Johannes Schwab

Gender differences in the manifestation of tako-tsubo cardiomyopathy

OBJECTIVE This study evaluated if there are gender differences in the manifestation of tako-tsubo cardiomyopathy (TTC). BACKGROUND TTC predominantly occurs in elderly females and mimics acute myocardial infarction (AMI) where men and women are known to have a different clinical profile. METHODS 324 patients from 37 hospitals were prospectively included in a TTC registry. Clinical, electrocardiographic, angiographic and outcome data from male and female patients were compared. RESULTS Of 324 patients 296 (91%) were female and 28 (9%) male. Mean age (68 ± 12 vs 66 ± 12 years) and prehospital delay were similar. A triggering event preceded TTC onset in 76% of women and 86% of men. Physical stress was more frequent in men (30% vs 57%, p=0.005) whereas more women experienced emotional or no stress. The prevalence of angina and dyspnea did not differ. Fewer females were admitted in cardiogenic shock and/or after out of hospital cardiac arrest (1% vs 14%, p=0.0006), and cardiac troponin was lower (median 7.2 vs 10.7 times the upper limit of normal, p=0.03). The QTc interval was longer in females than in males only on the day of admission (468 ± 52 vs 441 ± 51 ms, p=0.047). Overall, complications during the acute course (53% vs 40%) were comparable in both sexes. CONCLUSIONS In this large TTC registry, males and females showed a similar clinical profile. In males, physical stress as a trigger event and shock or cardiac arrest as presenting symptoms were more frequent. The QTc interval was longer in females only on admission but similar in males and females during the following days.

Complications in the clinical course of tako-tsubo cardiomyopathy

OBJECTIVE This study evaluated the frequency, severity and outcome of complications in the clinical course of tako-tsubo cardiomyopathy (TTC). BACKGROUND TTC is regarded as a benign disease since left ventricular (LV) function returns to normal within a short time. However, severe complications have been reported in selected patients. METHODS From 37 hospitals, 209 patients (189 female, age 69 ± 12 years) were prospectively included in a TTC registry. RESULTS Complications developed in 108/209 patients (52%); 23 (11%) had >2 complications. Complications occurred median 1 day after symptom onset, and 77% were seen within 3 days. Arrhythmias were documented in 45/209 patients (22%) including atrial fibrillation in 32 (15%) and ventricular tachycardia in 17 (8%). Of 8 patients resuscitated (4%), 6 survived. Additional complications were right ventricular involvement (24%), pulmonary edema (13%), cardiogenic shock (7%), transient intraventricular pressure gradients (5%), LV thrombi (3%) and stroke (1%). During hospitalization, 5/209 patients (2.5%) died. Patients with complications were older (70 ± 13 vs 67 ± 10 years, p=0.012), had a higher heart rate (91 ± 26 vs 83 ± 19/min, p=0.025), more frequently Q\ waves on the admission ECG (36% vs 21%, p=0.019) and a lower LV ejection fraction (47 ± 15 vs 54 ± 14%, p = 0.002). Multivariate regression analysis identified Q-waves on admission (OR 2.49, 95% CI 1.23-5.05, p=0.021) and ejection fraction ≤ 30% (OR 4.03, 95% CI 1.04-15.67, p=0.022) as independent predictors for complications. CONCLUSIONS TTC may be associated with severe complications in half of the patients. Since the majority of complications occur up to day 3, monitoring is advisable for this time period.

Renal resistive index in addition to low-grade albuminuria complements screening for target organ damage in therapy-resistant hypertension.

Objective We examined the value of renal resistive index (RRI) for prevalence of cardiovascular target organ damage in therapy-resistant hypertension in comparison to low-grade albuminuria. Methods Eighty-four patients with therapy-resistant hypertension (age 59.7 ± 8.1 years) were screened for cardiovascular target organ damage with coronary computed tomography, cardiac magnetic resonance imaging (MRI), Doppler sonography for the assessment of carotid intima media thickness and, RRI, pulse wave velocity and for low-grade albuminuria of at least 10 mg/day in men and 15 mg/day in women, respectively. Results In patients with RRI greater than 0.7 pulse wave velocity (11.6 ± 3.7 vs. 9.8 ± 2.2 m/s; P = 0.02) intima media thickness (0.85 ± 0.09 vs. 0.76 ± 0.1 mm; P = 0.007) and Agatston score of coronary calcification (640 ± 915 vs. 129 ± 256; P = 0.05) were increased, whereas left ventricular mass (127 ± 24.5 vs. 125 ± 15.0 g; P = 0.70) was similar between the two groups. When patients were categorized according to low-grade albuminuria left ventricular mass was significantly higher in those with low-grade albuminuria (123 ± 25.8 vs. 135 ± 15.7 g; P = 0.01), whereas vascular parameters (intima media thickness, Agatston score, pulse wave velocity) did not differ between the two groups. Conclusion In patients with therapy-resistant hypertension RRI reflects functional and structural vascular parameters, whereas low-grade albuminuria is related to cardiac structural changes. Thus, measurement of RRI in addition to low-grade albuminuria complements screening for target organ damage in therapy-resistant hypertension.

