medline archives (December 2002-April 2009), but only 26 (36 patients) matched our inclusion criteria. Left ventricular thrombus was detected in 32 patients (89%), whereas thromboembolic events occurred in 12 (33%). Morphological characteristics of thrombi are described through the article. Women >65 years of age presenting with deep/giant negative T-waves on admission ECG seem more likely to have thrombus-related embolic complications. CONCLUSIONS Important findings from this updated review indicate that LVT approximately occurs in 5% of the estimated worldwide SRC population, similar to historical incidence in patients with myocardial infarction. In a third of cases (approximately 1.6% of above guesstimate) nonfatal cardioembolic outcomes (brain ischemia in 75% of cases) have been documented. It is worthy considering early anticoagulant therapy, especially in patients at a higher risk of thromboembolic disease, irrespective of the presence of LVT at admission.

Cardiovascular autonomic control in myotonic dystrophy type 1: a correlative study with clinical and genetic data

The autonomic nervous system has been evaluated in myotonic dystrophy with contradictory results and its relationship with heart disturbances remains unclear. Twenty-three patients with myotonic dystrophy type 1 were investigated by a battery of six cardiovascular autonomic tests and power spectral analysis of heart rate variability. Although 15 patients (65%) revealed abnormal or borderline results in some tests, only one patient had a definite autonomic damage, as indicated by two or more abnormal tests. As a group, myotonic dystrophy type 1 patients showed a significant reduction of heart rate variability during deep breathing (P < 0.0001). The exclusive involvement of parasympathetic tests suggests that a mild vagal dysfunction occurs in some myotonic dystrophy type 1 patients. The results indicate that such autonomic abnormalities are not: (1) part of a peripheral neuropathy; (2) related to cytosine-thymine-guanine repeat size or breathing pattern. Power spectral analysis showed a reduction of supine low-frequency band, which is, but not exclusively, a marker of sympathetic activity. It was inversely correlated to disease duration (P < 0.04), suggesting a progression as the disease advances. A low-frequency power, recorded after standing, was significantly associated (P < 0.02) with presence of heart involvement. Our findings suggest that a mixed, especially parasympathetic, autonomic dysfunction may occur in myotonic dystrophy type 1, although it is not a major finding. It could play a role in the occurrence of cardiac abnormalities, or increase the risk of sudden cardiovascular events.

Renal Function–Adjusted Contrast Volume Redefines the Baseline Estimation of Contrast-Induced Acute Kidney Injury Risk in Patients Undergoing Primary Percutaneous Coronary Intervention

Background—Age, estimated glomerular renal function (eGFR), and ejection fraction are preprocedural predictors of contrast-induced acute kidney injury (CI-AKI) after primary percutaneous coronary intervention. The effect of renal function–adjusted contrast volume (CV) remains not totally explored, and a threshold has not yet been established. Methods and Results—Logistic regression and receiver-operating characteristic curve analyses were used to assess whether CV/eGFR was an independent predictor of CI-AKI. The increased discriminative value of CV/eGFR over the preprocedural model based on age, eGFR, and ejection fraction was examined using the net reclassification improvement analysis. Of 470 patients enrolled, we observed 25 (5.3%) cases of CI-AKI. Patients with CI-AKI had received a higher renal function–adjusted CV (CV/eGFR 3.62 versus 1.96; P<0.001), and CI-AKI incidence was higher (15%; P<0.001) in patients in the highest quartile of CV/eGFR, corresponding to the cutoff indicated by the receiver-operating characteristic curve (>2.5; area under the curve, 0.77). At multivariable analysis, CV/eGFR above the cutoff (odds ratio, 5.57; P=0.002) remained an independent predictor of CI-AKI. The model with CV/eGFR demonstrated a statistically significantly net reclassification improvement of 0.23 (P=0.021) over the baseline preprocedural model, largely driven by a correct decrease in risk estimates for patients not experiencing CI-AKI, with a likelihood ratio &khgr;2 of 5.973 (P=0.029). Conclusions—CV remains a key risk factor for CI-AKI after primary percutaneous coronary intervention and our study supports the need for minimizing CV, independently from baseline preprocedural risk. A CV restricted to no more than twice and a half the baseline eGFR might be valuable in reducing the risk of CI-AKI.

Genistein and endothelial function in postmenopausal women with metabolic syndrome.

Previous data have suggested that genistein could exert beneficial effects on endothelial function and on predictors of cardiovascular risk in healthy postmenopausal women. In a randomized clinical trial, we studied the effects of genistein on endothelial function in postmenopausal women with metabolic syndrome (MS).

