Stress Cardiomyopathy Precipitated by Withdrawal of Epoprostenol.

We describe a case of stress-induced cardiomyopathy following epoprostenol withdrawal. A patient with pulmonary arterial hypertension presented with a malfunctioning Hickman catheter. Inappropriate withdrawal of epoprostenol resulted in shock. Evaluation confirmed stress-induced cardiomyopathy. Restarting epoprostenol resolved the electrocardiographic and echocardiographic abnormalities. This case meets Taskforce on Takotsubo Syndrome Stress-Induced Cardiomyopathy criteria. (Level of Difficulty: Beginner.).

Systemic inflammation and brachial artery endothelial function in the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND AND OBJECTIVE: Inflammation and endothelial dysfunction have been implicated in the pathogenesis of atherosclerotic vascular disease. Brachial artery flow-mediated dilation (FMD) is a reliable, non-invasive method of assessing endothelial function. We hypothesised that increased levels of systemic inflammatory markers are associated with impaired endothelial function as assessed by FMD in a multi-ethnic cohort. METHODS: We assessed brachial artery FMD in 3501 participants (1739 men, 1762 women; median age 61 years) in the Multi-Ethnic Study of Atherosclerosis and measured serum concentrations of interleukin (IL)-6, C reactive protein (CRP) and tumour necrosis factor (TNF)-α receptor 1. Spearman correlation coefficients were used to evaluate the association of each inflammatory marker with FMD, adjusting for the effect of other variables associated with FMD. RESULTS: There was a significant inverse correlation between IL-6 levels and FMD (-0.042; p=0.02) after adjustment for age, gender, race/ethnicity, education, income, low-density lipoprotein, diabetes, glucose, hypertension status and treatment, waist circumference, triglycerides, baseline brachial diameter, recent infection and use of medications that may alter inflammation. There was no significant correlation between CRP and FMD (0.008; p=0.64) or TNF-α receptor 1 and FMD (0.014; p=0.57). There was no evidence of effect modification by race/ethnicity. CONCLUSIONS: In this multi-ethnic cohort, increased levels of the pro-inflammatory cytokine IL-6 were associated with impaired endothelial function assessed by FMD. Elevated IL-6 levels may reflect a state that promotes vascular inflammation and development of subclinical atherosclerosis independent of traditional cardiovascular risk factors.

Ictal bradycardia and atrioventricular block: a cardiac manifestation of epilepsy.

We describe a case of a patient with recurrent syncopal episodes that ultimately was discovered to be due to ictal bradycardia caused by temporal lobe epilepsy. A diagnostic dilemma was presented by a 55-year-old male who had recurrent syncopal events despite having an atrial pacemaker. The patient was noted to have automatisms and was diagnosed via electrocardiogram/electroencephalogram (EEG/ECG) co-registration to have ictal bradycardia and atrioventricular (AV) block leading to syncope. He was successfully managed with seizure control with the use of levetiracetam. Ictal bradycardia and AV block are uncommon manifestations of epilepsy and can progress to complete heart block and asystole. Diagnosis is best performed with simultaneous ECG and EEG recordings. Definitive management is seizure control with the use of antiepileptic drugs, with the question of pacemaker placement still up for debate.

Coffee consumption and incidence of heart failure in women.

BACKGROUND: Previous studies of the relationship between coffee consumption and incidence of heart failure (HF) have not been consistent, with both potential benefit and potential harm reported. We therefore examined the association between coffee consumption and HF hospitalization or mortality in women. METHODS AND RESULTS: We conducted a prospective, observational study of 34 551 participants of the Swedish Mammography Cohort who were 48 to 83 years old and did not have HF, diabetes, or myocardial infarction at baseline. Diet was measured using food-frequency questionnaires. Cox models were used to calculate hazard ratios of HF hospitalization or death from HF as the primary cause, as determined through the Swedish inpatient and cause-of-death registers between January 1, 1998, and December 31, 2006. Over 9 years of follow-up, 602 HF events occurred. Women who consumed ≥5 cups of coffee per day did not have higher rates of HF events than those who consumed <5 cups per day (multivariable-adjusted hazard ratio, 0.93; 95% confidence interval, 0.72 to 1.20). Compared with women who consumed ≤1 cup of coffee per day, hazard ratios were 1.01, 0.82, 0.94, and 0.87 for women who consumed 2, 3, 4, and ≥5 cups per day, respectively (P for trend=0.23). Further adjustment for self-reported hypertension did not change the results. CONCLUSIONS: In this population of middle-aged and older women, we did not find an association between coffee consumption and incidence of HF events.

Coffee consumption and risk of heart failure in men: an analysis from the Cohort of Swedish Men.