Diagnosis of left ventricular myxoma with cardiac magnetic resonance imaging

Ingrid Bar, MD Institut fur diagnostische und interventionelle Radiologie Klinikum Nurnberg-Sud 90471 Nurnberg, Germany Sirs: A 20-year-old man presented with palpitation without typical angina, dyspnoe, syncope and vertigo. There was no medical history and no family member had a history of syncope. ECG showed sinus rhythm, normal heart rate, normal PR interval and QRS duration, no ST-segment elevation or negative T-waves. 24-h ECG showed no pathological findings. All laboratory parameters including cardiac biomarkers were normal. Echocardiography (TTE) revealed a 21×26 mm large intracardiac tumor localized in the left ventricle (LV) attached to the anterior wall. LV diameter and function were normal. For further characterization of tumor pathology, a cardiac magnetic resonance (CMR) study was performed. Cine-CMR showed a normal size and function of the LV (EDD 153 ml, EDS 64 ml, LV-EF 59%, LV-cardiac output 4.9 l/min). CMR confirmed the echocardiographic findings: the tumor size was measured as 19×26 mm. The tumor was clearly attached to the anterior endocardium (segment 7) by a nar-

Cardiac angiosarcoma:case report and reviewof the literatur

With interest we read the article by Brandt et al. about the usefulness of modern imaging methods in the evaluation of cardiac tumors. The article about cardiac angiosarcoma and the review of the literature shows very impressively the value of the differentiated diagnostics for the spectrum of cardiac tumors. Beside echocardiography (TTE and/or TEE) and MSCT, cardiovascular magnetic resonance imaging (CMR) encompasses a variety of different techniques which provide a comprehensive evaluation of cardiac tumors. In addition to the excellent morphological localization of the tumor mass, CMR providing information by T1-weighted, T2weighted and contrast-enhanced magnetic resonace imaging is capable of soft-tissue characterization. These improvements in the noninvasive imaging technique allow quick visual interpretation of the benign or malignant quality of a cardiac tumor in the routine clinical setting. Table 1 provides information about the specific characteristics of the protocols for image acquisition in cardiac angiosarcoma. In our clinical case (43 year old, male patient) a non invasive differentiation of a cardiac mass as a cardiac angiosarcoma was possible prior to open heart surgery (Fig. 1). Clin Res Cardiol 95:351–353 (2006) DOI 10.1007/s00392-006-0386-7 LET TER TO THE EDITORS

Improved functional cardiac MR imaging using the intravascular contrast agent CLARISCAN

Purpose: Using segmented k-space turbo gradient echo MR techniques (TGE) contrast between blood and myocardium is often reduced in long axis views due to reduced in plane spin-refreshment, particularly in patients with low ejection fraction. The application of an intravascular contrast agent (CA) may improve endocardial border delineation. Materials and methods: In 15 patients cardiac cine loops in two long axis and two short axis views were acquired during breath hold using a TGE sequence without and with increasing doses of CA (0.75, 2.0, 5.0 mg Fe/kg). Two independent observers evaluated left ventricular function (LVEF, modified Simpsons rule) and assigned a visual score (range: 0 = ‘not visualized’ to 6 = ‘excellent visualization’) for endocardial border delineation. Signal- and contrast-to-noise ratios (SNR; CNR) were determined. Results: Endocardial border delineation score for TGE was 1.7 ± 0.6 and 3.9 ± 0.6**, 4.4 ± 0.5**, 4.6 ± 0.4** for 0.75, 2.0, 5.0 mg Fe/kg of CA, respectively ( **p < 0.01 vs. TGE). SNR of blood increased significantly with any dose of CA with a mild drop of myocardial SNR resulting in a significant increase of CNR blood/myocardium. The maximum effect with 2.0 mg Fe/kg was a >2-fold CNR increase. Inter- and intraobserver variability assessed according to the method of Bland–Altmann was reduced at 2.0 mg Fe/kg for determination of LVEF and reached statistical significance for LVEF <50%. Conclusion: Intravascular CA increased CNR between blood and myocardium by a factor >2 and significantly improved the determination of cardiac volumes. The benefit in accuracy was most for patients with left ventricular ejection fraction <50%.

