Left atrial minimal volume: association with diastolic dysfunction and heart failure in patients in sinus rhythm or atrial fibrillation with preserved ejection fraction.

BACKGROUND: Evidence of diastolic dysfunction (DD) required for the diagnosis of heart failure with preserved ejection fraction (HFpEF) is elusive in atrial fibrillation (AF). Left ventricular (LV) and left atrial (LA) speckle-tracking echocardiography (STE) may provide rhythm independent indications of DD. We aimed to find common LV/LA myocardial mechanics parameters to demonstrate DD, using STE in patients with AF. METHODS: 176 echocardiographic assessments of patients were studied retrospectively by STE. 109 patients with history of AF were divided in three groups: sinus with normal diastolic function (n = 32, ND), sinus with DD (n = 35, DD) and patients with AF during echocardiography (n = 42). These assessments were compared to 67 normal controls. Demographic, clinical, echocardiographic and myocardial mechanic characteristics were obtained. RESULTS: The patients with DD in sinus rhythm and patients with AF were similar in age, mostly women, and had cardiovascular risk factors as well as higher dyspnea prevalence compared to either controls or patients with ND. In the AF group, LV ejection fraction (LVEF) (p = 0.008), global longitudinal strain and LA emptying were lower (p < 0.001), whereas LA volumes were larger (p < 0.001) compared to the other groups. In a multivariable analysis of patients in sinus rhythm, LA minimal volume indexed to body surface area (Vmin-I) was found to be the single significant factor associated with DD (AUC 83%). In all study patients, Vmin-I correlated with dyspnea (AUC 80%) and pulmonary hypertension (AUC 90%). CONCLUSIONS: Vmin-I may be used to identify DD and assist in the diagnosis of HFpEF in patients with AF.

Clinical and echocardiographic characteristics of patients with preserved versus mid-range ejection fraction.

A wide range of ejection fraction (EF) thresholds have been used to categorize patients with heart failure (HF) with "preserved" EF. Our goal was to characterize the clinical and echocardiographic differences among patients with cardiac structural/functional alterations and mid-range EF (mrEF) (EF 40-49%) compared to preserved EF (pEF) (EF ≥ 50%), irrespective of HF. Patients with an EF ≥ 40% and echocardiographic evidence of structural alterations (left atrial enlargement and/or left ventricular hypertrophy) and/or functional alterations (evidence of diastolic dysfunction) were retrospectively selected. Patients with acute coronary syndromes and ≥ moderate left sided valvular diseases were excluded. Patients were divided according to EF to pEF group (n = 578) and mrEF (n = 86). Patients with mrEF were twice as likely to be men, had higher prevalence of hyperlipidemia, diabetes and smoking, compared to patients with pEF. History of coronary artery disease (CAD) was more frequent among mrEF (50% vs. 28%, p < 0.0001, respectively), and highest among the subgroup of patients with HF (83% vs. 35%, p < 0.0001, respectively). Patients with mrEF had increased LV mass index (131 ± 35 vs. 120 ± 26 g/m2, p < 0.001), LV end diastolic diameter (55 ± 5 vs 51 ± 3, p < 0.0001), mitral E to e' ratio (16 ± 7 vs. 14 ± 5, p = 0.001), and left atrial systolic diameter (44 ± 5 mm vs. 42 ± 4 mm, p = 0.01. respectively). Patients with mrEF demonstrated worse structural and functional echocardiographic alterations and were more likely to be men and to have CAD compared to patients with pEF.

The association between carotid calcium on dental panoramic radiographs and coronary calcium score on chest computerized tomography.

OBJECTIVES: Coronary artery calcium measured by CT predicts future coronary events. Similarly, carotid artery calcium on dental panoramic radiographs has been associated with increased cardiovascular events. Pre-procedural assessment of candidates for valve replacement in our institution includes panoramic radiographs and chest tomography. We aimed to assess the association of carotid calcium on panoramic radiographs with coronary artery calcium on chest tomography. METHODS: Paired pre-procedural panoramic radiographs and chest tomography scans were done in 177 consecutive patients between October 2016 and October 2017. Carotid calcium was quantified using NIH's ImageJ. Coronary artery calcium was quantified by the Agatston score using Philips Intellispace portal, v. 8.0.1.20640. RESULTS: Carotid calcium maximal intensity, area and perimeter were higher among patients with high coronary artery calcium. Non-zero carotid calcium was found in half of patients with high coronary artery calcium, doubling prevalence of low coronary artery calcium. CONCLUSION: Carotid calcium identified in panoramic radiographs was associated with high coronary artery calcium. Awareness of carotid calcium recognized by dental practitioners in low-cost, low radiation and commonly done panoramic radiographs may be useful to identify patients at risk of coronary disease with potential future cardiovascular events.

