Juan Pablo Costabel

Morphologic pattern of late gadolinium enhancement in Takotsubo cardiomyopathy detected by early cardiovascular magnetic resonance

Takotsubo cardiomyopathy (TTC) presents clinically as an acute coronary syndrome. It is characterized by transient left ventricular wall dyskinesis‐akinesis, without significant epicardial coronary lesions. Late gadolinium enhancement (LGE) sequences on cardiac magnetic resonance (CMR) allow to clarify the pathophysiology in patients with chest pain, elevated troponin, and normal epicardial coronary arteries; in patients with TTC, previous studies have shown absence of LGE.

A laboratory study on the reliability estimations of the mini-CEX

Reliability estimations of workplace-based assessments with the mini-CEX are typically based on real-life data. Estimations are based on the assumption of local independence: the object of the measurement should not be influenced by the measurement itself and samples should be completely independent. This is difficult to achieve. Furthermore, the variance caused by the case/patient or by assessor is completely confounded. We have no idea how much each of these factors contribute to the noise in the measurement. The aim of this study was to use a controlled setup that overcomes these difficulties and to estimate the reproducibility of the mini-CEX. Three encounters were videotaped from 21 residents. The patients were the same for all residents. Each encounter was assessed by 3 assessors who assessed all encounters for all residents. This delivered a fully crossed (all random) two-facet generalizability design. A quarter of the total variance was associated with universe score variance (28%). The largest source of variance was the general error term (34%) followed by the main effect of assessors (18%). Generalizability coefficients indicated that an approximate sample of 9 encounters was needed assuming a single different assessor per encounter and assuming different cases per encounter (the usual situation in real practice), 4 encounters when 2 raters were used and 3 encounters when 3 raters are used. Unexplained general error and the leniency/stringency of assessors are the major causes for unreliability in mini-CEX. To optimize reliability rater training might have an effect.

High-sensitive troponin T levels and complex coronary lesions

window with well-known adverse effects, some of which may themselves be life-threatening. These include ventricular arrhythmias, angina, myocardial infarction, pulmonary edema, sudden sharp increase in blood pressure, and intracranial hemorrhage [8]. Milder adverse effects include anxiety, fear, restlessness, headache, dizziness, palpitations, pallor, and tremor. Patients at higher risk for serious adverse effects from epinephrine are those with comorbidities such as underlying heart disease and those taking monoamine oxidase inhibitors, tricyclic antidepressants, antiarrhythmics, and cocaine [8]. Errors associated with epinephrine administration relate to dosing (related to concentration and ratio dose expressions, ie, 1:1000 and 1:10 000), name (mistaken with ephedrine), and route [8,9]. Furthermore, based on the recommended dosing for children (0.01 mg/kg of 1:1000 solution) and that only 2 fixed doses of epinephrine are available by autoinjector (0.15 and 0.3 mg), children weighing less than 15 kg are overdosed with the 0.15-mg autoinjector, whereas children weighing between 15 and 30 kg are underdosed if treated with 0.15 mg, yet overdosed if treated with 0.3 mg [8]. Despite the potential for adverse effects, medication interactions, and administration errors, epinephrine still remains the first-line treatment for anaphylaxis [2]. For the potentially fatal cases of anaphylaxis refractory to epinephrine, alternative therapies are essential. We feel that the benefits, highlighted in our report [1], compared with the risks, summarized in both our report and this correspondence, favor the use of methylene blue in cases of anaphylaxis refractory to conventional treatment.

Aortic Valve Replacement in a Patient With Osler-Rendu-Weber Disease

Osler-Rendu-Weber (hereditary hemorrhagic telangiectasia) disease is an uncommon disease characterized by the presence of abnormal telangiectasias and arteriovenous malformations that cause recurrent episodes of bleeding. We present a patient with Osler-Rendu-Weber disease, with a history of multiple major bleeding events and severe aortic valve stenosis, who underwent aortic valve replacement. Unexpectedly, the postoperative course was uneventful, and there was no untoward bleeding in the early or in the late postoperative follow-up.