Intralymphatic interleukin-2 in combination with zidovudine for the therapy of patients with AIDS

SummaryIn a pilot study the safety and therapeutic effects of an immunostimulatory intralymphatic treatment with natural human interleukin-2 (IL-2) in combination with zidovudine were evaluated in nine patients with AIDS. Therapy with IL-2 consisted of one subcutaneous injection of 0.1 μg/kg IL-2, followed by four intralymphatic IL-2 infusions of 0.1 μg/kg each within a period of up to 15 days. Enlargement of lymph nodes was seen in six and a transient increase of CD4 cells in five out of nine persons in association with the IL-2 therapy. An increase of HIV p24-antigenemia was observed only in the two patients in whom zidovudine dosage had to be reduced because of side effects. Moderate clinical side effects occurred in eight of the nine patients. Four patients developed zidovudine associated anemia. Six participants showed a favourable course of disease with survival of 25 to 54 months (median 30 months) despite a previous diagnosis of manifest AIDS before IL-2 therapy. This pilot study demonstrates that a combination therapy with intralymphatic IL-2 and zidovudine can induce positive immunomodulatory effects, even in the presence of manifest AIDS. Further studies should explore the tolerability and effects of a prolonged therapy with IL-2 in combination with a more potent antiviral drug combination therapy.

Low-dose eplerenone decreases left ventricular mass in treatment-resistant hypertension

Background: Mineralocorticoid receptor antagonists are increasingly used in patients with treatment-resistant hypertension (TRH). There is experimental evidence for blood pressure (BP) independent effects of mineralocorticoid receptor blockade on cardiovascular target organ damage. We hypothesized that low-dose eplerenone (50 mg) will reduce left ventricular mass (LVM) beyond its BP-lowering effects. Methods: We performed a randomized, double-blind, placebo-controlled, parallel group study in 51 patients with TRH. Patients were allocated to receive either eplerenone 50 mg or placebo for 6 months, while other antihypertensive agents could be added in both groups to achieve a BP target of less than 140/90 mmHg. LVM was assessed by MRI before and after treatment. Results: Baseline office BP was similar in the eplerenone and the placebo group (166 ± 21/91 ± 15 versus 159 ± 19/94 ± 8 mmHg, n.s.). BP was similarly reduced in the eplerenone versus the placebo group (−35 ± 20/−15 ± 11 versus −30 ± 19/−13 ± 7 mmHg, n.s.). However, LVM was reduced only in the eplerenone group (from 155 ± 33 to 136 ± 33 g, P < 0.001), but not in the placebo group (152 ± 32 versus 148 ± 38 g, P = 0.45). Conclusions: Despite similar BP-lowering, only patients with TRH who were allocated to eplerenone experienced a reduction of LVM. Thus, our data suggest that in patients with TRH, mineralocorticoid receptor antagonists should be used preferentially in order to achieve an effective reduction of LVM along with the improvement of BP control.

Giant right atrial myxoma verified by cardiovascular magnetic resonance.

A 72-year-old man was admitted because of reduction in cardiac output, nausea, drop attacks to the right site, alexia, sensorimotor aphasia, homonymous hemianopia to the right, and dyspnea. The patient had a history of ischemic stroke in 1985 with spastic brachiocephalic residues but no event of angina, syncope or symptomatic cardiac arrhythmias. A computed tomography scan of his brain showed the known left posterior postischemic defect but did not reveal any new signs of stroke, hemorrhage, or mass effect. Echocardiography uncovered a large right atrial tumor but allowed no further characterization. Cardiovascular magnetic resonance (CMR) was performed for additional noninvasive characterization of the right atrial mass (1.5-T Intera, Philips Medical Systems, Eindhoven, The Netherlands) [1, 2]. The giant polypoid right atrial mass (90 × 80 mm) was attached to the interatrial septum at the border of the oval fossa and prolapsed through the tricuspid valve into the right ventricle during diastole (Figures 1a and 1b) [4]. The right atrium and ventricle Figures 1a and 1b. a) Two-chamber right ventricular and b) four-chamber view showing right atrial tumor attached to the interatrial septum and protruded through the tricuspid valve into the right ventricle (RV) during diastole with a small circular pericardial effusion (PE). a b

Multimodal Imaging for the Assessment of a Cardiac Mass - A Case of Primary Cardiac Sarcoma

We present a case of an 85-year-old patient who underwent clinical work-up for chronic heart failure, acute coronary syndrome, and pulmonary embolism, until she was diagnosed with a cardiac mass that was histologically identified as sarcoma. The aim of this educational case report is to raise awareness of cardiac masses and to point out diagnostic hints towards a cardiac tumor on chest X-ray, coronary angiography, echocardiography, and chest CT. Moreover, the vital role of cardiac magnetic resonance for the diagnosis of a cardiac mass is highlighted.