Hui-Jeong Hwang

APACHE II Score, Rather Than Cardiac Function, May Predict Poor Prognosis in Patients With Stress-Induced Cardiomyopathy

While the disease course of stress-induced cardiomyopathy (SIC) is usually benign, it can be fatal. The prognostic factors to predict poorer outcome are not well established, however. We analyzed the Acute Physiology And Chronic Health Evaluation (APACHE) II score to assess its value for predicting poor prognosis in patients with SIC. Thirty-seven consecutive patients with SIC were followed prospectively during their hospitalization. Clinical factors, including APACHE II score, coronary angiogram, echocardiography and cardiac enzymes at presentation were analyzed. Of the 37 patients, 27 patients (73%) were women. The mean age was 66.1 ± 15.6 yr, and the most common presentation was chest pain (38%). Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% ± 9.3%, and the wall motion score index (WMSI) was 1.9 ± 0.3. Six patients (16%) expired during the follow-up period of hospitalization. Based on the analysis of characteristics and clinical factors, the only predictable variable in prognosis was APACHE II score. The patients with APACHE II score greater than 20 had tendency to expire than the others (P = 0.001). Based on present study, APACHE II score more than 20, rather than cardiac function, is associated with mortality in patients with SIC.

Takotsubo cardiomyopathy recurrence with left ventricular apical ballooning following isolated right ventricular involvement: A case report

We report a case of Takotsubo cardiomyopathy, which involved the right ventricle at first presentation and demonstrated involvement of the left ventricle during recurrence. The patient was admitted to Kyung Hee University Hospital due to a left hip fracture, which was considered a result of physical stress. Complete recovery was confirmed by echocardiography prior to recurrence. The cause of the second event was surgery for the left hip fracture. Recurrence of Takotsubo cardiomyopathy at various cardiac locations provides evidence against the existing hypotheses that variants of Takotsubo cardiomyopathy are associated with anatomically different distributions of cardiac adrenergic receptors, the degree of stimulation by sympathetic activity and different susceptibilities to such sympathetic stimulation.

Evolutionary change mimicking apical hypertrophic cardiomyopathy in a patient with takotsubo cardiomyopathy.

In this report, we introduce a case of thickening of the involved left ventricular apical segment on echocardiography and deep T‐wave inversions in precordial leads on electrocardiography transiently seen in the course of recovery from biventricular takotsubo cardiomyopathy, mimicking apical hypertrophic cardiomyopathy. This result suggests that the echocardiographic finding of transient myocardial edema can be identified by cardiac magnetic resonance imaging in takotsubo cardiomyopathy. Additionally, it persisted a few weeks after full functional recovery. We believe that this case will contribute in part toward clarifying the pathophysiology of takotsubo cardiomyopathy.

The Clinical Impact of Bedside Contrast Echocardiography in Intensive Care Settings: A Korean Multicenter Study

Background and Objectives We assessed the ability of portable echocardiography (with contrasts) to clearly delineate the cardiac structure, and evaluated the impact of its use on the diagnosis and management of critically ill patients in Korea. Subjects and Methods We prospectively enrolled 123 patients (mean age 66±16 years), who underwent portable transthoracic echocardiography (with contrast) for image enhancement at 12 medical centers. The quality of the global left ventricular (LV) images, the number of the regional LV segments visualized, the ability to visualize the LV apex and the right ventricle (RV), and any changes in the diagnostic procedure and treatment strategy were compared before and after the contrast. Results Of the 123 patients, 52 (42%) were using mechanical ventilators. The amount of poor or uninterpretable images decreased from 48% to 5% (p<0.001), after the contrast. Before the contrast, 15.6±1.1 of 16 LV segments were seen, which improved to 15.9±0.6 segments (p=0.001) after the contrast. The ability to visualize the LV apex increased from 47% to 94% (p<0.001), while the inability to clearly visualize the RV decreased from 46% to 19% (p<0.001). Changes in the diagnostic procedure (for example, not requiring other types of imaging studies) were observed in 18% of the patients, and the treatment plan (medication) was altered in 26% of patients after the contrast echocardiography. Conclusion The use of a contrast agent during the portable echocardiography, in intensive care settings, can improve the image quality and impact the diagnostic procedures and treatment for Korean patients.