Citalopram-induced long QT syndrome and torsade de pointes: Role for concomitant therapy and disease

Abstract Although citalopram is considered to be a safe antidepressant drug, some cases of arrhythmic disorders, syncope, or intoxication leading to lethal outcomes have been described over the last few years. We report the case of citalopram-induced long QT syndrome complicated by torsade de pointes in a young woman, in whom the role for antihypertensive treatment with diuretics and intercurrent flu-like syndrome is discussed.

The chance finding of echocardiographic complications of infective endocarditis

Fig. 1. Biatrial dilatation, a left ventricular dilatation, an interventricular septal hypertrophy, an anterior mitral leaflet abscess/perforation complication of infective endocarditis. Despite the progress in its knowledge and treatment, infective endocarditis [1–17] remains a therapeutic challenge [17]. We present a case of an infective endocarditis in a 62-year-old Italian man. A 62-year-old Italian man was admitted to the Cardiology Unit for a pre-operative cardiac risk assessment in colon cancer surgery. He reported a streptococcal infection two years ago. Echocardiographic evaluation revealed a biatrial dilatation and a left ventricular dilatationwith an interventricular septal hypertrophy. The semilunar aortic valves were markedly thickened with retraction of left and right cusps. A moderate–severe mitral regurgitation, a severe aortic regurgitation, a mild tricuspidal regurgitation, and an anterior mitral leaflet abscess/perforation complication of infective endocarditis were also observed. Also this case focuses attention on infective endocarditis.

The ACEF score as predictor of acute kidney injury in patients undergoing primary percutaneous coronary intervention

Acute kidney injury (AKI) is an important complication of iodinated contrast media administration [1]. It particularly occurs after coronary procedures; the reported incidencemaybe ashigh as50%, dependingon populations, baseline risk factors and definitions [2]. In patients undergoing primary percutaneous coronary interventions (PCI) for ST-segment elevation myocardial infarction (STEMI), AKI is an established predictor of mortality [3]. Apart from increasing mortality, AKI leads to prolonged hospital stay and additional cost [4] and is also associated with late cardiovascular adverse events [5]. The main purpose of this study was to investigate the risk factors associated with AKI development in patients with STEMI undergoing primary PCI and to evaluate the predictive value of the ACEF score [6]. All the patients consecutively referred to the Coronary Care Unit (CCU) of the University Hospital of Messina from January 2008 to June 2011 for primary PCI in the course of STEMI were included. Primary PCI wasperformed fromthe femoral approach according to standard clinical practice and the indication to intra-aortic balloon pump (IABP) support was left to the discretion of the attending cardiologists. Wall motion abnormalities and left ventricular ejection fraction (EF) were rapidly assessedwith echocardiography in all subjects, either in the Emergency Department or in the pre-cath room. The images were digitally stored and evaluated off-line. Blood samples were collected for measurement of serum creatinine (sCr) on admission, 6 h after the procedure, every day for the following 3 days, and at discharge from the CCU. The ACEF score was calculated according to the original study by Ranucci et al. [6]: age/EF(%) + 1 (if sCr ≥2.0 mg/dL). The primary end point of the study was the occurrence of AKI, defined as an absolute increase in sCr ≥0.5 mg/dL or an increase ≥25% from baseline within 72 h after the administration of contrast medium, without any other plausible etiology. Continuous variables are expressed as mean ± standard deviation and comparedwith t test; categorical variables are expressed as absolute counts and/or percentages and compared by Fisher’s exact test and χ test, as appropriate. Those variables associated with AKI development at univariate analysis were entered into a stepwise forward logistic regression model in order to assess their significance as independent predictors of AKI. The odds ratios (OR) and 95% confidence intervals (CI) are presented. Finally, logistic regression analysis, Hosmer–Lemeshow χ statistic and receiver-operating characteristic (ROC) curve analysis were performed to assess accuracy and calibration of ACEF score as predictor of AKI. A two-tailed p b 0.05 was always requested for statistical significance. The calculations were performed by using Statistical Package for Social Sciences, version 20. Four hundred eighty-one patients with STEMI undergoing primary PCI were enrolled. Demographic characteristics and procedural data are summarized in Table 1. We observed 25 (5.2%) cases of AKI. These patients (Table 1) were older, had a more severe impairment of both basal EF and global hemodynamic status, as expressed by the Killip score, and worse basal sCr thanpatientswithoutAKI. In addition, patientswithAKI had ahigher troponin at admission and a higher prevalence of hypertension and diabetes. From the procedural standpoint (Table 1), patients with AKI had not received a higher total contrast volume nor a higher number of stents. Conversely, they had had a poorer post-procedural TIMI flow (grade 3 in 76% Vs 91.5%, p b 0.001; on average 2.6 ± 0.9 Vs 2.9 ±0.4, p = 0.002) andweremore likely to have received an IABP. They had, on average, a 2-