Hernán Mejía-Rentería

Secondary forms of Takotsubo cardiomyopathy: A whole different prognosis.

Background: Takotsubo syndrome (TKS) usually mimics an acute coronary syndrome. However, several clinical forms have been reported. Our aim was to assess if different stressful triggers had prognostic influence on TKS, and to establish a working classification. Methods: We performed an analysis including patients with TKS between 2003–2013 from our prospective local database and the RETAKO National Registry, fulfilling Mayo criteria. Patients were divided in two groups regarding their potential triggers: (a) none/psychic stress as ‘primary forms’ and (b) physical factors (asthma, surgery, trauma, etc.) as ‘secondary forms’. Results: Finally, 328 patients were included, 90.2% women, with a mean age of 69.7 years. Patients were divided into primary TKS (n=265) and 63 secondary TKS groups. Age, gender, previous functional class and cardiovascular risk profile displayed no differences between groups before admission. However, primary-TKS patients suffered a main complaint of chest pain (89.4% vs 50.7%, p<0.0001) with frequent vegetative symptoms. Regarding treatment before admission, there were no differences either. During admission, differences were related to more intensive antithrombotic and anxiolytic drug use in the primary TKS group. Inotropic and mechanical ventilation use was higher in the secondary cohort. After discharge, a more frequent prescription of beta-blockers and statins in primary-TKS patients was seen. Secondary forms displayed more in-hospital stay and evolutive complications: death (hazard ratio (HR): 3.41; 95% confidence interval (CI): 1.14–10.16, p=0.02), combined event variable (MACE) (HR: 1.61; 95% CI: 1.01–2.6, p=0.04) and recurrences (HR: 1.85; 95% CI: 1.06–3.22, p=0.02). Conclusion: Secondary TKS could present or mark worse short and long-term prognoses in terms of mortality, recurrences and readmissions. We propose a simple working nomenclature for TKS.

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.

Targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests

The coronary microcirculation plays a key role in modulating blood supply to the myocardium. Several factors like myocardial oxygen demands, endothelial and neurogenic conditions determine its function. Although there is available evidence supporting microvascular dysfunction as an important cause of myocardial ischaemia, with both prognostic and symptomatic implications, its diagnosis and management in clinical practice is still relegated to a second plane. Both diagnostic and therapeutic approaches are hampered by the broadness of the concept of microvascular dysfunction, which fails addressing the plurality of mechanisms leading to dysfunction. Normal microcirculatory function requires both structural integrity of the microcirculatory vascular network and preserved signalling pathways ensuring adequate and brisk arteriolar resistance shifts in response to myocardial oxygen demands. Pathological mechanisms affecting these requirements include structural remodelling of microvessels, intraluminal plugging, extravascular compression or vasomotor dysregulation. Importantly, not every diagnostic technique provides evidence on which of these pathophysiological mechanisms is present or predominates in the microcirculation. In this paper we discuss the mechanisms of coronary microvascular dysfunction and the intracoronary tools currently available to detect it, as well as the potential role of each one to unmask the main underlying mechanism.

Bifurcation Culprit Lesions in ST-segment Elevation Myocardial Infarction: Procedural Success and 5-year Outcome Compared With Nonbifurcation Lesions

INTRODUCTION AND OBJECTIVES We assessed short- and long-term outcomes of primary angioplasty in ST-segment elevation myocardial infarction by comparing bifurcation culprit lesions (BCL) with non-BCL. METHODS Observational study with a propensity score matched control group. Among 2746 consecutive ST-segment elevation myocardial infarction patients, we found 274 (10%) patients with BCL. The primary outcome was a composite endpoint including all-cause death, myocardial infarction, coronary artery bypass grafting or target vessel revascularization, assessed at 30-days and 5-years. RESULTS Baseline characteristics showed no differences after propensity matching (1:1). In the BCL group, the most frequent strategy was provisional stenting of the main branch (84%). Compared with the non-BCL group, the procedures were technically more complex in the BCL group in terms of need for balloon dilatation (71% BCL vs 59% non-BCL; P = .003), longer procedural time (70 ± 29minutes BCL vs 62.8 ± 28.9minutes non-BCL; P = .004) and contrast use (256.2 ± 87.9mL BCL vs 221.1 ± 82.3mL non-BCL; P < .001). Main branch angiographic success was similar (93.4% BCL vs 93.8% non-BCL; P = .86). Thirty-day all-cause mortality was similar between groups: 4.7% BCL vs 5.1% non-BCL; P = .84. At the 5-year follow-up, there were no differences in all-cause death (12% BCL vs 13% non-BCL; P = .95) or the combined event (22% BCL vs 21% non-BCL; P = .43). CONCLUSIONS Primary angioplasty of a BCL was technically more complex; however, main branch angiographic success was similar, and there were no differences in long-term prognosis compared with non-BCL patients.

