Riccardo Ieva

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.

Incremental value and safety of oral ivabradine for heart rate reduction in computed tomography coronary angiography

BACKGROUND Heart rate (HR) reduction is essential to achieve optimal image quality and diagnostic accuracy with computed tomography coronary angiography (CTCA). Administration of ivabradine could be an attractive alternative to beta-blockade to reduce HR. METHODS One-hundred-twenty-three patients referred for CTCA were prospectively enrolled. Patients were divided in two groups depending on the absence or presence of chronic beta-blockade treatment. Within the two groups patients were randomized to either no additional premedication or oral ivabradine for 5 days prior to CTCA. In presence of chronic beta-blockade therapy it was shifted to atenolol 50mg twice a day for 5 days prior to CTCA. HR and blood pressure were assessed at admission (T0), immediately before CTCA (T1) and during CTCA (T2). The target HR was <65 bpm. RESULTS Ivabradine significantly reduced HR during CTCA. Mean relative HR reduction was 15% for controls, 12% for chronic beta-blockade, 19% for ivabradine and 24% for both chronic beta-blockade and ivabradine at T2 (p for trend <0.001). The rate of patients who reached the target HR at T2 was 83% in controls, 71% with chronic beta-blockade, 97% with ivabradine and 97% with both (p for trend <0.05). The percentage of patients that needed additional IV beta-blockade at T1 decreased from 69% to 40% with ivabradine and 30% with both (p for trend <0.05). CONCLUSIONS Ivabradine is safe and effective in increasing the rate of patients at target HR and in reducing the need for additional IV beta-blockade in patients referred for CTCA.

Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: In the beginning was basal hyperkinesis?

Tako-Tsubo cardiomyopathy (TTC), also known as stress inducedcardiomyopathy or apical ballooning syndrome, was first describedby Dote in 1991 [1].Itisdefined as a fully reversible acutedeterioration of left-ventricular function, which is mainly found inwomen after an episode of emotional or physical stress (e.g. psycho-social stress, sepsis, surgery) [2]. The underlying mechanisms remainunclear, although increased catecholamine levels were thought asmain responsible [3,4]. Even less known are the mechanismsunderlying the hyper-acute phase of TTC, which precede apicalballooning and are usually missed because they occur during thepre-hospital phase of the disease. We describe in this case thehyper-acute phase of TTC observed during early in-hospital recur-rence of TTC.A 74-year-old woman, with amyotrophic lateral sclerosis (ALS),referred for pneumonia, after a stressful event during hospitalization,complained of chest pain, with evidence at electrocardiogram of STelevation, negative T-waves in anterior leads, intra-ventricular

Time intervals and myocardial performance index by tissue Doppler imaging

The application of tissue Doppler imaging (TDI) has shown remarkable growth in clinical practice during the past few years, especially, in risk stratification of patients with coronary heart disease or heart failure (systolic and diastolic). Myocardial performance index (MPI) is a Doppler echocardiographic parameter defined as the sum of the isovolemic contraction and relaxation times divided by the ejection time. It is considered as a reliable parameter to assess global left ventricular function. Cardiac time intervals and MPI have also been found as new applications in diagnosing cardiotoxicity from chemotherapy, COPD, valvular heart disease, pulmonary hypertension and endocrinopathies.

Tako-tsubo cardiomyopathy following an allergic asthma attack after cephalosporin administration.

