Does surgical relief of obstruction improve prognosis for hypertrophic cardiomyopathy?

Unique genetic characteristics of hypertrophic cardiomyopathy (HCM), including heterogeneity and incomplete penetrance, have made making predictions about prognosis complex. We reviewed data from septal myectomy results as published from 1980 to 2011, most of which come from specialized tertiary care centers. We also performed a retrospective review of 132 consecutive patients who underwent HCM surgery at our institution. At a mean follow-up of 4.2 ± 3.2 years (range, 3 days to 14.2 years), there were no deaths within 30 days of surgery for our cohort. Over the course of 15 years, 2 deaths occurred in older patients, both of whom had surgery for HCM along with additional cardiac procedures. Age, the presence of comorbidities, and concomitant cardiac procedures were not statistically significant risk factors for mortality. Overall survival at 1, 5, and 10 years was excellent: 99%, 99%, and 92%, respectively. Surgical myectomy has been proven to be a safe and effective procedure for symptomatic obstructive HCM, and it confers excellent survival similar to that of the healthy population.     

Does sports activity enhance the risk of sudden death in adolescents and young adults?

OBJECTIVES: We sought to assess the risk of sudden death (SD) in both male and female athletes age 12 to 35 years. BACKGROUND: Little is known about the risk of SD in adolescents and young adults engaged in sports. METHODS: We did a 21-year prospective cohort study of all young people of the Veneto Region of Italy. From 1979 to 1999, the total population of adolescents and young adults averaged 1,386,600 (692,100 males and 694,500 females), of which 112,790 (90,690 males and 22,100 females) were competitive athletes. An analysis by gender of risk of SD and underlying pathologic substrates was performed in the athletic and non-athletic populations. RESULTS: There were 300 cases of SD, producing an overall cohort incidence rate of 1 in 100,000 persons per year. Fifty-five SDs occurred among athletes (2.3 in 100,000 per year) and 245 among non-athletes (0.9 in 100,000 per year), with an estimated relative risk (RR) of 2.5 (95% confidence interval [CI] 1.8 to 3.4; p < 0.0001). The RR of SD among athletes versus non-athletes was 1.95 (CI 1.3 to 2.6; p = 0.0001) for males and 2.00 (CI 0.6 to 4.9; p = 0.15) for females. The higher risk of SD in athletes was strongly related to underlying cardiovascular diseases such as congenital coronary artery anomaly (RR 79, CI 10 to 3,564; p < 0.0001), arrhythmogenic right ventricular cardiomyopathy (RR 5.4, CI 2.5 to 11.2; p < 0.0001), and premature coronary artery disease (RR 2.6, CI 1.2 to 5.1; p = 0.008). CONCLUSIONS: Sports activity in adolescents and young adults was associated with an increased risk of SD, both in males and females. Sports, per se, was not a cause of the enhanced mortality, but it triggered SD in those athletes who were affected by cardiovascular conditions predisposing to life-threatening ventricular arrhythmias during physical exercise.     

Does prior PCI increase the risk of subsequent CABG?

Chocron and colleagues have reported that prior percutaneouscoronary intervention (PCI) leads to a worse outcome in patientssubsequently undergoing coronary artery bypass graft (CABG).¹In view of the fact that around one-third of patients with multivesseldisease treated with bare metal stents will require re-interventionwithin a few years,² this conclusion is potentially worryingand raises several questions. (i) Is the conclusion justifiable?(ii) Are the findings consistent with other studies in the literature?(iii) If real, what are the likely pathophysiological mechanisms?(iv) Will the findings be different drug-eluting stents? (v)What are the clinical implications for patients and the economicimplications for health services? Is the conclusion justifiable? The obvious weakness of the study of     

Does diuretic therapy increase the risk of renal cell carcinoma?

Several studies have suggested that systemic hypertension as a disease or its therapy could increase the risk for malignancies. Diuretics reduce cardiovascular morbidity and mortality and constitute a cornerstone in the antihypertensive arsenal. To analyze the relation between diuretic therapy and the risk of malignancies, we conducted a comprehensive review of pertinent previous publications by searching the MEDLINE database for related articles in all languages published between January 1966 and April 1998. Within the past decade, we found 9 case control studies and 3 cohort studies in which the relation between diuretic use and renal cell carcinoma was examined. In the case control studies, the odds ratio of renal cell carcinoma occurring in patients treated with diuretics averaged 1.55 with a 95% confidence interval of 1.42 to 1.71 (p <0.00001) compared with nonusers of diuretics. In the 3 cohort studies of 1,226,229 patients, diuretic therapy was associated with a more than twofold risk of renal cell carcinoma when compared with patients not on diuretics. In 1 cohort study, and in the 7 case control studies in which the effects of gender were reported, women had a higher odds ratio (2.01, confidence interval 1.56 to 2.67) than men (1.69 confidence interval 1.34 to 2.13). Thus, cumulative evidence, possibly stronger in women than in men, suggests that the long-term use of diuretics may be associated with renal cell carcinoma. Although diuretics remain the best documented drug class to reduce morbidity and mortality in systemic hypertension, our data suggest a need for continued vigilance to assess the risk-benefit ratio of all drugs used for long-term therapy of cardiovascular disorders.     

Intractable cardiogenic shock in stress cardiomyopathy with left ventricular outflow tract obstruction: is extra‐corporeal life support the best treatment?

We report the use of extra‐corporeal cardiopulmonary support (ECLS), in a case of complicating refractory severe cardiogenic shock, in a patient with Tako‐tsubo cardiomyopathy (TC). Tako‐tsubo cardiomyopathy syndrome is characterized by left ventricular (LV) wall motion abnormalities, usually without coronary artery disease, mimicking the diagnosis of acute coronary syndrome. This ventricular dysfunction is typically reversible in the acute phase, though it can progress into refractory cardiogenic shock with limited therapeutic options available. Here, we report for the first time in a Tako‐tsubo patient with refractory cardiogenic shock, the use of ECLS treatment in order to unload the heart, sustain circulation and end‐organ perfusion, and promote potential ventricular recovery. Extra‐corporeal life support allowed inotropic drug weaning while maintaining end‐organ function and supported the patient until myocardial recovery. The patient recovered completely, and a normal LV ejection fraction was documented by 2D echocardiography on day 7. From our experience, ECLS can be an appropriate treatment for severe refractory cardiogenic shock in patients with TC. Extra‐corporeal life support was an effective ultimate solution.