Clinical, Surgical, and Sociopsychological Factors and Depression After Cardiothoracic Surgery.

BACKGROUND: Depression is highly prevalent in cardiac surgical patients and is associated with mortality. The objectives of the study were to evaluate depression scores longitudinally pre- and postoperatively and to examine the association between postoperative depression scores and clinical, surgical, and sociopsychological factors. METHODS: Depression scores were assessed using the Center for Epidemiological Study of Depression (CES-D) in 100 cardiac surgical patients who underwent cardiac surgery preoperatively, during hospitalization, and at 2 and 6 week after discharge. Clinical, surgical, and sociopsychological predictors of depression scores were recorded. RESULTS: The average depression scores significantly increased from preoperative levels (14.9 ± 1.07) to during hospitalization (21.5 ± 1.05) and decreased at both 2 weeks (15.8 ± 1.07) and 6 weeks after discharge (14.0 ± 1.06), as compared with scores during hospitalization (P < .001). The percentage of patients who scored CES-D > 16 increased significantly from preoperative (39%) to hospitalization (71%) and decreased gradually at 2 weeks (45%) and 6 weeks (37%) after discharge (P < .001). Significant predictors of high postoperative CES-D scores were female gender, ejection fraction < 50%, and high preoperative CES-D scores. CONCLUSIONS: High depression scores after cardiac surgery suggest that perioperative screening and management of depression after surgery are necessary and may improve outcomes of these patients who are at high risk for depression. Further understanding of the factors that contribute to high depression scores is required to facilitate clinical intervention.

Pre- and Post-Transcatheter Aortic Valve Replacement Serum Brain Natriuretic Peptide Levels and All-Cause Mortality.

BACKGROUND: Risk stratification in patients post-transcatheter aortic valve replacement (TAVR) is limited to and is based on clinical judgment and surgical scoring systems. Serum natriuretic peptides are used for general risk stratification in patients with aortic stenosis, reflecting the increase in their afterload and thereby stressing the need for valve intervention. The objective of this study was to determine the predictive value of pre- and post-procedural serum brain natriuretic peptide (BNP) on 1-year all-cause mortality in patients who underwent TAVR. METHODS: In this population-based study, we included 148 TAVR patients treated at the Poriya Medical Center between June 1, 2015, and May 31, 2018. Routine blood samples for serum BNP levels (pg/mL) were taken just before the TAVR and 24 h post-TAVR. Our primary clinical outcome was defined as 1-year all-cause mortality. We used backward regression models and included all variables that had a p value <0.1 in the univariable analysis. A receiver-operating characteristic curve was calculated for the prediction of all-cause mortality by serum BNP levels using the median as the cut-off point. RESULTS: In this study cohort, BNP levels 24 h post-TAVR higher than the cohort median versus lower than the cohort median (387.5 pg/mL; IQR 195-817.6) were the strongest predictor of 1-year mortality (hazard ratio 9; 95% CI 2.72-30.16; p < 0.001). The statistically significant relationship was seen in the unadjusted regression model as well as after the adjustment for clinical variables. CONCLUSIONS: Serum BNP levels 24 h post-procedure were found to be a meaningful marker in predicting 1-year all-cause mortality in patients after TAVR procedure.

Trends in Utilization and Safety of In-Hospital Coronary Artery Bypass Grafting During a Non-ST-Segment Elevation Myocardial Infarction.

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes.

Utilization and Complications of Catheter Ablation for Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy.

