Apical Hypertrophic Cardiomyopathy: Case Report and Literature Review.

BACKGROUND Apical hypertrophic cardiomyopathy (ApHCM) is a relatively rare form of hypertrophic cardiomyopathy that predominantly affects the apex of the left ventricle and typically has a nonobstructive physiology. Its variable presentation and clinical course render ApHCM a commonly delayed or missed diagnosis. CASE REPORT A 53-year-old Caucasian woman presented with chronic progressive chest pain. She was initially started on treatment for acute coronary syndrome. Diagnosis of ApHCM was initially missed on echocardiography, but made on subsequent cardiac catheterization and cardiac MRI. She improved clinically with metoprolol, had a work-up for implantable cardioverter-defibrillator placement, and was referred for genetic testing. CONCLUSIONS Despite earlier studies suggesting a more benign clinical course of ApHCM, recent studies report increased morbidity and mortality, which is comparable to the prognosis of other variants of hypertrophic cardiomyopathy such as hypertrophic obstructive cardiomyopathy. Thus, when formulating a differential diagnosis for chest pain, it is important to include structural heart disease including apical and other variants of hypertrophic cardiomyopathy as part of that differential, as appropriate management can prevent these devastating sequelae. Furthermore, when screening tests such as echocardiography cannot adequately establish the diagnosis of ApHCM, then cardiac MRI or invasive hemodynamic testing is necessary to establish or refute the diagnosis.

Percutaneous management of late leak after lariat transcatheter ligation of the left atrial appendage in patients with atrial fibrillation at high risk for stroke.

Left atrial appendage (LAA) occlusion or ligation is a novel approach to stroke prevention in atrial fibrillation that may obviate the need for long-term anticoagulation. The Lariat device has received Food and Drug Administration 510K clearance for the approximation of soft tissue and has been applied to transcatheter LAA ligation using a combined trans-pericardial and transseptal approach. The occurrence of late leak after transcatheter LAA ligation and its percutaneous management has not been previously reported. Herein, we report three cases of late leak with reconstitution of the LAA after initially successful Lariat closure, and present a simple percutaneous technique for leak closure.

Performance of electrocardiographic criteria to differentiate Takotsubo cardiomyopathy from acute anterior ST elevation myocardial infarction.

BACKGROUND: The initial electrocardiogram (ECG) in Takotsubo cardiomyopathy (TC) can mimic an acute, anterior ST-segment elevation myocardial infarction (STEMI). Given the profound and immediate treatment differences between TC and STEMI, it would be clinically valuable to distinguish them using ECG criteria. METHODS: Presenting ECGs for proven cases of TC and acute, anterior STEMI were retrospectively collected. QRS onset and J-point were manually identified using custom software to compute median ST deviation for each lead. Six published ECG criteria were examined for diagnostic accuracy using the clinical diagnosis as the gold standard. RESULTS: 33 TC and 263 acute, anterior STEMI cases were identified. ST-segment deviation differed significantly between groups for all leads except aVR, I, V5, and V6. All six published ECG criteria showed a marked reduction in diagnostic accuracy in our validation cohort, except for a combination of ST-elevation in leads V2<1.75 mm and V3<2.5 mm (sensitivity 79%, specificity 73% for TC). CONCLUSION: Our study demonstrates the limited diagnostic accuracy of published ECG rules to distinguish TC from acute, anterior STEMI. Given the rarity of TC and the clinical consequences of a "false positive" TC diagnosis based on ECG criteria alone, such rules should not be used in practice. TC remains a diagnosis of exclusion after emergent angiography in patients with an acute coronary syndrome and significant ST-segment elevation.

Takotsubo cardiomyopathy induced by dobutamine infusion: a new phenomenon or an old disease with a new name.

Takotsubo cardiomyopathy mimics acute myocardial infarction but is a separate clinical entity characterized by distinct wall motion abnormalities in the absence of obstructive coronary lesions. The prevalence of this condition is relatively uncommon yet has gained increasing recognition in recent years. It has rarely been associated with the use of dobutamine infusion during cardiac stress testing. We present in detail two cases of dobutamine-induced Takotsubo cardiomyopathy from our case series, one from 2002 and the other from 2008. While both cases display the typical features of Takotsubo cardiomyopathy, the former was initially diagnosed as dobutamine-induced vasospasm. These cases may provide insight into the pathophysiological mechanism of the condition and suggest that the increasing recognition of Takotsubo cardiomyopathy results from increasing familiarity of the condition.

Epidemiology of hypertension in the elderly.

Hypertension is clearly associated with cardiovascular disease (CVD) and death. With age, the incidence of hypertension increases, making it imperative that we understand the pathophysiology and treatment of hypertension, especially in the elderly. Data regarding individuals older than 80 years are emerging, with more attention being given to patterns and treatment of hypertension in the elderly. Thus far, we have done a poor job with treating hypertension; this is due to multiple factors, including a reluctance of physicians to treat hypertension in the elderly because of concern of causing harm. In this article, the author's discuss the history and pathophysiology of hypertension, hypertension population studies, and hypertension treatment studies with a focus on the elderly. The author's findings both justify and encourage antihypertensive treatment in all hypertensive adults.

Predictive utility of pulse pressure and other blood pressure measures for cardiovascular outcomes.

Data are sparse regarding the actual predictive utility of pulse pressure and other blood pressure measures for cardiovascular events. We included all of the participants from the Chicago Heart Association Detection Project in Industry who were free of cardiovascular disease and not receiving antihypertensive treatment at baseline (1967-1973). Baseline blood pressure measures were assessed for predictive utility for fatal and nonfatal events over 33 years. Among 36 314 participants (mean age: 39+/-13 years; 43.4% women), there were 11 452 deaths: 745 were attributed to stroke, 2812 to coronary disease, and 599 to heart failure. Of the 16 393 participants who attained Medicare eligibility, 3050, 1367, and 2207 had >or=1 hospitalization for stroke, myocardial infarction, or heart failure, respectively. In univariate analyses, hazards ratios for stroke death per SD of pulse, systolic, and diastolic pressure, respectively, were 1.49, 1.75, and 1.71. Likelihood ratio chi(2) (134.3, 302.0, and 232.6, respectively), Bayes information criteria values (15 142, 14 974, and 15 044, respectively), and areas under receiver-operating characteristic curves (0.59, 0.64, and 0.63, respectively) all indicated better predictive utility for systolic and diastolic compared with pulse pressure. Results for coronary or heart failure death and stroke, myocardial infarction, or heart failure hospitalization were similar. Pulse pressure had weaker predictive utility at all ages but particularly for those <50 years. In this large cohort study, pulse pressure had predictive utility for cardiovascular events that was inferior to systolic or diastolic pressure. These findings support the approach of current guidelines in the use of systolic and diastolic blood pressure to assess risk and the need for treatment.