Takotsubo Cardiomyopathy Induced by Stress From Amyotrophic Lateral Sclerosis and a Mechanical Fall.

Named after the Japanese octopus trap, Takotsubo cardiomyopathy is an acute myocardial condition characterized by a reversible ventricular dysfunction with ballooning of the left ventricle (LV) during systole. A catecholamine surge is likely the primary mechanism responsible for myocardial damage in this condition. The association between amyotrophic lateral sclerosis (ALS) and Takotsubo cardiomyopathy has not been well established. We present a unique case of Takotsubo cardiomyopathy diagnosed in a patient with ALS who presented after a fall with shortness of breath, generalized weakness, and hypotension. She was found to have troponinemia, elevated brain natriuretic peptide, and Osborn waves without ST-segment changes noted on electrocardiography (EKG). The diagnosis of Takotsubo cardiomyopathy was confirmed via transthoracic echocardiography (TTE), which revealed reduced left ventricular ejection fraction, apical ballooning of the LV, akinesis of the ventricular apex, and hyperkinesis of the base of the heart. Coronary angiography revealed no coronary artery disease. She was managed medically and was hemodynamically stable at the time of discharge.

The Poisoned Heart: A Case of Takotsubo Cardiomyopathy Induced by Carbon Monoxide Poisoning.

BACKGROUND: Carbon monoxide is a common environmental toxin, and some patients present with features of cardiac injury in addition to the noxious effects of carbon monoxide poisoning. A very small fraction of those have a transient left ventricular apical ballooning syndrome or Takotsubo cardiomyopathy, both terms are used to define a syndrome that affects the systolic function of the heart. It usually presents with elevated troponin levels with or without electrocardiographic changes. Cardiac angiograms generally illustrate coronary arteries without significant obstruction. CASE REPORT: Here we report the curious case of a 37-year-old Hispanic man brought in for carbon monoxide poisoning, but found to have significantly elevated troponin levels. Echocardiogram demonstrated decreased ejection fraction of 35%. Left heart catheterization 2 days after admission revealed patent coronary arteries, improved ejection fraction to 45%, and wall motion abnormalities plus apical ballooning compatible with Takotsubo cardiomyopathy. The case is unusual because our patient differs from the classically defined elderly, postmenopausal female demographic, and did not experience an emotional crisis that could have provoked this series of events. It is also noteworthy for the fact that the only identifiable trigger was exposure to carbon monoxide. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Carbon monoxide poisoning is a common occurrence resulting in a multitude of annual emergency department visits. Given the known toxic effects of carbon monoxide poisoning on the heart, prompt cardiac workup is important to prevent overlooking a major, although rare, manifestation of carbon monoxide exposure.

Prognostic value of real time dobutamine stress myocardial contrast echocardiography in patients with chest pain syndrome.

The aims of this study were (1) to evaluate the prognostic value of negative wall motion (WM) and myocardial perfusion during contrast-dobutamine stress echocardiography (DSE), (2) to determine whether WM-myocardial contrast echocardiography (MCE) had incremental prognostic value over just WM during DSE in patients with chest pain in the emergency room (ER), and (3) to compare the prognostic value of negative DSE-WM, and DSE-WM-MCE to nuclear-myocardial perfusion imaging (N-MPI) in a similar patient population over the same time period. We retrospectively studied 569 patients with real time contrast DSE, and 147 patients underwent N-MPI for evaluation of chest pain. Follow-up for cardiac events was obtained between 12 and 25 months. The cumulative cardiac event-free survival was 94.5% in negative DSE-WM, 97.1% in negative DSE-WM-MCE and 96.7% in negative N-MPI group. Cardiac event-free survival of the negative DSE-WM-MCE group was significantly higher than the DSE-WM group (log rank P < 0.01), and similar in the DSE-WM-MCE group compared to the N-MPI group. Combined WM and perfusion during DSE was the strongest independent predictor for cardiac events. The negative predictive power of DSE-WM-MCE is superior to that of just negative DSE-WM and is comparable to that of N-MPI. Myocardial perfusion and WM analysis during DSE provide independent information for predicting cardiac events in patients with chest pain syndrome in the ER.

Granulocyte macrophage-colony stimulating factor (GM-CSF) recruits immune cells to the pancreas and delays STZ-induced diabetes.

Granulocyte macrophage-colony stimulating factor (GM-CSF) is one of the most widely used growth factors for enhancing immune responses and is known to recruit and activate antigen-presenting cells (APCs). This study hypothesized that overexpression of this cytokine within the pancreatic beta-cells would recruit, expand, and activate APCs. The question was whether this would lead to tolerance or autoimmunity to pancreatic antigens. This possibility was tested by preparing transgenic mice (ins-GM-CSF) whose islets expressed murine GM-CSF. By 6-8 weeks of age, these mice developed a profound mononuclear cell infiltration that often overwhelmed the exocrine pancreas, although no changes in enzyme or hormone function were apparent. The majority of the mononuclear infiltrate within the pancreas was identified as F4/80+ macrophages. Transgenic ins-GM-CSF mice had splenomegaly due to a massive increase in the macrophage population. Additionally, mononuclear cells were found within the livers of transgenic mice, with F4/80+ cells also identified within the infiltrate, indicating that GM-CSF-activated mononuclear cells circulated to organs other than the pancreas. To assess the disease potential, this study tested whether macrophage recruitment to the pancreas might accelerate or protect the islets from diabetes. It was found that the induction of diabetes by low-dose streptozotocin (STZ) was delayed and reduced within ins-GM-CSF transgenic mice, in comparison with negative littermates. Together, these data highlight the role of GM-CSF in recruiting APCs such as macrophages. Advanced cellular infiltration does not overtly harm, and may even protect, pancreatic function, as seen with the delay in chemically induced diabetes.