Francesco Musaico

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.

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.

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.

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.

Incomplete leaflet coaptation and tricuspid regurgitation mechanism in right ventricular Tako-Tsubo cardiomyopathy

Tako-Tsubo cardiomyopathy (TTC) is a well-known form of acuteand reversible heart failure due to either an emotional or a physicalstressor,whichinvolvesmainlytheleftventriclewithatypicalechocar-diographic pattern (apical ballooningand basal hyperkinesis) [1].Rightventricular(RV)involvementhasaprevalenceof25%[2].Aclinicalcase,a short literature review and possible explaining mechanism areprovided.An86-yearoldwoman,withoutcardiovascularriskfactorsandwithhistory of bipolardisorder [3] cameto the emergency department afteran episode of syncope. At admission blood pressure was 70/50 mm Hg,ECG showed atrial fibrillation and ST-elevation in anterior and lateralleads (V2–V4, DI, aVL) (Fig. 1). Troponin I levels were increased(4.54 ng/ml, n.v. b 0.10). Trans-thoracic echocardiogram showed leftventricular (LV) systolic dysfunction (ejection fraction of 25%),akinesisofLVmidventricularsegments,dyskinesisofRVapicalsegmentsandin-complete coaptation of tricuspid leaflets (Video 1). At color-Dopplermild mitral regurgitation and severe tricuspid regurgitation werefound (Figs. 2 and 3, Video 2). Coronary angiography showed diffuseatherosclerosis not needing coronary intervention. Echocardiographyanomalies gradually recovered and the patient was discharged after acouple of weeks (Figs. 4 and 5) (Video 3). Discharge electrocardiogramshowed negative T-waves in anterior leads previously interested byST-elevation and diffuse decrease in QRS amplitude [4].Despite TTC affects mainly left ventricle, RV involvement is presentinoneoutoffourpatientsaffectedbyTTC.Severalechocardiographicstudies described acute mitral regurgitation and its clinical impor-tance in TTC[5], but, to the best of our knowledge, possible mecha-nism of tricuspid regurgitationduring RV TTC was never describedbefore.We report a case of RV apical dyskinesis causing traction of thepostero-lateral papillary muscle and consequent compromised coapta-tion of thetricuspid valve leaflets (Fig. 2);that could have led to severetricuspid regurgitation completely reversible after RV recovery.The mechanism of RV regurgitation seems to be different from thatwe have previously described in the left ventricle. LV basal hyperkinesis, consequent mitral valve area reduction and mitral leafletsredundancy may lead to LV outflow tract obstruction, increased intraventricular pressure and mitral regurgitation [6,7]. Systolic anteriormotion and tethering have been shown as independent predictors ofacute mitral regurgitation in patients with TTC [8].In thecaseof mid-LVballooning, rightward movement of midseptalsegmentsmayhaveincreasedRVpressure,thusimpairingRVgeometryand kinesis, and precipitating RV ballooning.Tricuspid regurgitation has not yet been evaluated as a marker ofprognosisinTTC;however,inacutemyocardialinfarctionoftheinferiorwall, moderate tricuspid regurgitation, affecting about one third ofpatients, is a predictor of rehospitalization at one-year follow-up [9].Although no in-hospital complication was present in our case, RVsystolic dysfunction represents an independent predictor of worseprognosis and is associated with a higher rate of in-hospital complica-tion both in inferior myocardial infarction [10] and TTC [2].Haghiet al. found in 34 patients with TTC that RV involvement is associatedwith a severe impairment in LV systolic function and a higher rate ofbilateral pleural effusion [2]. Elesber et al. showed in a population of30patientswithTTCthatRVinvolvementcarriesahigherriskofseverecongestive heart failure and longer in-hospital stay [11].We therefore believe that a systematic evaluation of RV function byechocardiogram is recommended for an optimal management of pa-tients with TTC. When an impaired LVEF is associated with abnormalRV function, there is a higher risk of hemodynamic complications.Therefore a strict monitoring is required and an early therapeuticstrategy including diuretics, levosimendan infusion and intra-aorticballoon pump counterpulsation should be considered [12–14].In conclusion, RV involvement in TTC may lead to severe tricuspidregurgitationduetoincompletecoaptationofvalveleaflets.This finding

Additional Prognostic Value of EAS index in predicting the occurrence of rehospitalizations 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 newly developed TDI parameters, however, still needs to be documented.