Tako-tsubo Syndrome in Men: Rare, but With Poor Prognosis

INTRODUCTION AND OBJECTIVES Tako-tsubo syndrome is a potentially serious disease during the acute phase. It mimics myocardial infarction, but with no potentially causative coronary lesions. The aim of this study was to analyze the clinical course and outcome of patients with tako-tsubo syndrome by sex. METHODS We analyzed the characteristics of patients included in the RETAKO registry from 2003 to 2015, a multicenter registry with participation of 32 Spanish hospitals. RESULTS Of 562 patients included, 493 (87.7%) were women. Chest pain was less frequent as an initial symptom in men than in women (43 [66.2%] vs 390 [82.8%]; P < .01). The prognosis was worse in men, with higher in-hospital mortality (3 [4.4%] vs 1 [0.2%]; P < .01), longer intensive care stay (4.2 ± 3.7 vs 3.2 ± 3.2 days; P = .03) and a higher frequency of severe heart failure (22 [33.3%] vs 95 [20.3%]; P = .02). However, dynamic obstruction at the left-ventricular outflow tract occurred exclusively in women (39 [7.9%] vs 0 [0.0%]; P = .02). The incidence of functional mitral regurgitation was also higher in women (52 [10.6%] vs 2 [2.9%]; P = .04). CONCLUSIONS Tako-tsubo syndrome shows wide differences by sex in terms of its incidence, presentation, and outcomes. Prognosis is worse in men.

Secondary Percutaneous Revascularization After Coronary Artery Bypass Graft Surgery

Better longevity and increasing rates of myocardial revascularization have resulted in higher rates of secondary revascularization procedures. This phenomenon is particularly pertinent to surgically revascularized patients due to the common occurrence of graft failure and progression of native vessel disease. Secondary revascularization procedures have a higher degree of complexity and higher procedural risks due to the presence of diffuse stenosis and chronic total occlusions, as well as the association with many comorbidities, such as diabetes, chronic renal failure, and peripheral arterial disease. In this chapter we will address the decision-making process in repeat revascularization procedures, underlining the importance of the Heart Team; and will describe the particularities and the evidence regarding percutaneous treatment of saphenous vein grafts, arterial grafts, and native arteries in patients with previous revascularization surgery.

Comprehensive Assessment of the Coronary Circulation Using Pressure and Flow Measurements

While fractional flow reserve has greatly contributed to the clinical applicability of ischemia-driven revascularization, it cannot provide information on whether other realms of the coronary circulation, which also cause myocardial ischemia, such as the microvasculature, are affected. A growing body of evidence suggests that the combined use of coronary flow reserve and fractional flow reserve can provide a much richer view of the status the coronary circulation. Such multimodal physiological assessment of the coronary circulation can be further enriched with the incorporation of measurements of resistance derived from thermodilution or Doppler flow velocity and intracoronary pressure. In this chapter we review the rationale for and available evidence on multimodal coronary physiology, providing examples of its applicability in the clinical field.

Measurements of Microcirculatory Resistance

The coronary microvasculature is an extremely dynamic system that responds to multiple physiological conditions in order to maintain adequate myocardial perfusion [1, 2]. Modulation of microcirculatory resistance plays a key role in this regulatory process. The underling pathophysiology and adaptive mechanisms of the microcirculation are fully described in other chapters in this book. In patients with ischemic heart disease (IHD), obstructive lesions in epicardial vessels are not a prerequisite for myocardial ischemia [3], which may arise from microcirculatory dysfunction (MCD). It has been shown that MCD is an independent predictor of poorer clinical outcomes in different clinical scenarios [4, 5] and, therefore, outlining its presence in such clinical situations might be important.

TCT-50 Impact of a bifurcation culprit lesion in ST elevation myocardial infarction: procedural success, clinical outcome and 5-year follow-up.

Coronary artery bifurcation is a challenging scenario for percutaneous coronary intervention (PCI). We aimed to assess the impact of a bifurcation culprit lesion in the setting of primary PCI for ST elevation myocardial infarction (STEMI). From 2747 STEMI patients (January 2004 to January 2015)

Case reportTransient apical dyskinesia with a pacemaker: Electrocardiographic featuresDiscinesia apical transitória com pacemaker: características eletrocardiográficas

Transient apical dyskinesia syndromes present features similar to acute coronary syndromes, but with normal coronary arteries and rapid complete resolution of wall motion alterations. We report the case of a 73-year-old woman who was admitted to hospital because of typical chest pain at rest after her brothers death. She had had a pacemaker implanted in 2001. Troponin levels were elevated and apical hypokinesia was shown by ventriculography and echocardiography, with normal coronary arteries. Evolving ECG alterations were observed in spite of the continued pacing rhythm. All these alterations were fully resolved after discharge. This case shows that, even in the presence of a pacemaker, evolving ECG alterations can be observed in Takotsubo syndrome.