Background Atrial fibrillation (AF) is common and bears a major clinical impact in patients with hypertrophic cardiomyopathy (HCM). We aimed to investigate the use and real-world safety of catheter ablation for AF in patients with HCM. Methods and Results We drew data from the US National Inpatient Sample to identify cases of AF ablation in HCM patients between 2003 and 2015. Sociodemographic and clinical data were collected, and incidence of catheter ablation complications, mortality, and length of stay were analyzed, including trends between the early (2003-2008) and later (2009-2015) study years. Among a weighted total of 1563 catheter ablation cases in patients with HCM, the median age was 62 (interquartile range, 52-72), 832 (53.2%) were male, and 1150 (73.6%) were white. The average annual volume of AF ablations in patients with HCM doubled between the early and the later study period (79-156). At least 1 complication occurred in 16.1% of cases, and the in-hospital mortality rate was 1%. Cardiac and pericardial complications declined from 8.8% to 2.3% and from 2.8% to 0.9%, respectively, between the early and the later study years (P<0.01). Independent predictors of complications included female sex (odds ratio [OR], 4.81; 95% CI, 2.72-8.51), diabetes mellitus (OR, 6.57; 95% CI, 2.68-16.09) and obesity (OR, 3.82; 95% CI, 1.61-9.06). Conclusions Despite some decline in procedural complications over the years, catheter ablation for AF is still associated with a relatively high periprocedural morbidity and even mortality in patients with HCM. This emphasizes the importance of careful clinical consideration, by an experienced electrophysiologist, in referring patients with HCM for an AF ablation.

Veno-arterial extracorporeal membrane oxygenation for electrical injury induced cardiogenic shock support: a case report.

BACKGROUND: High voltage electrical injury (HVEI) of more than 1000 V is a potentially devastating form of a multisystem injury associated with high morbidity and mortality. We present the first case of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a life saving device for treating a patient with severe cardiogenic shock after a high voltage electrical injury. CASE PRESENTATION: A 26-year-old male sustained HVEI while working with a concrete mixer pump that came in contact with a high voltage cable of 10,000 V. He was immediately disconnected from the mixer pump, underwent cardiopulmonary resuscitation and was transported to the nearest medical centre with severe cardiogenic shock with an ejection fraction (EF) of < 10%. Upon arrival, he was in critical condition, sedated and mechanically ventilated, haemodynamically unstable and supported by intravenous (IV) inotropes after a few events of ventricular fibrillation, with an electrical entry point on the left hand and an exit point located on his right leg. Blood pH was 6.8, PCO2 53 mmHg, PaO2 of 57 mmHg, lactate 8 mmol/L, and Troponin 38,000 ng/dl. The EF was 10% with global severe left ventricular dysfunction. During cardiopulmonary resuscitation (CPR), including cardiac massage and few electrical shocks, he was immediately connected to the VA-ECMO via open right femoral approach with distal arterial leg perfusion. He was treated with IV broad spectrum antibiotics, and high volume fluids to prevent rhabdomyolysis-induced acute kidney injury, total parenteral nutrition, topical silver sulfadiazine cream, and Granuflex for severe electrical burns. He was gradually weaned from inotropes over the next 3 days, during which his clinical condition and bloodwork improved tremendously. His EF gradually increased to 50% and he was weaned from the VA-ECMO, and underwent decannulation 86 h after initialization. He was discharged on day 27 without any sequelae. CONCLUSION: The VA-ECMO treatment can be a lifesaving device for treating severe cardiogenic shock caused by high voltage electrical injury, and should be considered while treating these "high-mortality risk" patients.

Dental screening prior to valve interventions: Should we prepare transcatheter aortic valve replacement candidates for "surgery"?

