Observed Clinical, Laboratory, and Echocardiographic Parameters in Takotsubo Syndrome Patients with Mortality and Decreased Ejection Fraction During Initial Hospital Admission.

CONTEXT: Approximately 1-2% of patients with suspected acute coronary syndrome also develop Takotsubo syndrome (TTS). This syndrome is characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle that mimics myocardial infarction in the absence of obstructive coronary artery disease. Up to 21.8% of TTS patients develop serious complications, including death. Currently, there is no consensus on management of these patients and their complications. Thus, identifying TTS patients at higher risk for complications becomes valuable in managing their hospital course. The aim of this study was to examine the predictive significance of laboratory, echocardiographic, and clinical parameters on in-hospital mortality in a sample subgroup of TTS patients. Secondary analyses were performed on patients with reduced (i.e., <35%) ejection fractions. METHODS: This retrospective study at a community hospital identified patients from October 1, 2009 to August 31, 2015 who presented with ACS and underwent cardiac catheterization. Patients were diagnosed with TTS by features of cardiomyopathy on cardiac catheterization or echocardiogram. RESULTS: The authors analyzed data from a total of 177 eligible patients identified with TTS. The in-hospital mortality rate was 5.65%. Compared to the non-mortality subgroup, patients who suffered in-hospital mortality had significantly lower diastolic blood pressure on admission (p < 0.050), lower hemoglobin levels (p < 0.001), lower sodium (p = 0.020), higher blood urea nitrogen (p = 0.009), lower glomerular filtration rate (p = 0.016), and lower albumin levels (p < 0.001). Cox regression analyses demonstrated admission hemoglobin was significant, yielding a mortality hazard ratio of 0.760 (95% CI of 0.594-0.972, p = 0.029). CONCLUSIONS: Patients who present with TTS and hypotension, anemia, low albumin levels, elevated lactic acid and renal dysfunction were associated with higher rates of in-hospital mortality in this study's sample population. Further, admission hemoglobin had the strongest association with death. Every unit decrease in hemoglobin increased mortality risk by 24%.

Takotsubo Cardiomyopathy and Non-ST-Segment Elevation Myocardial Infarction: Predictors of Left Ventricular Dysfunction.

BACKGROUND: Acute coronary syndrome (ACS) from non-ST-segment elevation myocardial infarction (NSTEMI) and Takotsubo (TK) cardiomyopathy present with similar initial clinical features and can result in left ventricular (LV) dysfunction and acute heart failure. METHODS: This study was a retrospective case-control study that identified patients aged 18 years and older who presented with ACS and underwent cardiac catheterization. RESULTS: There were a total of 321 patients in the TK group and 1031 patients in the NSTEMI group. There was significantly worse LV dysfunction in the TK group with average ejection fraction (EF) of 44.35% (±15.11%) versus NSTEMI with an average EF of 47.36% (±13.5%) (P < .001). The presence of TK yielded of an odds ratio (OR) of 2.373 (95% confidence interval [CI]: 1.165-3.618) and presence of peripheral artery disease (PAD) yielded an OR of 2.053 (95% CI: 1.165-3.618). CONCLUSIONS: The presence of TK cardiomyopathy and PAD were independent predictors of patients who had LVEF of <35% and elevated B-type natriuretic peptide levels.

Point-of-Care, Ultraportable Echocardiography Predicts Diuretic Response in Patients Admitted with Acute Decompensated Heart Failure.

BACKGROUND: Routine management of patients with acute decompensated heart failure (ADHF) requires careful attentiveness to fluid status and diuretic treatment efficacy. New advances in ultrasound have made ultraportable echocardiography (UE) available to physicians for point-of-care use. The purpose of this study is to explore physiologic measures of intravascular fluid volume derived from UE and explore predictors of diuretic response in ADHF. METHODS: Various echocardiography imaging measurements, particularly diameter and collapse of inferior vena cava (IVC), were collected from 77 patients admitted with a primary diagnosis of ADHF. Patients were divided into two groups based on whether or not they achieved a net negative fluid output of 3 L within 48 hours. The demographic information, serum laboratory markers, and physical characteristics of the subjects were obtained to correlate with daily ultrasound measurements. Univariate and multivariate analyses were used to compare diuretic "responders" to "nonresponders." RESULTS: A negative change in the IVC diameter at 48 hours was robust in prediction of diuretic response. For every 1 mm decrease in the IVC diameter at 48 hours, there was an odds ratio of 1.62 (95% CI: 1.20-2.19) for responding to diuretic therapy independent of other variables including baseline renal filtration function and blood B-type natriuretic peptide. CONCLUSION: Assessment of central venous pressure as a proxy for passive renal congestion independently predicts initial diuretic response in ADHF. Future research is needed to further understand the individual variation in response to loop diuresis and to identify optimal treatment approaches that utilize anatomic and physiologic measures such as venous ultrasound.

