Acute cardiac sympathetic disruption and left ventricular wall motion abnormality in takotsubo syndrome

Abstract

Takotsubo syndrome (TS) is characterized by a unique pattern of transient circumferential left ventricular wall motion abnormality (LVWMA). The LVWMA in TS may be localized to the apical, mid-apical, mid-ventricular, mid-basal or basal regions of the left ventricle. Focal and generialized (global) LVWMA have also been reported. In the acute phase of TS, the hyperkinetic valve-like motion of the basal segments and/or the hyperkinetic slingshot-like motion of the apical segments combined with the firm stunned a-, hypokinetic segments result in a conspicuous left ventricular ballooning during systole. The LVWMA in TS follows most probably the local cardiac sympathetic nerve distribution and caused by local cardiac sympathetic disruption and noradrenaline spillover.     

Long-term survival in patients with mild or moderate impairment of left ventricular contractility during routine diagnostic left ventriculography

Long-term survival in patients with mild to moderate impairment of left ventricular contractility in the absence of coronary artery disease has not been studied extensively but the prognosis is assumed to be good. One hundred sixty-eight patients with angiographic evidence of mild or moderate impairment of left ventricular contractility and no other significant cardiac disease at the time of routine diagnostic cardiac catheterization were studied to determine long-term survival and event-free survival. Clinical characteristics, electrocardiograms, chest X-rays, laboratory data, and hemodynamics including end-diastolic volume, end-systolic volume, stroke volume, ejection fraction, and regional wall motion at the time of catheterization were examined. Patients with moderate impairment were more likely to have dyspnea (P = 0.005) and an abnormal electrocardiogram (P = 0.006) than patients with mild impairment. Mean ejection fraction was 57% (P = 0.0001 vs. normal) in patients with mild impairment and was 47% (P = 0.0001 vs. normal) in patients with moderate impairment. Wall motion studies showed impairment to be generalized and more significantly abnormal in patients with moderate impairment. Survival at a mean of 138 months could be determined in 162 of the 168 patients (96%). Fourteen year actuarial survival was 92% for patients with mild impairment compared to 75% for patients with moderate impairment (P = 0.01). Long-term prognosis is good in patients found to have mild generalized impairment at the time of routine diagnostic cardiac catheterization. In patients with moderate impairment, closer follow-up to prevent arrhythmia and the onset of congestive heart failure appears to be warranted. Cathet. Cardiovasc. Diagn. 44:283–290, 1998. © 1998 Wiley-Liss, Inc.     

Pregnancy-induced severe left ventricular systolic dysfunction in a patient with hypertrophic cardiomyopathy

This paper reports the first case of hypertrophic cardiomyopathy (HCM) that developed postpartum congestive heart failure (CHF) and severe left ventricular (LV) systolic dysfunction. Review of the literature and clinical implications are discussed.     

Clinical and echocardiographic analysis of patients suffering from recurrent takotsubo cardiomyopathy

Background Recurrence of takotsubo cardiomyopathy (TTC) is a well-known complication. However, current literature lists only a few isolated cases. We aimed to determine the incidence and clinical significance of recurrent TTC. Methods & Results Our institutional database constituted a collective of 114 patients diagnosed with TTC since 2003. Close follow-up of these patients revealed a recurrence of TTC in seven of these (6.1%). The time interval between the index event and its recurrence varied between six months and six years. Arterial hypertension was more revealed in the recurrence group of TTC compared to non-recurrence group, (P = 0.02). Chronic obstructive pulmonary disease and/or asthma was more diagnosed in the recurrence group, (P = 0.04). Clinical events like right ventricular involvement, TTC related complications such as life-threatening arrhythmias, pulmonary congestion and in hospital death were observed more frequently in the recurrent episode. Over a mean follow-up of one year the mortality rate was similar in both groups. Conclusions Recurrence of TTC with?in six years after index event is not an uncommon phenomenon. In the event of right ventricular involvement in the relapse phase, it might be associated with a higher complication rate. TTC recurrence should be the first differential diagnosis in patients with a past history of TTC.     

The clinical quandary of left and right ventricular diastolic dysfunction and diastolic heart failure

Summary

Diastolic heart failure is a common clinical entity that is indistinguishable from systolic heart failure without direct evaluation of left ventricular function. Diastolic heart failure is a clinical diagnosis in patients with signs and symptoms of heart failure but with preserved left ventricular function and normal ejection fraction, and is often seen in patients with a long-standing history of hypertension or infiltrative cardiac diseases. In contrast, diastolic dysfunction represents a mechanical malfunction of the relaxation of the left ventricular chamber that is primarily diagnosed by two-dimensional transthoracic echocardiography and usually does not present clinically as heart failure. The abnormal relaxation is usually separated in different degrees, based on the severity of reduction in passive compliance and active myocardial relaxation. The question whether diastolic dysfunction ultimately will lead to diastolic heart failure is critically reviewed, based on data from the literature. Treatment recommendations for diastolic heart failure are primarily targeted at risk reduction and symptom relief. Currently, few data only are reported on diastolic dysfunction and its progression to systolic heart failure.     