The Value of Assessing Myocardial Deformation at Recovery after Dobutamine Stress Echocardiography

Background The purpose of this study was to evaluate whether performing an assessment of myocardial deformation using speckle tracking imaging during the recovery period after dobutamine stress echocardiography (DSE) allows detection of significant coronary artery disease (CAD) in patients with chest discomfort. Methods DSE and coronary angiography were performed in 44 patients with chest discomfort. The mean global longitudinal peak systolic strain (GLS) was measured at rest, at low stress (dobutamine infusion rate of 10 µg/kg/min) and at recovery (5 min after cessation of dobutamine infusion) of DSE using automated function imaging with apical views. Fractional flow reserve (FFR) was also performed in patients with intermediate coronary stenosis. CAD was defined as having a ≥ 70% diameter stenosis on coronary angiography or as having a FFR < 0.8. Patients were divided two groups based on the absence or presence of CAD [CAD (-) group vs. CAD (+) group]. Results There were no significant differences in the clinical characteristics and results of conventional echocardiography between the two groups. GLS at recovery was lower in the CAD (+) group than in the CAD (-) group (-18.0 ± 3.4% vs. -21.0 ± 1.9%, p = 0.003). The optimal cutoff of GLS at recovery for detection of CAD was -19% (sensitivity of 70.6%, specificity of 83.3%). Conclusion Assessment of GLS at recovery of DSE is a reliable and objective method for detection of CAD. This finding may suggest that systolic myocardial stunning remains even after recovery of wall motion abnormalities in patients with CAD.

Massive right coronary air embolism in the right coronary artery during left coronary angiography: A case report

Coronary air embolism is one of the inadvertent complications of coronary angiography. We report a case of unexpected massive right coronary air embolism during left coronary angiography with a JL4 diagnostic catheter. This report demonstrates that air embolism may occur in the contralateral coronary artery and therefore complete air aspiration must be ensured during coronary angiography.

Increased interarm blood pressure difference is associated with autonomic dysfunction and atherosclerosis in patients with chest pain and no history of coronary artery disease

OBJECTIVES Interarm blood pressure (BP) difference has been reported to be associated with atherosclerosis and increased cardiovascular death. We were to investigate associations of interarm systolic blood pressure (SBP) difference with heart rate recovery (HRR) after exercise, an index of autonomic function, and carotid atherosclerotic markers, and to evaluate the association of interarm SBP difference with concurrent coronary artery disease (CAD). METHODS A total of 995 consecutive patients who underwent treadmill stress echocardiography with chest pain but no history of CAD were enrolled. Interarm SBP difference, carotid intima-media thickness (IMT) and plaque were measured before exercise, and HRR 2min following exercise was assessed. Suspected CAD was defined as newly developed wall motion abnormalities after treadmill exercise. RESULTS Patients with an interarm SBP difference≥10mmHg had higher prevalence of hypertension, increased right and left SBP, right diastolic BP, mean arterial pressure, body mass index and carotid IMT, existent carotid plaque, lower metabolic equivalents and slower HRR. Interarm SBP difference≥10mmHg was independently associated with slower HRR and existent carotid plaque. Suspected CAD was associated with existent carotid plaque or slower HRR, but not with an interarm SBP difference≥10mmHg. CONCLUSIONS Increased interarm SBP difference was associated with lower autonomic modulation and carotid atherosclerosis in patients with chest pain and no history of CAD, but not with suspected CAD. Observed adverse prognosis in patients with increased interarm BP difference might result from long-term persistent autonomic dysfunction and atherosclerosis.

