Frequency of Takotsubo cardiomyopathy in postmenopausal women presenting with an acute coronary syndrome.

Takotsubo cardiomyopathy (TC) may be more common than previously reported in postmenopausal women (PMW) presenting with acute coronary syndrome (ACS). TC often masquerades as an ACS with electrocardiographic changes, elevated troponins, and/or chest discomfort. Its exact incidence in ACS is unknown but most studies suggest it is 1% to 2.2%. As most patients with TC are PMW, it was hypothesized that the incidence would be greater in this population. A prospective evaluation was carried out in all middle-aged and older women (≥45 years of age) presumed to be peri- or postmenopausal with an elevated troponin presenting to a community hospital over a 1-year period (July 2011 to July 2012). Troponin results above the upper limit of normal were screened on a daily basis through a computerized system. The patients' in-hospital charts were reviewed and determined if they fulfilled the criteria for acute myocardial infarction according to the universal definition of myocardial infarction. Prespecified criteria were used to identify all patients with TC. Of the 1,297 PMW screened for positive troponins, 323 patients (24.9%) fulfilled the criteria for acute myocardial infarction and of these, 19 (5.9%) met the prespecified criteria for TC. Three additional patients with TC had acute neurologic events. Most patients (81.8%) had the apical variant. In conclusion, TC may be more common than reported in PMW with clinical and laboratory criteria suggesting acute myocardial infarction. Heightened awareness of TC in this population appears warranted.

Diuretics in heart failure: practical considerations.

This review discusses the role of diuretics in heart failure by focusing on different classifications and mechanisms of action. Pharmacodynamic and pharmacokinetic properties of diuretics are elucidated. The predominant discussion highlights the use of loop diuretics, which are the most commonly used drugs in heart failure. Different methods of using this therapy in different settings along with a comprehensive review of the side-effect profile are highlighted. Special situations necessitating adjustment and the phenomenon of diuretic resistance are explained.

Comparison of risk scores to estimate perioperative mortality in aortic valve replacement surgery.

BACKGROUND: Transaortic valve implantation has recently been introduced as an alternative to aortic valve replacement (AVR) for high-risk patients with aortic stenosis. However, accurate assessment of surgical risk is critical for appropriate patient selection. We compared the accuracy of The Society of Thoracic Surgeons (STS) risk score, the European System for Cardiac Risk Evaluation (EuroSCORE), and the Veterans Administration (VA) risk score in predicting perioperative mortality after AVR. METHODS: We included 537 consecutive patients who underwent AVR for severe aortic stenosis at the Minneapolis VA Medical Center between 1997 and 2008. Observed and predicted perioperative (30-day) mortality rates were compared. Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic curves were performed to assess the performance of the scores. RESULTS: Perioperative mortality rate was 5.9% (n=32). Predicted mortality rates for the EuroSCORE, STS score, and VA score were 15.6%, 3.6%, and 6.7%, respectively (p=0.001). The EuroSCORE overestimated mortality in all patients, most notably among those with ejection fraction less than 35% (49% predicted versus 9% observed). The EuroSCORE had poor calibration (goodness-of-fit test p<0.008), whereas the STS and the VA scores were well calibrated. However, all three scores displayed good discrimination characteristics per the areas under the receiver operating characteristic curves: STS score 0.73 (95% confidence interval: 0.69 to 0.77); VA score 0.66 (95% confidence interval: 0.62 to 0.70); and EuroSCORE 0.68 (95% confidence interval: 0.64 to 0.72; p>0.05). CONCLUSIONS: The EuroSCORE substantially overestimates perioperative mortality risk in AVR, particularly in patients with low ejection fraction. These data have implications when deciding the appropriate intervention (transaortic valve implantation versus AVR) for high-risk aortic stenosis patients.