BACKGROUND: 40% of cases of infective endocarditis (IE) are likely caused by oral bacteria. IE prevalence after transcatheter aortic valve replacement (TAVR) is comparable to IE following surgical prosthetic valve replacement (SVR). Current guidelines recommend pre-operative dental screening for SVR, without specific recommendations regarding TAVR. We aimed to compare oral dental findings in TAVR vs. surgical valve replacement (SVR) candidates and assess the need for routine dental screening and treatment prior to TAVR similar to the SVR patients. METHODS: 150 patients (58 TAVR candidates and 92 surgical candidates) were all referred for screening and appropriate treatment before intervention to our Oral medicine team, blinded to the planned interventional type. All patients were scored for oral hygiene and dental findings that required intervention. An oral health score (OHS, general hygiene: 0-good, 1-bad, need for immediate treatment: 0-no, 1-yes, need for future treatment: 0-no, 1-yes) was calculated and compared. Patients were clinically followed for IE for 14 ±â€¯5 months (rage 8-28) post intervention. RESULTS: While candidates for SVR were younger than TAVR (66 + 10 vs. 81 ±â€¯6 respectively, P < 0.0001), oral-dental findings were similar. OHS was 1.6 for SVR and 1.7 for TAVR candidates, p = 0.45). Half of patients in either group had findings requiring pre-procedural dental treatment. There were two IE cases during follow-up, one in each group. CONCLUSION: Oral health and need for pre-procedural dental treatment were not different among candidates for SVR and TAVR. IE preventive oral-dental care seems to be justified in patients undergoing TAVR initially denied SVR due to prohibitive operative risk.

Serum BNP levels are associated with malignant pericardial effusion.

INTRODUCTION: The development of malignant pericardial effusion indicates a poor prognosis and is the leading cause of cardiac tamponade. The objectives of the study were to examine the levels of BNP in traumatic, malignant and non-malignant pericardial effusion etiologies, and to assess the value of serum and pericardial fluid BNP levels in the prognosis of malignant pericardial effusion. METHODS: A of 56 patients with clinical and echocardiographic diagnosis of pre-tamponade or tamponade who required pericardiocentesis were included in the study. BNP levels were assessed in the serum and within the pericardial fluid. The diagnostic value of BNP levels in discriminating between malignant and non- malignant etiology of pericardial effusion was examined using a receiver-operating characteristic (ROC). RESULTS: Pericardial fluid BNP levels were similar across all etiology groups. In patients with malignant etiology, the amount of pericardial fluid was high and their serum BNP levels were relatively low. BNP levels were strong predictors of malignant pericardial effusion, and the cut-off point of BNP ≤ 250 pg/ml demonstrated the highest sensitivity (90.0%) for malignant etiology. CONCLUSIONS: Low serum BNP levels were significantly associated with malignancy in patients undergoing pericardiocentesis for pericardial effusions. Serum BNP levels <250 pg/ml may trigger more extensive diagnostic testing for malignant pericardial effusion in patients with small pericardial effusion who are not considered for pericardiocentesis due to small effusion, in whom the etiology is unclear.

Natriuretic peptides system in the pulmonary tissue of rats with heart failure: potential involvement in lung edema and inflammation.

Congestive heart failure (CHF) often leads to progressive cardiac hypertrophy and salt/water retention as evident by peripheral and lung edema. Although the pathogenesis of CHF remains largely unclarified, it is widely accepted that neurohormonal changes and inflammatory processes are profoundly involved in structural and functional deterioration of vital organs including, heart, kidney and lungs. Corin, a cardiac serine protease, is responsible for converting pro-ANP and pro-BNP to biologically active natriuretic peptides (NPs). Although the involvement of corin in cardiac hypertrophy and heart failure was extensively studied, the alterations in corin and PCSK6, a key enzyme in the conversion of procorin to corin, have not been studied in the pulmonary tissue. Thus, this study aims at examining the status of PCSK6/Corin in the lung of rats with CHF induced by the creation of aorto-caval fistula (ACF) between the abdominal aorta and vena cava in SD rats. Rats with ACF were divided into 2 subgroups based on the pattern of their daily sodium excretion, compensated and decompensated CHF. Placement of ACF led to cardiac hypertrophy, pulmonary congestion, and renal dysfunction, which were more severe in the decompensated subgroup, despite remarkable elevation of circulatory ANP and BNP levels. Corin mRNA and immunoreactive peptide were detected in pulmonary tissue of all experimental groups. However, the expression and abundance of pulmonary corin significantly increased in the decompensated animals, but not in the compensated ones. Noteworthy, the expression of PCSK6 and ANP/BNP in the pulmonary tissue followed a similar pattern as corin. The upregulation of pulmonary Corin/PCSK6 and NPs were accompanied by local activation of cathepsin L and certain cytokines including IL-6. In light of the anti-inflammatory role of NPs, we postulate that the obtained upregulation of pulmonary PCSK6/Corin along NPs in rats with decompensated CHF may represent a counterbalance response to the inflammatory milieu characterizing CHF especially in severe cases.