Comparative clinical implications of admission electrocardiographic findings for patients with non-st-segment elevation myocardial infarction

Abstract Early risk stratification is crucial for appropriate management using invasive strategies in non-ST elevation myocardial infarction (NSTEMI), and electrocardiography (ECG) has been widely used for risk stratification. However, ECG findings in NSTEMI vary, and there is a need to define the clinical characteristics and outcomes according to ECG. We analyzed the admission ECGs of 345 NSTEMI patients who underwent coronary angiography from 2006 to 2013. Demographics, procedural characteristics, and clinical outcomes were analyzed. The ST-segment depression, T-wave inversion, and no ECG change groups included 114, 90, and 141 patients, respectively. The ST-segment depression group trended toward older, nonsmoking, and female, with a lower body mass index (BMI) and a higher incidence of comorbidities, than the no ECG change group. The ST-segment depression group also had a higher Killip class, a lower left ventricular ejection fraction, a higher regional wall motion score index (RWMSI), and 3-vessel coronary artery disease angiographically, than the no ECG change group. Patients with T-wave inversion trended toward older, female, lower BMI, less smoking, lower creatine kinase MB, and more left anterior descending (LAD) artery involvement, than the no ECG change group. In clinical outcomes, the ST-segment depression group had a higher mortality rate at 30 days and 12 months after the index procedure than the no ECG change group, whereas the T-wave inversion group showed similar clinical outcomes. Patients with ST-segment depression have a greater burden of comorbidities with risk factors and worse clinical outcomes, whereas patients with T-wave inversion have an intermediate number of risk factors but similar outcomes, compared with the no ECG change group. Further study is necessary to evaluate the prognostic impact of the baseline ECG on admission.

Pneumopericardium after pericardiostomy

An 81-year-old woman presented to our hospital with complaints of abdominal discomfort and mild dyspnea. The chest radiograph showed cardiomegaly, and echocardiographic findings showed a moderate to severe pericardial effusion. Pericardiostomy through the subxiphoid area was performed, and 600 mL of hemorrhagic pericardial fluid was aspirated and a chest tube was inserted at the pericardial sac. On the next day, the patient became asymptomatic; her blood pressure was 113/66 mmHg and heart rate was 91 beats/min but pneumopericardium was evident on the chest radiograph (Figure 1). We found that the pneumopericardium was caused by an incorrectly connected watersealed drainage system in the chest bottle. We readjusted it immediately and performed suction with negative pressure to drain the air rapidly. A follow-up chest radiograph showed a decrease in the amount of air. At this point, the patient’s blood pressure was 107/68 mmHg and heart rate was 76 beats/min. We removed the chest tube 7 days later and she was discharged without complications. Pneumopericardium is a rare condition and the most common causes are traumatic injury, complications of diagnostic and therapeutic procedures such as pericardiocentesis, barotrauma, infection or fistula to the pericardium, pulmonary emphysema, pulmonary aspergillosis, and aspiration of foreign body. A meticulous procedural technique and close postprocedural surveillance is

PS 05-39 INCREASED INTERARM BLOOD PRESSURE DIFFERENCE IS ASSOCIATED WITH SLOW HEART RATE RECOVERY IN PATIENTS WITH CHEST DISCOMFORT

Objective: Interarm blood pressure difference which is observed relatively common in clinical practice has been reported with association to the increased cardiovascular or all-cause death as well as several atherosclerotic markers. The aim of this study is to investigate the association between interarm systolic blood pressure (SBP) difference and heart rate recovery (HRR) after symptom-limited treadmill exercise, an index of autonomic dysfunction in patients with chest discomfort. Design and Method: One thousand thirteen patients (56 ± 10 yrs) who measured SBP in both arms with ankle-brachial index (ABI) and underwent treadmill stress echocardiography with chest discomfort were consecutively enrolled. Carotid arterial evaluations including intima-media thickness (IMT), existence of plaques, maximal plaque size and segments with plaques and HRR at 2 minutes following exercise were also assessed. Results: Patients with interarm SBP difference ≥ 10 mmHg had higher body mass index, and mean blood pressure, increased carotid IMT, more existence of plaques, larger maximal plaque size and segments with plaques and lower ABI and metabolic equivalents and slower HRR. Among them, the interarm SBP difference ≥ 10 mmHg was independently associated with slower HRR after adjusting for all possible confounders. Conclusions: Increased interarm SBP difference was associated with slower HRR in patients with chest discomfort. This result may suggest that one possible mechanism related to adverse outcome in patients with increased interarm SBP difference is linked to abnormalities of parasympathetic activation.