Severo Torres

Intramyocardial dissecting haematoma: a rare complication of acute myocardial infarction

Intramyocardial dissecting haematoma (IDH) is a rare complication of myocardial infarction, with very scarce reports in medical literature. Before the advent of non-invasive imaging techniques, the diagnosis of IDH was only made by necropsy. It can develop in the left ventricular free wall, the right ventricle, or the interventricular septum. We present a case of a patient with an IDH after acute anterolateral myocardial infarction, focusing on the utility of echocardiography in the diagnosis and follow-up of this unusual complication. By this imaging modality, it was possible to see the various acoustic densities of the progressive clotting of the intramyocardial haematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Based on this report, we believe that serial two-dimensional echocardiography, added, when necessary, by the use of contrast agents is the non-invasive method ideally suited to confirm the diagnosis and monitor its evolution at the patients bedside.

Stunned Myocardium following Ischemic Stroke

Neuromediated stunned myocardium is a well-known complication of subarachnoid hemorrhage but has rarely been reported in association with other central nervous system disorders. The pathophysiology of this entity remains unclear, but a catecholamine-induced neurocardiogenic injury has been proposed as a causal factor. Typically, patients have rapid full cardiovascular recovery within a few days. We report a case of ischemic stroke, coexisting with ischemic electrocardiographic changes, increased cardiac-specific necrosis biomarkers, regional wall motion abnormalities and a cardiac SPECT consistent with inferior myocardial infarction despite normal coronary arteries. Interestingly, left-ventricular dysfunction in this case persisted longer than usually described despite full neurologic recovery. This case also illustrates the diagnostic challenges posed by this entity which frequently mimics acute myocardial infarction and emphasizes the investigation needed in this area.

Adiponectin Levels Are Elevated in Patients With Pulmonary Arterial Hypertension

In addition to insulin‐sensitizing effects, adiponectin influences several mechanisms involved in pulmonary arterial hypertension (PAH) pathobiology. Insulin resistance has been associated with PAH, and elevated adiponectin levels have been described in left heart failure (HF) as a response to the increased metabolic stress. No studies have been performed in right HF or PAH patients.

Cardiac Rehabilitation after an Acute Coronary Syndrome: The Impact in Elderly Patients

Introduction: Cardiac rehabilitation (CR) has been shown to decrease mortality and morbidity, improve the control of risk factors and the quality of life of patients with coronary artery disease. However, the elderly are underrepresented in most studies and in real-life CR programs. Our goal was to evaluate the impact of CR after an acute coronary syndrome in the elderly population. Methods: A cutoff of 65 years was used to dichotomize age. Our main focus was on the effects of ambulatory supervised exercise training on several surrogate markers, namely total cholesterol, low- and high-density lipoprotein cholesterol, triglycerides, body mass index, fasting glucose, glycated hemoglobin, probrain natriuretic peptide, International Physical Activity Questionnaire score, maximal exercise capacity, chronotropic response index and heart rate recovery. We evaluated those variables at the beginning and at the end of phase II of the CR program (after 3 months) and repeated the treadmill test at 12 months. Results: A total of 548 patients with a recent acute coronary syndrome were enrolled; 37% were 65 years old or older. Both age groups had a statistically significant improvement in all the evaluated parameters. Interestingly, at 12 months both groups maintained the improvement in functional capacity seen immediately after 3 months. Conclusions: The benefits of CR in terms of functional capacity, metabolic profile and other prognostic parameters were significant in both younger and older patients. Therefore, all eligible patients should be referred to CR programs, irrespective of age.

Lack of Benefit of Ischemic Postconditioning After Routine Thrombus Aspiration During Reperfusion Immediate and Midterm Results

Objectives: The underutilization of manual thrombus aspiration (MTA) may have reduced the benefits of ischemic postconditioning (PostCon), as it reduces thrombus embolization. We aimed to assess the benefits of PostCon in patients with ST-segment elevation myocardial infarction (STEMI) after the systematic utilization of MTA. Methods: A total of 87 patients were enrolled in a prospective, randomized trial (43 PostCon and 44 controls). After MTA, PostCon was performed on the treatment group by applying 4 cycles of alternate reperfusion and reocclusion (60 seconds each) using the angioplasty balloon. The primary end point was infarct size assessed by the area under the curve (AUC) of troponin T (TnT) activity. The secondary end points were left ventricle ejection fraction (LVEF) and major cardiac events (new myocardial infarction or cardiac death) both at discharge and at follow-up. Results: The AUC for TnT was no different with respect to study arms (median [interquartile range]): PostCon = 8.9 (10.6) versus control = 8.2 (10.6), P = .68. Left ventricle ejection fraction improved from in-hospital to follow-up (9 ± 3 months) for the entire cohort (46.3% ± 7.3% vs 52.2% ± 10.7%, P < .001), with no differences between PostCon and controls (51.6% ± 9.5% vs 52.7% ± 11.9%, P = .89); major cardiac events at 14 ± 4 months of follow-up were also no different (PostCon = 1.0 (2.3%) vs control = 0, P = .49). Conclusion: In patients with STEMI treated with MTA, PostCon offered no benefits to infarct size, LVEF, or major cardiac events.

Hyponatremia – an unusual trigger of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.

Preinfarction angina: clinical significance and relationship with total ischemic time in patients with ST-elevation myocardial infarction.