High-sensitivity troponin and right ventricular function in acute pulmonary embolism

INTRODUCTION Right ventricular (RV) dysfunction has proved to be an important predictor of morbidity and mortality in patients with pulmonary embolism (PE). Tricuspid annular plane systolic excursion (TAPSE) is one of the parameters that have been validated as predictor of outcomes. The aim of our study was to evaluate the performance (sensitivity and specificity) of high-sensitivity cardiac troponin T (hs-cTnT) to predict RV dysfunction defined as TAPSE <16 mm. METHODS We conducted a single-center retrospective analysis of 40 patients prospectively included. Median age was 66 years (59-76) and PESI score was 81 (67-100). RESULTS Right ventricular dysfunction was present in 30% of the patients and was associated with higher median troponin values (33.5 ng/L vs 16 ng/L; P= .03). A logarithmic relation was observed between hs-cTnT and lower TAPSE values (r(2)= 0.36; P< .0001). The area under the ROC curve of hs-cTnT to predict RV dysfunction was 0.77 (0.63-0.92). CONCLUSION hs-cTnT is a biomarker with good performance to identify RV dysfunction in PE.

Vernakalant: Perception of state of health in patients with a recent-onset atrial fibrillation

BACKGROUND Vernakalant is a new, safe and effective drug used intravenously, which has proved to be more rapid in converting recent onset atrial fibrillation (AF) to sinus rhythm compared to placebo, amiodarone, propafenone, and flecainide in clinical studies. Until now no study has been conducted comparing the perception of state of health in patients who received vernakalant versus propafenone or flecainide for conversion of recent-onset AF. The aim of our study is to compare the change of perception of state of health from screening to hour 2 in patients treated with vernakalant and propafenone or flecainide for conversion of recent-onset AF. METHODS Eighty hemodynamically stable patients with recent onset AF without structural heart disease were prospectively included. A single oral dose of propafenone 600 mg was administered to 30 patients, 30 patients received intravenous vernakalant and the remaining 20 patients received a single oral dose of flecainide 300 mg. Clinical, laboratory variables and perception of state of health from screening to hour 2 treated with these drugs measured by the EQ-5 D quality-of-life assessments visual analog scale were recorded. RESULTS Baseline characteristics were similar in the three groups. Treatment with vernakalant resulted in a significantly greater improvement in patient perception of state of health at hour 2 compared with propafenone and flecainide. In the vernakalant group, a mean increase (from baseline) of 12.1 points was seen compared with a mean increase of 5.4 points in the propafenone group or 5.2 points in flecainide group (p < 0.01). CONCLUSIONS The change of perception of state of health from screening to hour 2 treated with vernakalant had a significantly statistical improvement compared with propafenone or flecainide for conversion recent-onset AF.

Flecainide or Propafenone vs Vernakalant for Conversion of Recent-Onset Atrial Fibrillation

To the Editor: Several studies have demonstrated the efficacy of flecainide and propafenone for conversion of recent-onset atrial fibrillation (AF) to sinus rhythm. Randomized controlled studies demonstrated conversion to sinus rhythm within 8 hours in about 70% of patients treated with either agent. A single oral dose of flecainide or propafenone is widely used for conversion of recent-onset AF in hemodynamically stable patients without structural heart disease. The European guidelines consider flecainide or propafenone class IA agents for this application. Vernakalant is a novel, rapidly acting intravenous drug with proven effectiveness and safety compared with placebo and amiodarone in randomized clinical trials. Our study compared the time for conversion of recent-onset AF in patients treated with vernakalant vs flecainide or propafenone. Hemodynamically stable patients (n 1⁄4 51) with recentonset AF without structural heart disease were prospectively and consecutively included. Patients received single oral doses of flecainide 300 mg (n 1⁄4 15) or propafenone 600 mg (n 1⁄4 19), or intravenous vernakalant (n 1⁄4 17) at standard doses. Baseline characteristics were similar in all groups. Median time to conversion to sinus rhythm was 161 minutes (interquartile range [IQR], 125-312 minutes) in the flecainide group, 166 minutes (IQR, 120-300 minutes) in the propafenone group, and 9 minutes (IQR, 6-18 minutes) in the vernakalant group (P 1⁄4 0.0001 vs flecainide or propafenone). Median hospital stay was shorter in the vernakalant group, 238 minutes (IQR, 190-278 minutes), vs flecainide, 402 minutes (IQR, 337-741 minutes; P 1⁄4 0.001), or propafenone, 416 minutes (IQR, 337-741 minutes; P 1⁄4 0.001). We conclude that conversion of AF to sinus rhythm is faster with vernakalant than with flecainide or propafenone

Recent-Onset Atrial Fibrillation in Patients With Left Ventricular Dysfunction: Amiodarone or Vernakalant?