Implementation of ultraportable echocardiography in an adolescent sudden cardiac arrest screening program.

BACKGROUND: Over a 12-month period, adolescent heart-screening programs were performed for identifying at-risk adolescents for sudden cardiac death (SCD) in our community. Novel to our study, all adolescents received an abbreviated, ultraportable echocardiography (UPE). In this report, we describe the use of UPE in this screening program. METHODS AND RESULTS: Four hundred thirty-two adolescents underwent cardiac screening with medical history questionnaire, physical examination, 12-lead electrocardiogram (ECG), and an abbreviated transthoracic echocardiographic examination. There were 11 abnormalities identified with uncertain/varying clinical risk significance. In this population, 75 adolescents had a murmur or high ECG voltage, of which only three had subsequent structural abnormalities on echocardiography that may pose risk. Conversely, UPE discovered four adolescents who had a cardiovascular structural abnormality that was not signaled by the 12-lead ECG, medical history questionnaire, and/or physical examination. CONCLUSIONS: The utilization of ultraportable, handheld echocardiography is feasible in large-scale adolescent cardiovascular screening programs. UPE appears to be useful for finding additional structural abnormalities and for risk-stratifying abnormalities of uncertain potential of adolescents' sudden death.

Mortality in patients with ST-segment elevation myocardial infarction who do not undergo reperfusion.

Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥ 3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.

Development and validation of a predictive screening tool for uninterpretable coronary CT angiography results.

BACKGROUND: Coronary CT angiography (CCTA) is an excellent tool for noninvasive assessment of coronary arteries in low- to intermediate-risk individuals. However, the accuracy of CCTA heavily depends on image quality. Our objective was to develop and validate a tool to predict pre-CCTA risk of obtaining an uninterpretable result in symptomatic patients. METHODS AND RESULTS: Among 8585 symptomatic patients, we identified variables independently associated with the presence of at least 1 uninterpretable major coronary segment to create the uninterpretable risk score (URS). This risk score was developed using both clinical variables and patient variables acquired at the time the CCTA was performed (heart rate and coronary calcium). The URS was then prospectively validated among an additional 915 symptomatic patients. The URS was predictive of uninterpretable results in both the development and the validation cohorts. For every 4-point increase in the URS (range, 0 to 12), the rate of at least 1 uninterpretable coronary segment per 100 CCTA studies increased ≈1.5 fold. Increased heart rate and coronary artery calcium score were predictive of uninterpretable CCTA study results. Uninterpretable results were associated with 3-month outcomes in the development cohort. CONCLUSIONS: The URS can categorize patients who are likely to have at least 1 uninterpretable major coronary segment on CCTA. This may aid in appropriate patient selection for CCTA and avoiding radiation exposure in those likely to have an uninterpretable study. Clinical Trial Registration- URL: http:///www.clinicaltrials.gov. Unique identifier: NCT00640068.

Isolated left ventricular apical hypoplasia.

Isolated left ventricular (LV) apical hypoplasia is a recently described congenital abnormality characterized by: (1) a truncated and spherical LV configuration with rightward bulging of the interventricular septum, (2) deficiency of the myocardium within the LV apex with adipose tissue infiltrating the apex, (3) origin of the papillary muscle in the flattened anterior apex, and (4) elongation of the right ventricle wrapping around the deficient LV apex. In this report, we demonstrate these characteristic features with cardiac magnetic resonance imaging and summarize the existing information on isolated LV apical hypoplasia.

Galectin-3: a novel blood test for the evaluation and management of patients with heart failure.