Ethnicity of Symptomatic Coronary Artery Disease Referred for Coronary Angiography in the Galilee: Prevalence, Risk Factors, and a Case for Screening and Modification.

BACKGROUND: Coronary artery disease (CAD) has known risk factors. Individual risks related to specific ethnicities are complex and depend on genetic predisposition and lifestyle. OBJECTIVES: To compare the nature and prevalence of risk factors in Arab and non-Arab ethnic patients with symptomatic obstructive CAD referred for coronary angiography. METHODS: CAD, defined as coronary angiography with a ≥ 50% narrowing in ≥ 1 vessel, was diagnosed in 1029 patients admitted to a medical center between April 2014 and October 2015. Patients were divided into two groups according to ethnic origin: Arab vs. non-Arab. Demographics, clinical presentation, and coronary risk profiles were compared. RESULTS: The diagnosis of CAD was made during ST-elevation myocardial infarction (STEMI) in 198 patients (19%) who arrived at the clinic, 620 (60%) with unstable angina/non-STEMI, and 211 (21%) with stable angina. Patients with symptomatic CAD and Arab ethnicity were 47% more prevalent than non-Arab patients presenting with CAD. The Arab patients were appoximately 5 years younger, 50% more likely to be active smokers, 25% more likely to be obese, and more likely to have a family history of CAD. Other coronary risk factors were similar between the two groups. CONCLUSIONS: Smoking and obesity, which are potentially modifiable CAD risk factors, stood out as major risk factors, in addition to genetic disposition, among Arab and non-Arab patients with symptomatic CAD. Screening and educational interventions for smoking cessation, obesity control, and compliance to treatment of co-morbidities should be attempted in order to decrease CAD in the Arab population.

Clinical and echocardiographic characteristics of patients in sinus rhythm, normal left ventricular function, and indeterminate diastolic function.

BACKGROUND: Diastolic dysfunction (DDFx) is the major underlying mechanism of heart failure with preserved left ventricular ejection fraction (EF). Yet, the echocardiographic diagnosis of DDFx in patients in sinus rhythm is challenging and up to 25% of studies have discrepant measures making assessment of DDFx indeterminate. We aimed to describe the clinical and echocardiographic characteristics of patients with indeterminate diastolic function compared to patients with definite normal and abnormal diastolic function. METHODS: One thousand six hundred seventy-four patients were identified from the echocardiography database in sinus rhythm, EF ≥ 45% without wall-motion abnormalities, valvular, congenital heart diseases, cardiomyopathies or pulmonary disease. Patients were divided according to their lateral mitral E/E' ratio and left atrial systolic diameter: normal diastolic function (DFx) (left atrial systolic diameter [LASd] <40 mm, E/E' < 10), DDFx (LASd ≥ 40 mm, E/E' ≥ 10) and indeterminate DFx (discrepant LASd diameter and E/E' ratio). RESULTS: Clinical and echocardiographic characteristics of the 3 groups, DDFx (n = 186), indeterminate diastolic function (IndtDFx) (n = 207), and normal diastolic function (NDFx) (n = 1281) were significantly different. IndtDFx demonstrated intermediate parameter abnormalities, largely overlapping with DDFx. LASd and E/E' were similarly associated with the inability to determine diastolic function. Age, female gender, renal failure, E/E' and pulmonary pressure were found to be independent predictors of heart failure symptoms (RR = 1.02, 1.5, 2.5, 1.1, 1.1, respectively, P < .0001, r = .35). CONCLUSION: Clinically and echocardiographically patients with IndtDFx are more closely related to DDfx than to NDFx. Although LAd was abnormal in IndtDFx it was not predictive of heart failure symptoms. Further study is suggested to establish whether LA function rather than its maximal size can provide additional information.

Left Circumflex Coronary Artery as the Culprit Vessel in ST-Segment-Elevation Myocardial Infarction.