Recent-Onset Atrial Fibrillation in Patients WithLeft Ventricular Dysfunction: Amiodarone orVernakalant?To the Editor:Conversion of recent-onset atrial fibrillation (AF) to sinusrhythm with antiarrhythmic drugs reduces the risk of hemo-dynamic instability, hospitalization, and atrial remodellingwith persistent AF.

Relationship between high-sensitive troponin T levels in patients with acute coronary syndrome with ST elevation and complex coronary lesions

High-sensitive troponin T (hsTnT) has been associated with diagnosis and prognostic of acute coronary syndromes, and it was associate in some studies with the extension and severe coronary lesions in the acute coronary syndromes without ST elevation, but it is not well established the relationship with the extension and severe coronary lesions in patients with an acute coronary syndromewith ST elevation (STEMI) [1-5]. We sought to explore the relation between hsTnT levels and extension of coronary artery disease (CAD) and the presence of more complex and severe coronary lesions in patients with STEMI. This is an observational study, which included 53 patients admitted with STEMI. High-sensitive troponin T was performed at a median time of 3 hours after admission and analyzed. We consider a positive hsTnT when was more than 14 ng/L. Angiogramswere read, and complex coronary lesionwas defined as the presence of at least one of the following: coronary lesion more than 90%, coronary lesion more than 50% in the left main coronary artery, 2 or more vessels affected with lesion more than 70%, the presence of thrombus, TIMI flow less than 2, or ulcerated plaque. The levels of hsTnT were directly related to the extent of the CAD. Patients with complex coronary lesions had higher levels of hsTnT compared with those without complex coronary lesions. After adjusting for clinical and electrocardiographic variables and positive hsTnT (odds ratio, 3.20; 95% confidence interval, 2.50-4.11; P b .0001) and median hsTnT levels (odds ratio, 2.12; 95% confidence interval, 2.01-2.74; P b .01) independently contributed to the prediction of complex coronary lesions. We conclude that patients with STEMI hsTnT levels progressively increase with the severity of CAD. Increased levels of hsTnT independently predict the presence of more complex coronary lesions. This study showed similar results than patients with acute coronary syndromes without ST elevation.

Algorithm for probable acute coronary syndrome using high-sensitivity troponin T assay vs fourth-generation troponin T assay

BACKGROUND Chest pain represents between 5% and 10% of annual visits to emergency departments (EDs) and near 25% of hospitalizations. Characterization of chest pain is sometimes difficult, and strategies should focus on preventing inappropriate discharge of patients with acute coronary syndrome. The goal of our study is to compare negative predictive value of the algorithm in the chest pain unit using the fourth-generation troponin T assay (4GTT) vs high-sensitivity troponin T assay (HSTT). METHODS We included 600 patients with probable acute coronary syndrome, who were discharged from the chest pain unit without an acute coronary syndrome: 300 patients in the 4GTT group and 300 patients in the HSTT group. Clinical and laboratory variables were analyzed. All the patients were followed up at 30 days, and the cardiovascular events were recorded. RESULTS Major cardiac events occurred in only 3 (1.2%) in the HSTT group vs 5 (1.7%) in the 4GTT group (P, nonsignificant). The negative predictive value was 99% in both groups. Emergency department length of stay was 4.3 ± 2.6 hours in HSTT group vs 10 ± 3.4 hours in the 4GTT group (P = .01). CONCLUSION The algorithm in the chest pain unit using HSTT showed to have the same negative predictive value as the algorithm with the 4GTT but with a shorter stay in the ED.