BACKGROUND: A previous study found that consuming 5 or more cups of coffee per day was associated with increased incidence of heart failure (HF). We sought to evaluate this association in a larger population. METHODS: We measured coffee consumption using food frequency questionnaires among 37,315 men without history of myocardial infarction, diabetes, or HF. They were observed for HF hospitalization or mortality from January 1, 1998, until December 31, 2006, using record linkage to the Swedish inpatient and cause of death registries. Cox proportional hazards models adjusted for age, dietary, and demographic factors were used to calculate incidence rate ratios (RR) and 95% confidence intervals (CIs). RESULTS: For 9 years of follow-up, 784 men experienced an HF event. Compared to men who drank or=5 cups/d (P for trend in RR = .61). CONCLUSIONS: This study did not support the hypothesis that high coffee consumption is associated with increased rates of HF hospitalization or mortality.

Clinical characteristics and four-year outcomes of patients in the Rhode Island Takotsubo Cardiomyopathy Registry.

The aim was to establish a registry of patients with a diagnosis of Takotsubo cardiomyopathy (TC) to help learn more about the characteristics, treatment strategies, and natural history of this disease. Data for patients with TC diagnosed from July 2004 to April 2008 at 2 major hospitals in Rhode Island were obtained. A data set was created that included baseline demographics and characteristics, hospital, course, and clinical outcomes. TC was diagnosed in 70 patients during the study period. Postmenopausal women comprised 95% of the cohort. Six patients presented with cardiogenic shock, 9 required intubation, 3 experienced sustained ventricular arrhythmias, and 1 patient died of cardiac causes. Average ejection fraction was 37% at cardiac catheterization. Troponin-I was increased in all except 1 patient. Follow-up echocardiography showed full recovery of wall motion abnormalities, with an average ejection fraction of 59%. Most patients were treated using standard cardiovascular medications for acute coronary syndrome, and 43% were discharged on warfarin therapy because of severe apical wall motion abnormalities. Univariate analysis suggested that long-term use of angiotensin-converting enzyme inhibitors before the onset of TC was protective against cardiogenic shock, sustained ventricular arrhythmia, and death. Consecutive cases grouped into different seasons showed a statistically significant spike in the occurrence of TC during the summer months. In conclusion, the acute phase of this condition may lead to critical illness and death, and use of an angiotensin-converting enzyme inhibitor may have a protective effect. Overall long-term prognosis and recovery of left ventricular function were excellent.

Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy is a disease in which patients present with signs and symptoms mimicking an acute coronary syndrome and, thus, undergo cardiac catheterization. At the time of catheterization, however, no critical coronary lesions are found. Most of these patients have a characteristic left ventriculogram and recent history of a preceding stressor. While the acute phase of the illness can lead to ventricular tachyarrhythmias and possibly even death, a key feature of this syndrome in the majority of patients is its generally benign course and reversibility in myocardial dysfunction over a period of days to weeks. The pathophysiology of Takotsubo cardiomyopathy remains unclear. Optimal long-term medical therapy has not been well established at this time, since the etiology of the disease process remains a source of debate.

Comparison of outcome in patients with ST-elevation versus non-ST-elevation acute myocardial infarction treated with percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry).

Patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are increasingly being treated with percutaneous coronary intervention (PCI) and we sought to determine risk of adverse outcomes by type of MI. Patients enrolled in the National Heart, Lung, and Blood Institute Dynamic Registry from 1999 to 2004 who presented with an acute MI as an indication for PCI were studied. Baseline data and in-hospital and 1-year outcomes were compared based on ST-segment elevation (STEMI, n = 903; NSTEMI, n = 583) at presentation. Patients with STEMI were younger, had fewer co-morbidities, and had less extensive coronary artery disease than did patients with NSTEMI. Angiographic success and periprocedural complications were similar by MI type. In-hospital coronary artery bypass grafting, stroke, bleeding and recurrent MI were similar but mortality was higher in patients with STEMI (4.0% vs 1.4%, p = 0.004). Cardiogenic shock was associated with the greatest risk of in-hospital death (odds ratio 26.7, 95% confidence interval 11.4 to 62.3, p = 0.0001), but STEMI was also independently predictive of mortality. At 1 year, there was no influence of MI type on outcome. Age, cardiogenic shock, renal disease, peripheral vascular disease, and cancer were predictive of death and MI. Multivessel disease and a larger number of >50% lesions were associated with the need for repeat revascularization. In conclusion, STEMI was associated with a higher likelihood of in-hospital death than was NSTEMI, but long-term outcomes after PCI were independent of MI type. At 1 year, associated co-morbidities were strongly associated with death and MI, whereas only angiographic characteristics predicted the need for repeat revascularization.