[Peripheral arterial occlusive disease as predictor of high atherosclerotic burden]. / Periphere arterielle Verschlusskrankheit als Prädiktor einer hohen Atheroskleroselast.

Atherosclerosis is a disease which affects the whole arterial vascular tree. In particular patients with peripheral arterial occlusive disease (PAOD) often suffer from additional atherosclerotic manifestations in other vascular territories. This has a direct impact on cardiovascular prognosis. Atherosclerosis is an inflammatory disease. A high inflammatory burden is associated with polyvascular atherosclerosis and also with the occurrence of cardiovascular events. Control of cardiovascular risk factors is crucial for the treatment of patients with polyvascular atherosclerosis. In addition, anticoagulation treatment is very important in patients with atherosclerosis. Moreover, exercise training is an important treatment option in PAOD patients not only to improve walking distance but also for multiple additional positive effects. So far the role of anti-inflammatory treatment is not clear and must be further elaborated by future clinical research.

Cardiac MR enables diagnosis in 90% of patients with acute chest pain, elevated biomarkers and unobstructed coronary arteries.

OBJECTIVE: To assess the diagnostic value of cardiac MRI (CMR) in patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram. METHODS: This study included a total of 125 patients treated in the chest pain unit during a 39-month period. Each included patient underwent MRI within a median of 3 days after cardiac catheterization. The MRI protocol comprised cine, oedema-sensitive and late gadolinium-enhancement imaging. The standard of reference was a consensus diagnosis based on clinical follow-up and the synopsis of all clinical, laboratory and imaging data. RESULTS: MRI revealed a multitude of diagnoses, including ischaemic cardiomyopathy (CM), dilated CM, myocarditis, Takotsubo CM, hypertensive heart disease, hypertrophic CM, cardiac amyloidosis and non-compaction CM. MRI-based diagnoses were the same as the final reference diagnoses in 113/125 patients (90%), with the two diagnoses differing in only 12/125 patients. In two patients, no final diagnosis could be established. CONCLUSION: CMR performed early after the onset of symptoms revealed a broad spectrum of diseases. CMR delivered a correct final diagnosis in 90% of patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram. ADVANCES IN KNOWLEDGE: Diagnosing patients with acute coronary syndrome but unobstructed coronary arteries remains a challenge for cardiologists. CMR performed early after catheterization reveals a broad spectrum of diseases with only a simple and quick examination protocol, and there is a high concordance between MRI-based diagnoses and final reference diagnoses.

Tako-Tsubo syndrome: dying of a broken heart?

AIM: The aim of the article is to review the etiology, pathology and epidemiology of a disease entity named Tako-Tsubo syndrome, receiving this name according to the picture obtained during ventriculography resembling a Japanese octopus trap. The Tako-Tsubo syndrome is a diagnosis encountered in patients with acute coronary syndrome and, therefore, is important to consider. METHODS: The literature search was performed in the MEDLINE database to identify the relevant topics. The references reported were used to complete the literature search. RESULTS: The Tako-Tsubo syndrome is rising in incidence and makes up a relevant part of patients with acute coronary syndrome. The prevalence is described to be 0.6-2.5%. Especially, older women in the postmenopause with emotional stress are affected. The clinical changes and ECG alterations resemble the same characteristics like in acute coronary syndrome; however, the coronary arteries often show no impaired blood flow or only marginal changes. The reason for this syndrome is allocated to stress reactions with increased levels of stress hormones. As well, some patients develop contraction abnormalities like in Tako-Tsubo syndrome during intracranial bleeding, pheochromocytoma, seizures, infectious causes and sepsis, showing that not only emotional stress is responsible for the manifestation of this disease. CONCLUSION: The prevalence of Tako-Tsubo syndrome is about 2%, therefore this syndrome has to be considered in patients with acute coronary syndrome. Despite the life-threatening complications during the acute phase, a complete regression of the contraction abnormality is often reported.