Incidence and angiographic characteristics of patients With apical ballooning syndrome (takotsubo/stress cardiomyopathy) in the HORIZONS‐AMI trial

Objectives : To determine the incidence, clinical characteristics, and the coronary angiographic features of patients with apical ballooning syndrome (ABS) among those recruited into a large, prospective, international, multicenter trial. Background : ABS is an important entity in the differential diagnosis of ST‐elevation myocardial infarction (STEMI). Current data regarding ABS are limited to single center registries. Methods : Patients with ABS were identified, based on the Mayo Clinic diagnostic criteria, from those enrolled into the HORIZONS‐AMI trial. Quantitative angiography was performed by a core laboratory to identify the frequency and severity of coronary artery disease. Results : Among the 2,648 patients who had left ventriculography in addition to coronary angiography, 12 patients were identified with ABS. All patients were female and they were compared to the remaining 571 female patients with STEMI. Compared with patients with STEMI (97.9% of our cohort), patients with ABS (2.1%) had a lower prevalence (42% vs. 100%, P < 0.05) and severity (number of plaques measuring >30% diameter stenosis per patient: 0.58 ± 0.90 vs. 4.13 ± 2.68, P < 0.0001) of coronary artery disease. There were no in‐hospital deaths or major adverse cardiovascular events (MACE) in the ABS group vs. 2.1% and 3.7% respectively in the STEMI group, nor at 2‐year follow up (death: 0% vs. 5.5%, MACE: 0% vs. 19.4%), but these differences were not statistically significant. Conclusions : In HORIZONS‐AMI, ABS was identified exclusively in women (2.1% of female patients, 0.5% of all patients) and MACE were absent in this uncommon but important group of patients. Coronary artery disease was often present in patients with ABS, but its prevalence and severity was significantly less compared with STEMI patients. © 2011 Wiley Periodicals, Inc.     

The mechanics of left ventricular dysfunction in patients with Churg-Strauss syndrome

Background: Heart is frequently involved in Churg‐Strauss syndrome (CSS). However, the mechanics of left ventricular (LV) dysfunction in CSS has not been studied. Objective: To assess the mechanics of LV function and to characterize the contribution of longitudinal, circumferential and rotational deformation to LV dysfunction in CSS. Methods: We enrolled 22 CSS patients (eight males, mean age 43.2 ± 9.5 years) in remission of their disease and 22 sex‐ and age‐matched healthy subjects. All patients underwent conventional and two‐dimensional speckle‐tracking echocardiography. Global longitudinal, circumferential and rotational deformation parameters were calculated. Results: CSS subjects demonstrated lower LV ejection fraction (EF) than controls (56.6 ± 15.0% vs 63.8 ± 3.4%; P < 0.05). When compared to those with LVEF ≥ 50% (n = 14), CSS patients with LVEF < 50% (n = 7) had decreased global peak‐systolic longitudinal and circumferential strain/strain rate (all P < 0.001) and tended to have lower global peak‐systolic radial strain (P = 0.05). There were no differences between these two subgroups in global peak‐systolic radial strain rate and LV twist/torsion. When comparing individual systolic and diastolic parameters early diastolic longitudinal and circumferential strain rate demonstrated the highest correlation with corresponding global longitudinal and circumferential peak‐systolic strain/strain rate (r < ?0.80, P < 0.001 for all correlations). Conclusions: In CSS LV systolic dysfunction strongly correlates with longitudinal and circumferential, but not radial or rotational systolic components, indicating that impaired LV systolic function may result predominantly from impaired contraction of inner and middle, but not outer myocardial fiber layers. The spatial correspondence between systolic and diastolic deformation parameters suggests the similar impact of pathologic process on systolic and diastolic function in CSS. (Echocardiography 2012;29:568‐578)     

Congestive heart failure with preserved left ventricular systolic function after acute myocardial infarction: clinical and prognostic implications