Tako-Tsubo (TT) syndrome is characterized by acute onset ofchest symptoms, ECG changes with elevated cardiac markers mim-icking acute myocardial infarction, left ventricular (LV) wall motionabnormalities in the apical region with preserved function of base,and normal coronary arteries [1]. Those affected are typically olderwomen presenting after a stressful trigger, either emotional orphysical.A 70-year-old woman with history of hypertension, diabetes,asthma and allergy, was admitted with chest pain and dyspnea,whichsuddenly appearedafter asingle 1 g doseof ceftriaxonei.m.as-sumed because of cough and fever. On physical examination, bloodpressure was 120/70 mm Hg, heart rate 110 bpm, respiratory rate22 breaths/min, and diffuse bilateral wheezes were found. ECGshowed sinus rhythm and mild ST-elevation in anterior leads(Fig. 1a); troponin-I levels were increased (1.09 m ng/ml (n.v.b0.03)). Trans-thoracic echocardiogram showed LV systolic dysfunc-tion (ejection fraction [EF] 25%) with both apical dyskinesis andbasal hyperkinesis (Fig. 1c), and right ventricular (RV) apical dyskin-esis (Fig. 1d). Mild mitral regurgitation and tricuspid regurgitationwere also detectable at color Doppler analysis. Total IgE circulatinglevels were increased (1270 I.U./ml (n.v. b240 I.U./ml). Coronary an-giography showed normal coronary arteries and confirmed LV apicalballooning (Fig. 1e–f). Medical treatment with furosemide,levosimendan,ramipril,andbisoprololwasthereforestarted.Thepatientgradually recovered, and was discharged a week later, when all ECGanomalies, after transient onset of negative T-waves ( Fig. 1b) disap-peared. Pre-discharge echocardiography showed both improved LV (EF55%) and RV systolic functions.We report a case of transient apical ballooning triggered by admin-istration of antibiotics (cephalosporin). We therefore hypothesize thatallergic activation induced by antibiotic and featured by increased IgElevels may be related to TT phenomenon, as previously reported [2].RV apical ballooning, as found in this patient, was reported in 25% ofcases with TT syndrome [3].The exact mechanism leading to transient apical systolic dysfunc-tion is still not well elucidated. Increased catecholamine levels werethoughas responsible [4] , but also coronaryspasm has been reportedin subjects showing TT phenomenon [5].Several prior reports linked TT syndrome to bronchial asthma [6]anaphylactic reaction [7,8] and even cephalosporin administration[9], although in all these cases apical systolic dysfunction usually fol-lowed administration of i.v. epinephrine. We therefore postulate inthis patient a catecholamine independent pathway leading to TT phe-nomenon. Direct histamine effect consequent to allergic activationmay be presumed as responsible for transient apical dysfunction.Two cases of profound reversible myocardial dysfunction occurring inthe setting of anaphylaxis, with histamine discussed as a potential myo-cardial depressor, were previously reported [10]. Raper et al. noted thatstimulation of histamine receptors in both animal and human hearts ex-perimentally leads to myocardial depression, providing a possibleexplaining mechanism for our findings.References

Troponin in newborns and pediatric patients.

Cardiac troponin represents a sensitive and specific marker of ischemic myocardial damage in adult and neonatal populations. Cardiac function in neonates could be influenced by the severity of respiratory distress and its ventilatory management. This short review summarizes the experimental and clinical evidence regarding the role of cardiac troponin in assessment of cardiac function, in following findings: neonatal intensive care, respiratory distress syndrome, asphyxia, congenital heart disease and post cardiac surgery.

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.

Combined exogenous and endogenous catecholamine release associated with Tako-Tsubo like syndrome in a patient with atrio-ventricular block undergoing pace-maker implantation.

We report the case of a 65-year-old woman with complete atrio-ventricular block who underwent orciprenaline administration and pacemaker implantation. The intervention was complicated by pneumothorax and acute left ventricular systolic dysfunction with typical apical ballooning (Tako-Tsubo like syndrome). The patient was treated with diuretics and calcium-sensitizers and completely recovered. We speculate that both external and internal catecholamine triggered an acute left ventricular impairment with typical Tako-Tsubo features.

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.

Tako-Tsubo cardiomyopathy in a teen girl with pheochromocytoma

A 17-year-old adolescent woman with hypertension related to a pheochromocytoma was admitted to the intensive care unit with epigastric pain, headache, psychomotor agitation, nausea, and vomiting. Arterial blood pressure was 170/140 mmHg and heart rate was 170 bpm. The ECG showed sinus tachycardia with ST-segment elevation in anterior and inferior leads (V3–V6, DII, DIII, and aVF) (Fig. 1a and b). Trans-thoracic echocardiography unexpectedly showed severe left ventricular dysfunction (ejection fraction 20%) with apical dyskinesis and basal hyperkinesis (apical ballooning) (Fig. 1c, video 1). Troponin-I levels were mildly elevated (1.56 ng/ml, n.v. 0.03), NTBNP 8850 pg/ml (n.v. b900), urinary noradrenaline 2945 μg/24 h (n.v. b85.5), and C-reactive protein 12.28 mg/L (n.v. b5). The patient, on the basis of a prior diagnosis of pheochromocytoma, was therefore treated with alpha and beta-1-adrenergic blockers (doxazosin, esmolol). The girl gradually recovered and 7 days later was discharged with a normal ECG and echocardiography showing improved left ventricular ejection fraction (>55%) (Fig. 1d and e, video 2). The patient eventually underwent excision of the adrenal mass one month later; histology confirmed the adrenal mass to be a pheochromocytoma. Pheochromocytomas are rare neuro-endocrine catecholaminesecreting tumors with a highly variable clinical presentation but most