Replacement of functional myocytes with crosslinked collagen as a result of tissue fibrosis is a final common pathway that is central to the progression of heart failure (HF), irrespective of etiology. In response to a variety of mechanical and neurohormonal stimuli, macrophages secrete galectin-3, which works as a paracrine and endocrine factor to stimulate additional macrophages, pericytes, myofibroblasts, and fibroblasts. The response to this signal is cellular proliferation and secretion of procollagen I. This protein is then irreversibly crosslinked to form collagen and result in cardiac fibrosis. With a commercially available assay, galectin-3 can now be measured in blood and has been found to aid in the prognosis of both systolic and nonsystolic HF. Measurement of galectin-3 before hospital discharge, on outpatient evaluation for suspected HF, and approximately twice per year for those with stable symptoms is supported by the evidence available at this time. Levels > 25.9 ng/mL, independent of symptoms, clinical findings, and other laboratory measures, predict a patient who is likely to have rapid progression of HF, resulting in hospitalization and death. In addition, a doubling in galectin-3 level over the course of 6 months, irrespective of baseline value, identifies a high-risk patient in whom additional care management efforts and advanced therapies could be warranted.

Influence of myocardial ischemia on outcomes in patients with systolic versus non-systolic heart failure.

BACKGROUND: Heart failure (HF) is a leading cause of adult hospitalization, morbidity, and mortality. We evaluated the influence of myocardial ischemia and left ventricular ejection fraction (LVEF) on outcomes in patients who were hospitalized with new onset HF. METHODS: We prospectively recruited 201 consecutive patients hospitalized for a first episode of HF from 17 medical centers across Europe and North America. All patients received gated single-photon emission computed tomographic testing with standardized study interpretations by trained core laboratory investigators. Predefined data from routine care were collected and aggregated. Computerized scoring was performed at the core laboratory and participants with a summed difference score ≥4 were defined as having myocardial ischemia. Participants were categorized as having systolic heart failure (SHF) (LVEF<40%) or nonsystolic heart failure (NS-HF) (LVEF≥40%). A proportional hazards model was used to assess the impact of clinical predictors on the outcomes of mortality, cardiac rehospitalization and a combined outcome within 2 years of study enrollment. RESULTS: 180 patients (mean age was 65.5 ± 14.6 years and 57.2% male) fulfilled study criteria and were included. Myocardial ischemia was present in 45 (41.2%) patients with SHF and 19 (27.5%) patients with NS-HF (p <0.01). During the follow-up period, 11.1% (n=20) died and 42.2% (n=76) experienced a recurrent hospitalization. Patients with NS-HF and ischemia had the highest (73.7%) event rate compared with the other cohorts (multivariate OR=3.29, 95% CI 1.69-6.42, p=0.001). CONCLUSIONS: In new-onset HF, those with NS-HF and myocardial ischemia are at the highest risk for poor outcomes.

Myocardial ischemia in patients with diastolic dysfunction and heart failure.

Coronary artery disease is present in 40-55% of patients with diastolic heart failure, and myocardial ischemia is both a cause and a precipitant of diastolic heart failure. Failure to recognize and treat acute and chronic ischemia in patients with this disorder results in rapid disease progression and poor outcomes. In diastolic heart failure patients without obstructive coronary artery disease, ischemia can be induced by other diseases that diminish perfusion gradient, cause myocardium to outgrow blood supply, or decrease diastolic filling time. In this article, we review the role of ischemia and development of fibrosis in the epidemiology, pathophysiology, and evaluation of patients with diastolic dysfunction and diastolic heart failure.

Subarachnoid hemorrhage with neurocardiogenic stunning.

A well-recognized complication of acute neurologic injury from intracranial bleeding is cardiotoxicity with electrocardiographic changes and transient left ventricular dysfunction. The phenomenon, called neurocardiogenic stunning (NCS), occurs in 20% to 30% cases of patients with acute subarachnoid hemorrhage (SAH). In this article, we describe a patient with acute SAH complicated by NCS and use this case to highlight the pathogenesis, diagnostic challenges, and management dilemmas that arise in such patients. We also review conventional surgical and medical treatment and present new therapeutic options for this problem.

Subclinical coronary atherosclerosis identified by coronary computed tomographic angiography in asymptomatic morbidly obese patients.