AIMS: To characterise the prevalence, in-hospital complications, management, and long-term outcome of patients with congestive heart failure but preserved left ventricular systolic function after acute myocardial infarction. METHODS: 3166 consecutive patients screened for entry in the Bucindolol Evaluation in Acute Myocardial Infarction Trial with definite acute myocardial infarction and echocardiographic assessment of left ventricular systolic function were included between 1998 and 1999 in this prospective observational study. Main outcome measures were occurrences of in-hospital complications and all cause mortality. RESULTS: Congestive heart failure was seen during hospitalisation in 1464 patients (46%), 717 patients had preserved left ventricular systolic function (wall motion index > or =1.3 corresponding to ejection fraction > or =0.40), and 732 patients had systolic dysfunction (wall motion index <1.3). One year mortality in patients with no heart failure, heart failure with preserved systolic function, and heart failure with systolic dysfunction were 6, 22 and 35%, P<0.0001. Unadjusted risk of death from all causes associated with heart failure and preserved systolic function was 3.3 (95% CI 2.8-4.0), and after adjustment for baseline characteristics and left ventricular systolic function in multivariate Cox proportional hazards analysis the risk was 2.1 (95% CI 1.7-2.6), P<0.0001. CONCLUSIONS: Congestive heart failure is frequently present in patients with preserved left ventricular systolic function, and is associated with increased risk of in-hospital complications and death following acute myocardial infarction.     

Hemodynamic assessment of prenalterol: A cardioselective beta agonist in patients with impaired left ventricular function

The hemodynamic effects of a new cardioselective beta agonist, prenalterol, were evaluated in 12 patients with moderate or severe impairment of left ventricular function due to coronary heart disease or primary cardiomyopathy. In doses up to 7 mg the drug led to a substantial increase of left ventricular pressure rise (+55%) and mean circumferential fiber shortening (+59%) and a decrease of left ventricular end-diastolic pressure (–52%), mean pulmonary artery pressure (–24%) and pulmonary vascular resistance (–37%) indicating augmented myocardial contractility and reduced left ventricular preload. Cardiac output was increased only in 4 of 12 patients, heart rate, left ventricular systolic and mean right atrial pressures and the pressure-rate product as an index for myocardial oxygen demand remained essentially unchanged. The same is true for stroke index, stroke work index, total peripheral resistance, left ventricular end-diastolic and end-systolic volume and ejection fraction. The positive inotropic effect was achieved with good tolerance and without arrhythmogenic or other side effects. Prenalterol may be especially useful in patients with low sympathetic activity and hypotension. In patients with diffuse congestive cardiomyopathy, high sympathetic activity, pronounced peripheral vasoconstriction and normal blood pressure, vasodilator therapy alone or in combination with prenalterol should be considered.     

应用斑点追踪成像技术评价心力衰竭患者左室短轴二维应变

目的:应用斑点追踪成像技术（STI）测量正常人及慢性心力衰竭患者(HF)左室短轴各节段二维应变,探讨STI技术评价HF患者左室功能的临床价值。方法: 采集HF患者及对照组左室短轴(二尖瓣、乳头肌、心尖水平)二维高帧频图像,测量各节段的收缩期径向应变（Rs）、环向应变（Cs）。结果: 对照组Rs在同一水平各节段间差异无统计学意义,乳头肌水平显著高于心尖水平,Cs在同一水平各节段间差异有统计学意义（P<0.05）。HF组各短轴水平整体Rs、Cs及各节段的Rs、Cs均显著低于对照组（P<0.01）。结论: HF患者左室各短轴水平及各节段收缩期径向及环向应变均明显低于正常人,提示其左室短轴收缩功能明显受损。     

Cardiodepressant effects of mexiletine in patients with severe left ventricular dysfunction.

Mexiletine is thought to exert minimal negative inotropic actions, but its effects have not been evaluated in patients with severe congestive heart failure. The haemodynamic response to an oral loading dose of mexiletine (400 mg) was assessed in 20 patients with severe chronic heart failure. Mexiletine caused marked haemodynamic deterioration, with stroke work index decreasing in 18 of the patients. Two hours after mexiletine, mean cardiac and stroke work indexes decreased by 15% and 25%, respectively (both P less than 0.001), while heart rate and systemic vascular resistance increased by 10% and 20%, respectively (both P less than 0.05). Simultaneously, left ventricular filling pressure and right atrial pressure increased by 37% and 36%, respectively (both P less than 0.001), but mean arterial pressure did not change. Furthermore, clinical deterioration, with onset of dyspnoea at rest, developed in five patients at the time of peak haemodynamic effect. Plasma mexiletine concentrations were within the accepted therapeutic range of 0.5 to 2.0 micrograms.ml-1 in all but two of the patients. Nevertheless, the plasma concentration was an important determinant of haemodynamic effect. The stroke work index decreased by 38% in the patients with a mexiletine level above the median value of 1.3 micrograms.ml-1 (range 25 to 56%), but only 13% (range 15 to 43) in patients with lower plasma concentrations. In conclusion, although mexiletine may cause cardiodepressant effects in any patient with severe left ventricular dysfunction, dosing which results in a high (but still therapeutic) plasma level is more likely to cause haemodynamic deterioration.     