Area at risk and viability after myocardial ischemia and reperfusion can be determined by contrast-enhanced cardiac magnetic resonance imaging.

BACKGROUND/AIMS: Clinical differentiation between infarcted and viable myocardium in the ischemic area at risk is controversial. We investigated the potential of contrast-enhanced cardiac magnetic resonance imaging (ceCMRI) in determining the area at risk 24 h after ischemia. METHODS: Myocardial ischemia was induced by percutaneous coronary intervention of the left anterior descending coronary artery in pigs. Coronary occlusion time was 30 min in group A, which caused little myocardial infarction and 45 min in group B, which led to irreversible damage. 24 h after reperfusion ceCMRI was performed at 2 and 15 min after administration of gadolinium-diethylenetriamine pentaacetic acid. The area at risk was determined by intravenous injection of Evans blue and myocardial viability by triphenyltetrazolium-chloride staining. RESULTS: The signal-intense areas at 2 and 15 min after contrast administration matched the area at risk in groups A and B. Nonviable myocardium in group A was overestimated (14-15%) while good agreement was present in group B. CONCLUSION: The area at risk of reperfused ischemic myocardium can be determined by ceCMRI 24 h after coronary recanalization. This type of information might have relevant clinical implications in the treatment and stratification of patients with acute coronary syndrome in particular after surgical interventions.

[Non-invasive assessment of coronary artery bypass grafts -- an update]. / Koronare Bypassdiagnostik mit CT und MRT -- eine Bestandsaufnahme.

The limited lifetime and the correlation between graft occlusion and recurring symptoms underline the need for repeated imaging of coronary artery bypass grafts. CT and MRI allow for non-invasive imaging of coronary bypasses with high accuracies concerning the patency of these vessels. Multidetector CT seems to be the CT technique of choice, especially after the introduction of 16 slice CT scanners for morphologic assessment of coronary artery bypass grafts. Compared with MRI, CT is a robust technique for assessment of cardiac anastomoses, native coronary arteries, and for the detection of graft stenoses. MRI, however, is able to deliver functional information about the grafts and the recipient coronary arteries by determining the coronary flow reserve. Furthermore, it can be integrated in a multiparametric MR examination protocol. The follow-up of asymptomatic patients can primarily be done by these non-invasive techniques as nearly every third patient reveals an asymptomatic bypass occlusion 5 years after operation. Furthermore, patients with atypical complaints after the operation may undergo non-invasive imaging as long as documented patency of the bypass averts coronary angiography. Patients with recurrent angina pectoris and/or myocardial ischemia discovered by other cardiologic tests have to undergo coronary angiography.

Late improvement of regional wall motion after the subacute phase of myocardial infarction treated by acute PTCA in a 6-month follow-up.

BACKGROUND: The aim of this follow-up study was to investigate the late effects of acute coronary angioplasty (PTCA) on regional wall motion after the subacute phase of myocardial infarction (MI). METHODS AND RESULTS: Seventeen patients were investigated initially at a median of 11 days and again at 6 months after acute PTCA for myocardial infarction (< 8 hours after onset of symptoms) by cardiac magnetic resonance imaging. Corresponding short-axis slices encompassing the left ventricle (LV) were acquired using a standard cine MR for regional wall motion analysis and using delayed contrast enhanced magnetic resonance imaging (ceMRI) for infarct size quantification. The infarct size was similar in the subacute phase and the 6 month follow-up (20.8 and 21.9%, respectively; n.s.). Regional wall motion improved significantly in the area of hyperenhancement [percentage wall thickening (PWT) 21.9% and 37.9%, p < 0.05] in contrast to remote normal myocardium (46.4% and 38.4%; n.s.). Regional wall motion was significantly poorer in transmural compared with nontransmural MI in the subacute stage, and a late improvement could only be observed in transmural MI. CONCLUSION: Transmural areas of hyperenhancement displayed significant late long-term improvement of regional wall motion after acute PTCA, possibly related to prolonged stunning compared with nontransmural areas.