ObjectivesPreinfarction angina (PIA) may play a protective role in patients with ST-elevation myocardial infarction. Data on the relationship between PIA and time to reperfusion are scarce. We aimed to assess infarct size by peak troponin-T (TnT) in patients with or without PIA in three different time intervals to a primary percutaneous coronary intervention (PPCI), the relationship between PIA and left ventricular ejection fraction, and its impact on midterm survival. Patients and methodsSingle-center, retrospective analyses were carried out of 575 consecutive PPCI-treated patients, divided into three groups from symptom onset to reperfusion: less than 3, 3–6, and greater than 6 h. ResultsPatients with PIA had smaller infarct size [TnT=3.76 (5.07) vs. 5 (6.12) ng/ml, P=0.024]. Infarct size of patients with PIA versus no-PIA was lower for patients presenting within 3–6 h from onset of symptoms [3.73 (5.38) vs. 5.53 (6.9) ng/ml, P=0.028], but not different for those who presented less than 3 h [4.15 (5.53) vs. 4.0 (3.96) ng/ml, P=0.702] nor for those who presented greater than 6 h [3.65 (4.24) vs. 5.0 (5.9) ng/ml, P=0.141]. On multivariate analyses, only PIA protected from moderate to severe left ventricle dysfunction (odds ratio=0.557, 95% confidence interval: 0.352–0.881, P=0.012), but failed to reduce overall mortality [hazard ratio=0.784, 95% confidence interval: 0.356–1.724, P=0.545; median follow-up time=23 (20) months]. ConclusionPPCI-treated patients within 3–6 h from symptom onset had smaller infarcts if they had experienced PIA, with no benefit for those who presented less than 3 h nor for those who presented greater than 6 h from symptom onset. Moderate to severe left ventricle dysfunction was less prevalent in PIA patients. However, PIA failed to have an independent impact on midterm survival.

A trombectomia aspirativa na reperfusão do enfarte agudo de miocárdio: preditores e impacto clínico da sua ineficácia

INTRODUCTION AND OBJECTIVES The benefit of manual thrombus aspiration (TA) in the reperfusion of patients with ST-elevation myocardial infarction (STEMI) has been hotly debated. In most series, failure of TA has been largely unreported. Our objectives were to assess the rate, predictors, and impact on cumulative mortality of failed TA during primary percutaneous coronary intervention (PPCI). METHODS This was a single-center, retrospective study of consecutive STEMI patients undergoing PPCI with TA. TA was considered ineffective if, before angioplasty, coronary flow was TIMI <2. Independent predictors of TA failure were assessed by logistic regression, and predictors of cumulative mortality were assessed by Cox regression analysis. RESULTS Of 574 patients, TA was used in 417 (72.6%), and was effective in 365 (87.5%) and ineffective in 52 (12.5%). On multivariate analysis, SYNTAX score (OR=1.049, 95% CI: 1.015-1.084, p=0.005) and total ischemic time (OR=1.001, 95% CI: 1.000-1.003, p=0.02) were independent predictors of TA failure. Moderate or severe left ventricular dysfunction (HR=6.256, 95% CI: 1.896-20.644, p=0.003), APPROACH score (HR=1.094, 95% CI: 1.016-1.177, p=0.017), Killip class III/IV (HR=2.953, 95% CI: 1.122-7.770, p=0.028) and creatinine clearance on admission (HR=0.973, 95% CI: 0.953-0.994, p=0.011) were independently related to cumulative mortality at 24 ± 0.82 months. CONCLUSIONS Total ischemic time and SYNTAX score were independent predictors of TA failure. However, in medium-term follow-up, ineffective manual TA was not independently related to cumulative mortality.

Left-sided infective endocarditis: Analysis of in-hospital and medium-term outcome and predictors of mortality

INTRODUCTION Despite diagnostic and therapeutic advances, infective endocarditis (IE) remains a challenging and potentially lethal disease. The prognosis of IE remains poor; in the last 30 years, its incidence and mortality have only been marginally reduced. Early identification of high-risk patients can change the course of the disease and improve outcomes. OBJECTIVES AND METHODS To describe and investigate predictors of mortality during hospital stay and in the six months after discharge in a cohort of left-sided IE patients in two tertiary centers. All patients diagnosed with IE (ICD9 code 133) were registered in a uniform database. RESULTS One hundred and forty-seven consecutive case patients with left-sided IE were included in this study. Thirty-five patients (23.8%) died during hospital stay. The variables significantly associated with increased mortality in univariate analysis were Charlson index ≥ 5, use of immunosuppressants, sepsis (severe sepsis and/or septic shock), cardiogenic shock and inappropriate use of antibiotic therapy. Conversely, surgical therapy and hospital length of stay ≥ 30 days were significantly associated with lower mortality. In multivariate analysis the most important predictors of in-hospital mortality were sepsis (severe and/or shock), use of immunosuppressants and inappropriate use of antibiotic therapy. There was a significant relation between the use of immunosuppressants and the occurrence of sepsis. The presence of significant valve disease after IE significantly increased the risk of heart failure. CONCLUSIONS Our results may help to identify IE patients at increased risk for in-hospital mortality and medium-term disability. These findings can help to identify candidates for earlier and more aggressive management.

Thyroid storm and arrhythmic storm: a potentially fatal combination.

Thyroid storm is a rare clinical emergency with a mortality rate between 20% and 30%. Cardiac arrhythmias associated with thyrotoxicosis are usually supraventricular. Ventricular arrhythmias are rarely associated with this entity and tend to occur in patients with intrinsic cardiac disease. We present a 35-year-old woman with Graves disease and a thyroid storm manifested with multiple malignant dysrhythmic episodes, without underlying cardiac disease. The mechanism for ventricular arrhythmia is not clear but seems to be due to the increased myocardial excitability directly caused by the thyroid hormones. The presence of myocarditis lesions may constitute an arrhythmogenic substratum and contribute further to this manifestation. This case emphasizes the importance of cardiac monitoring in patients with thyroid storm.