Reverse Takotsubo Cardiomyopathy following Exogenous Epinephrine Administration in the Early Postpartum Period

Takotsubo cardiomyopathy (TCM) is typically triggered by stress and can often mimic acute myocardial infarction. It is typically characterized by ballooning of the apex of the left ventricle following emotional or physical stress. Reverse TCM is a rare variant in which the cardiac apex is hyperkinetic and ballooning occurs at the base of the heart. We present a case of reverse TCM in the immediate postpartum period following an injection of local epinephrine, followed by spontaneous resolution within 24 hours.     

Dofetilide in patients with left ventricular dysfunction and either heart failure or acute myocardial infarction: Rationale,design, and patient characteristics of the DIAMOND studies

Background: Attempts to prolong life with antiarrhythmic drugs in patients at increased risk of sudden cardiac death have so far been disappointing or inconclusive. Hypothesis: The Danish Investigations of Arrhythmia and Mortality ON Dofetilide (DIAMOND) encompass two survival studies testing the prophylactic use of the selective potassium-channel blocker, dofetilide, in patients at high risk of sudden death. Methods: The first study includes patients admitted to hospital with congestive heart failure (CHF), the other includes patients with acute myocardial infarction (MI) within the previous 7 days. In both studies patients must have left ventricular systolic dysfunction (ejection fraction 35%) determined by echocardiography. Each of the two studies are planned to enroll 1500 patients. Consecutive hospitalized patients with MI or CHF are screened in 37 Danish hospitals. Eligible patients are randomized to receive dofetilide or matching placebo. All patients are continuously monitored by telemetry for the first 3 days of the study to detect possible arrhythmic events and to ensure resuscitation in case of serious arrhythmias. Minimum duration of follow-up is 12 months. Results: Between November 1993 and July 1996, a total of 5812 consecutive patients with CHF and 8688 consecutive patients with MI was screened for entry. Of these, 1518 patients were included in the CHF study and 1510 patients in the MI study. Overall 1-year mortality of randomized patients were 28 and 22%, respectively. Conclusion: DIAMOND will provide important data on the safety and efficacy of dofetilide in high-risk patients with left ventricular dysfunction and either CHF or MI, as well as evaluate tolerability in these populations.     

Beneficial clinical effect of very early enalapril treatment in patients with acute left ventricular failure complicating myocardial infarction

Acute myocardial infarction (AMI) leads to left ventricular dysfunction, the extent of which predicts mortality. We studied the effect of very early enalapril treatment in patients with left ventricular failure (Killip classification II-III) resulting from AMI. In a double-blind randomized trial, patients on conventional treatment were started on placebo (PL, n = 15) or 2.5 mg enalapril (EN, n = 15) twice daily as early as 24 to 30 h after AMI and were followed up over a period of 21 days. One patient died in each treatment group. There were three dropouts in the placebo group (progressive heart failure requiring antiotensin-converting enzyme inhibition) and one dropout in the enalapril group (malignant ventricular arrhythmias). Plasma atrial natriuretic peptide (ANP) and norepinephrine decreased similarly in both groups from elevated baseline concentrations. The patients with the highest baseline ANP levels died in both groups: EN: 579 fmol/ml (mean 65.3 ± 34.4 fmol/ml), PL: 403 fmol/ml (mean 63.5 ± 37.6 fmol/ml). Killip classification improved in 9 of 13 patients on enalapril but only in 5 of 11 patients on placebo. On echocardiography an increase in fractional shortening (FS) (3.2 ± 7.5%, p < 0.05) was found with enalapril only. Patients on placebo required more diuretics, and plasma aldosterone increased threefold. Thus, very early enalapril treatment may help prevent left ventricular failure after AMI. Extremely high initial plasma ANP concentrations may predict an unfavorable outcome.     

Anaemia is an independent predictor of mortality in patients with left ventricular systolic dysfunction following acute myocardial infarction

BACKGROUND: In patients with chronic heart failure (HF), mortality is inversely related to haemoglobin (hgb) concentration. We investigated the prognostic importance of anaemia in patients with acute myocardial infarction (AMI) and left ventricular systolic dysfunction (LVSD) with and without HF. METHODS AND RESULTS: We studied 1731 patients with AMI and left ventricular ejection fraction 相似文献   

急性左心衰患者50例院前急救临床分析

目的探讨急性左心衰患者院前急救的临床效果。方法回顾性分析98例急性左心衰患者的临床资料,其中院前急救组（A组）50例,自行来院就诊患者为对照组（B组）48例,对两组有效救治的时间、治疗效果及病死率进行比较。结果A组从发病到救治的时间显著早于B组[（10．52±2．11）min比（45．23±5．23）min．P〈0．05]。A组治疗1h后有效率优于B组,差异有统计学意义（96％比79％,P〈0．05）。A组24h内病死率明显低于B组的,差异有统计学意义（2．16％比4．52％,P〈0．05）。结论院前急救可较早改善急性左心衰患者的临床症状,阻止病情恶化,降低病死率。