Tako-tsubo cardiomyopathy after administration of ergometrine following elective caesarean delivery: a case report.

INTRODUCTION: Tako-tsubo cardiomyopathy (stress-induced cardiomyopathy or transient left ventricular ballooning) is characterized by clinical suspicion of an acute myocardial infarction with transient apical or midventricular dyskinesia of the left ventricle without significant coronary stenosis on angiography. The etiology of this disease remains obscure. One of the possible causes is myocardial ischemia induced by coronary vasospasm due to sympathetic activation. It has been hypothesized that the application of ergometrine could induce tako-tsubo cardiomyopathy. CASE PRESENTATION: We report the case of a 28-year-old Turkish woman who developed tako-tsubo cardiomyopathy after administration of ergometrine for release of placenta and prevention of bleeding during the post-partum phase in the course of an elective caesarean delivery. Tako-tsubo cardiomyopathy was diagnosed by echocardiography and urgent cardiac magnetic resonance imaging. A coronary angiography was not performed because of the absence of myocardial necrosis or ischemia and signs of myocarditis on cardiac magnetic resonance imaging. CONCLUSION: This life-threatening disease should be excluded in the differential diagnosis by comparing the symptoms with those of typical heart failure, particularly after use of ergometrine.

Clinical, angiographic and cardiovascular magnetic resonance findings in consecutive patients with Takotsubo cardiomyopathy.

BACKGROUND: The aim was to assess clinical, angiographic and cardiovascular magnetic resonance (CMR) findings in patients with Takotsubo cardiomyopathy. METHODS: Between 2003 and 2007, 20 consecutive patients admitted to our hospital with suspected acute myocardial infarction and presenting with apical ballooning in the left ventricular (LV) angiogram in the absence of a significant coronary artery disease, were included in the study. Echocardiography and CMR was performed in all patients. RESULTS: The mean age of patients with Takotsubo cardiomyopathy was 62 +/- 8 years (range 43-78 years). Eighteen (90%) were female. Clinical presentations included chest pain (95%) and cardiogenic shock (5%). The mean angiographic LV ejection fraction on admission was 45% +/- 9% (range 26%-60%) and resolved rapidly in all cases. Mean time delay between presentation CMR was 2 +/- 1 days (range 1-6 days). Mean ejection fraction was 51% +/- 15% (range 25%-81%). While 19 (95%) patients showed no evidence of late enhancement or signs of myocarditis in the CMR, 1 (5%) patient who was resuscitated showed hyperenhancement confined to the apex. CONCLUSION: In patients showing the clinical picture of an acute myocardial syndrome and angiographic picture of a TakoTsubo cardiomyopathy, CMR might be helpful in confirming the diagnosis through the exclusion of other causes for the acute LV dysfunction.

Beta-blocker treatment of chronic systolic heart failure improves prognosis even in patients meeting one or more exclusion criteria of the MERIT-HF study.

AIMS: Improved prognosis of patients with chronic systolic heart failure by treatment with beta-blockers has been shown in several randomized controlled multicentre trials. However, in clinical practice only a part of heart failure patients meet the inclusion criteria of these trials. The present study evaluates whether reduction of mortality by beta-blockers also can be achieved in patients presenting one or more exclusion criteria of the MERIT-HF trial. METHODS AND RESULTS: From the Ludwigshafen Heart Failure Registry 675 patients with chronic systolic heart failure consecutively enrolled between January 1995 and June 2004 were divided in two groups either meeting the inclusion criteria of the MERIT-HF trial ('trial patients': n = 278, 60% treated with beta-blockers) or not ('non-trial patients': n = 397; 51% treated with beta-blockers). The distribution of the MERIT-HF exclusion criteria in the group of 'non-trial patients' was as follows: acute myocardial infarction 9.6%; systolic blood pressure <100 mmHg 7.5%; chronic obstructive lung disease 33.2%; other serious diseases potentially limiting prognosis 16.9%; acutely performed or planned ICD, bypass surgery, PCI, heart transplantation: 17.1, 15.9, 7.8, and 4.8%, respectively. Median follow-up was 31.3 months (upper/lower quartile 16.3/50.0 months). All-cause mortality was significantly reduced by beta-blocker treatment not only in 'trial patients' (adjusted hazard ratio 0.57, 95% CI 0.38-0.86) but also in 'non-trial patients' (adjusted hazard ratio 0.72, 95% CI 0.53-0.97). CONCLUSION: In clinical practice only the smaller part of the population to be treated for chronic systolic heart failure meets the inclusion criteria of the MERIT-HF study. However, beta-blocker treatment is associated with a significantly reduced long-term mortality even in patients meeting one or more exclusion criteria of the MERIT-HF study.

Exercise anaerobic threshold and ventilatory efficiency identify heart failure patients for high risk of early death.

BACKGROUND: The maximal oxygen uptake (peak VO2) is used in risk stratification of patients with chronic heart failure (CHF). Peak VO2 might be lower than maximally possible if exercise is stopped early because of lack of patient motivation or premature cessation by the investigator. In contrast, the anaerobic threshold (VO2AT) and the ventilatory efficiency (VE versus VCO2 slope) are less subject to these influences. Thus, we compared these parameters with peak VO2 in identifying patients with CHF at increased risk for death within 6 months after evaluation. METHODS AND RESULTS: We performed cardiopulmonary exercise tests with gas exchange measurements in 223 consecutive patients with CHF (114 coronary artery disease, 92 dilated cardiomyopathy, 17 others) at the Herzzentrum Ludwigshafen between 1995 and 1998. We measured peak VO2, VO2AT and VE versus VCO2 slope. We selected peak VO2 of < or =14 mL/kg per minute, VO2AT of <11 mL/kg per minute, and VE versus VCO2 slope of >34 as threshold values for high risk of death. The median follow-up time was 644 days. Patients with peak VO2 of < or =14 mL/kg per minute had a >3-fold-increased risk (OR=3.4; CI, 1.3 to 9.1), with VO2AT <11 mL/min per kg or VE versus VCO2 slope >34 a 5-fold increased risk for early death (OR=5.3; CI, 1.5 to 19.0; OR=4.8; CI, 1.7 to 13.8, respectively). In patients with both VO2AT <11 mL/kg per minute and VE versus VCO2 slope >34, the risk of early death was 10-fold higher (OR=9.6; CI, 2.1 to 44.7). After correction for age, sex, left ventricular ejection fraction, and New York Heart Association class in a multivariate analysis, the combination of VO2AT <11 mL/kg per minute and VE versus VCO2 slope >34 was the best predictor of 6-month mortality (RR=5.1, P=0.001). CONCLUSIONS: VO2AT of <11 mL/kg per minute and slope of VE versus VCO2 >34, combined, better identified patients at high risk for early death from CHF than did peak VO2 and should therefore be considered when prioritizing patients for heart transplantation.