Obesity is a common public health problem and obese individuals in particular have a disproportionate incidence of acute coronary events. This study was undertaken to identify coronary artery lesions as well as associated clinical features, risk factors and demographics in patients with a body mass index (BMI) >40 kg/m(2) without known coronary artery disease (CAD). Morbidly obese subjects were prospectively recruited to undergo coronary computed tomographic angiography (CCTA) using a dual-source computed tomography (CT) system. CAD was defined as the presence of any atherosclerotic lesion in any one coronary artery segment. The presence, location, and severity of atherosclerosis were related to patient characteristics. Forty-one patients (28 women, mean age, 50.4±10.0 years, mean BMI, 43.8±4.8 kg/m(2)) served as the study population. Of these, 25 patients (61%) had at least one coronary stenosis. All but 2 patients within the CAD cohort had coronary artery calcium (CAC) scores >0, and most plaques identified (75.4%) were non-calcified. There was a predilection of calcified and non-calcified atherosclerosis involving the left anterior descending (LAD) coronary artery compared with other coronary segments. Univariate predictors of CAD included older age, dyslipidemia, and diabetes. In this preliminary study of young morbidly obese patients, CCTA detected a high prevalence of calcified and non-calcified CAD, although the later predominated.

Albuminuria and renal function in obese adults evaluated for obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with hypertension, obesity and metabolic syndrome that are risk factors for cardiovascular and chronic kidney disease. Few data are available regarding renal parameters in patients with OSA. METHODS: We conducted a cross-sectional study of 91 obese adults who had routine polysomnography before bariatric surgery. Presence and severity of OSA were determined by the apnea-hypopnea index (AHI <5 = no OSA and AHI > or = 5 = OSA). Clinical and laboratory data were available within a month of polysomnography. RESULTS: Mean +/- SD age was 44.9 +/- 9.9 years. There were 66 women. Mean +/- SD body mass index was 48.3 +/- 8.9 kg/m2 with hypertension and type 2 diabetes present in 55 and 31 subjects, respectively. There were 36 subjects with no OSA and 55 with OSA. The two groups had similar demographic characteristics, blood pressure (BP), lipid profile and medication use except for difference in mean +/- SD hemoglobin A1c (5.6 +/- 0.6% in no OSA, 6.0 +/- 0.8% in OSA; p = 0.029) and use of renin-angiotensin system blocking agents (22.2% in no OSA, 46.4% in OSA; p = 0.024). Median (interquartile range) urine albumin:creatinine ratio (ACR) was not different between the two groups [6 (4-14.5) mg/g in no OSA, 8 (5-16) mg/g in OSA; p = 0.723], while significant difference existed in serum creatinine (0.8 +/- 0.2 mg/dl in no OSA, 0.9 +/- 0.2 mg/dl in OSA, p = 0.013). Age- and gender-adjusted correlations were observed between log-log ACR and systolic BP (r = 0.265; p = 0.016), log-log ACR and diastolic BP (r = 0.245; p = 0.026) and between serum creatinine and log AHI (r = 0.188, p = 0.089). Multiple linear regression analysis demonstrated log-log ACR to be associated with diastolic BP (p = 0.046), while serum creatinine was associated with log AHI (p = 0.044). CONCLUSION: In obese adults, increasing severity of OSA is associated with higher serum creatinine but not greater degree of albuminuria.

Lipoproteins, inflammatory biomarkers, and cardiovascular imaging in the assessment of atherosclerotic disease activity.

Atherosclerosis is present in about 50% of asymptomatic adults at middle age and in nearly all elderly individuals. The traditional diagnostic and treatment paradigm has addressed risk detection and reduction of binary events, including myocardial infarction (MI), stroke, and cardiovascular death. About 50% of all acute coronary syndromes occur in previously asymptomatic subjects, 90% of whom have modifiable risk factors; yet our current screening approaches fail to prevent the 1.2 million acute cardiovascular events that occur annually in the United States. In a patient with active disease, multiple treatment targets can be approached with a variety of lifestyle changes and medical therapy to render the disease quiescent in theory. A future approach may be interception of atherosclerosis before the identification of theoretical or actual risk of episodic events. This case review highlights use of advanced biomarkers and imaging to assess atherosclerotic disease activity in a 49-year-old asymptomatic woman who presents for evaluation after the death of her father from MI.

Cardiorespiratory fitness and sedentary lifestyle in the morbidly obese.

BACKGROUND: Sedentary lifestyles and poor physical fitness are major contributors to the current obesity and cardiovascular disease pandemic. HYPOTHESIS: Daily physical activity and cardiorespiratory fitness are correlated in morbidly obese individuals in their free-living environment. METHODS: Ten morbidly obese participants continuously wore an activity sensor that measured caloric expenditure, minute-by-minute physical activity, and steps/day over a 72-h period. Following collection of the device data, structured cardiorespiratory fitness testing was performed on each subject. RESULTS: Mean caloric expenditure for all individuals was 2,668+/-481 kcal/d. On average, subjects took 3,763+/-2,223 steps. On average 23 h and 51.6 min per d were spent sleeping or engaged in sedentary activity (<3 metabolic equivalents [METs]) and the remaining 8.4 min were spent in moderate activity (3-6 METs). Average peak VO2 was 16.8+/-4.7 mL/kg/min. Higher peak VO2 correlated with higher total caloric expenditure (TCE; r=0.628, p=0.05) and trended with higher steps/day (r=0.591, p=0.07). CONCLUSIONS: Most morbidly obese participants in this study were markedly sedentary. These study results may provide important links between obesity, poor fitness, and cardiovascular disease.

Cardiorespiratory fitness and obstructive sleep apnea syndrome in morbidly obese patients.

BACKGROUND: Conflicting data exist regarding the effects of obstructive sleep apnea syndrome (OSAS) on cardiorespiratory fitness in morbidly obese individuals with normal resting left ventricular function. METHODS: Ninety-two morbidly obese subjects without any prior diagnosis of OSAS underwent cardiorespiratory fitness testing, two-dimensional echocardiography, and overnight polysomnography. Using the results of the polysomnogram, comparisons were made between subjects with (n = 42) and without (n = 50) OSAS. RESULTS: Mean body mass index (BMI) for the study population (n = 92) was 48.6 +/- 9.3 kg/m(2) (+/- SD); mean age was 45.5 +/- 9.8 years, and approximately 69% were female. Despite having a higher resting, exercise, and resting mean arterial pressures, the OSAS cohort had a maximum oxygen consumption that was lower than the cohort without OSAS (21.1 mL/kg/min vs 17.6 mL/kg/min; p < 0.001). There was no difference in BMI, age, gender, waist circumference, and neck circumference between those with and without OSAS. Differences were observed between the cohorts in systolic BP, diastolic BP, and heart rate during rest, exercise, and recovery periods. There was no difference in ejection fraction, diastolic dysfunction, and treadmill test duration between cohorts. CONCLUSIONS: Morbidly obese individuals with OSAS demonstrate reduced cardiorespiratory fitness and differing hemodynamic responses to exercise testing as compared with their counterparts without this disorder. These data suggest chronic sympathetic nervous system activation negatively influences aerobic capacity in OSAS.

New insights in preventive cardiology and cardiac rehabilitation.

PURPOSE OF REVIEW: To summarize changing paradigms and perceptions in the prevention and treatment of cardiovascular disease. RECENT FINDINGS: Recent studies have shown that arterial inflammation probably plays a key role in the development and progression of atherosclerosis, that acute myocardial infarctions often evolve from mild-to-moderate coronary artery stenoses, that patients who experience a fatal coronary event invariably had antecedent exposure to one or more major coronary risk factors, that angiographic findings may vastly underestimate underlying atherosclerotic coronary artery disease, and that many elective coronary revascularization procedures may be unnecessary. Moreover, cardiorespiratory fitness appears to be one of the strongest prognostic markers in persons with and without heart disease. SUMMARY: Collectively, these data highlight the value of comprehensive risk factor modification in the prevention of initial and recurrent cardiovascular events.

Body weight limitations of United States cardiac catheterization laboratories including restricted access for the morbidly obese.

A telephone survey was performed to determine the current weight limits of cardiovascular catheterization laboratories (n = 94) in the United States. The minimum, mean, and maximum weight limits of the catheterization laboratories in this survey were 160, 198.9, and 250 kg (350, 437.5, and 550 lb), respectively. Twenty-two percent of respondents (n = 21) referred to other institutions when asked what they did when patients were too heavy, and 70% of respondents (n = 66) could not provide an answer. In this population, 5.2 +/- 3.4 patients/hospital/year were rejected for being over the weight limit. In conclusion, these results provide useful information for the future management of this growing population.

Assessment of knowledge, awareness, and self-reported risk factors for type II diabetes among adolescents.

This study assessed adolescents' level of knowledge of and self-reported risk factors for type II diabetes mellitus (T2DM). We found adolescents had a relatively high level of knowledge and perception of health consequences from T2DM, but also had a high rate of self-reported risk factors.