The prevalence of the left circumflex coronary artery (LCx) as the culprit vessel in ST-segment-elevation myocardial infarction (STEMI) is reportedly lowest among that of the 3 main epicardial arteries, and has not been described for non-STEMI (NSTEMI) and stable angina pectoris. We sought to define the distribution of culprit arteries in these clinical presentations and suggest mechanisms for the differences. We reviewed 189 coronary angiograms of patients with STEMI, 203 with NSTEMI, and 548 with stable angina (n=940), and compared distributions of stenotic and culprit coronary arteries (lesions prompting intervention). Obstructive coronary lesions (≥50% narrowing) were more prevalent in the left anterior descending coronary artery (LAD) (36%-38%) and similar in the LCx and right coronary artery (RCA) (27%-29%), regardless of clinical presentation (P <0.01). In NSTEMI and stable angina, culprit vessels and total obstructive disease had the same distribution. In STEMI, however, a culprit LCx was significantly less prevalent (17%) than was total obstructive disease (27%; P <0.01), or a culprit LAD (47%) or RCA (34%) (both P <0.001). In our computed tomographic angiographic model of coronary longitudinal strain (percentage of shortening), LCx strain was only 1.5% ± 2.4%, versus 9.5% ± 2.9% for LAD strain and 10.1% ± 3.9% for RCA strain. In STEMI, LCx plaques seem less prone to rupturing. Culprit and total disease distributions are similar in NSTEMI and angina, suggesting a different ischemic pathophysiology in these presentations. Lower LCx longitudinal strain might contribute to reduced plaque rupture in STEMI.

[SUDDEN CARDIAC DEATH IN A YOUNG ADULT WITH DIFFUSE CORONARY ARTERY DISEASE].

INTRODUCTION: We present a very unusual case in which a high-school student was admitted to our cardiac center unconscious and intubated after suffering from out of hospital SCD. There was no history of fever, substance abuse, family history of sudden cardiac death and/or coronary artery disease, arthralgia, hypercoagulable state or familial hyperlipidemia. An emergent coronary angiogram revealed diffuse obstructive coronary artery disease which was treated with several stents. The following days of his admission were characterized by hemodynamic instability, necessitating temporary support via extracorporeal membrane oxygenation (ECMO), from which he was weaned off at a later stage. A full work-up regarding the etiology of the premature coronary artery disease was negative including cardiac magnetic resonance imaging, yet an empirical steroids course trial was given. Eventually, the patient regained full recovery, both cardiac and neurological, and returned to his usual daily activities. BACKGROUND: Diffuse coronary artery disease at a young age, manifesting itself as sudden cardiac death (SCD) is a rare event.

Comparison of echocardiographic parameters between pre-clinical and clinical advanced diastolic dysfunction patients.

BACKGROUND: The diagnosis of heart failure (HF) with preserved ejection fraction requires evidence of grade 2 or 3 (advanced) diastolic dysfunction (ADD), but many patients with ADD do not have clinical HF manifestations, hence termed pre-clinical diastolic dysfunction (PDD). The prevalence and characteristics of PDD in comparison to overt HF disease (clinical-ADD) are still debated. METHODS: We retrospectively analyzed 373 patients with LVEF≥45% and ADD in our echo-lab database. Exclusion criteria were acute coronary syndromes, ≥moderate valvular disease, cardiomyopathies or pericardial disease. Patients were divided into 2 groups according to the presence/absence of HF symptoms, namely PDD (n=249) and clinical-ADD (n=124). Demographic, clinical and echocardiographic parameters were compared between the groups. RESULTS: Age, gender and comorbidities were similar between groups, with only a higher body mass index and renal failure significantly more prevalent in the clinical-ADD patients. Neither LV mass nor the ADD severity was related to the presence of symptoms; lateral mitral E/E' and pulmonary artery systolic pressure were significantly higher in clinical-ADD patients (14±5 vs. 12±4, p<0.05 and 40±13 vs. 36±11mmHg, p<0.05, respectively) and were the only parameters to correlate with the presence of symptoms of clinical-ADD in multivariable logistic regression (odds ratio=1.07 (CI 1.02-1.1, p=0.008) and 1.03 (CI 1.01-1.05, p=0.01), respectively). CONCLUSIONS: In patients referred for an echocardiogram at a community cardiology center, PDD was twice as common as clinical-ADD. Hemodynamic parameters reflecting elevated filling and pulmonary pressures, rather than traditional comorbidities and/or classical structural abnormalities, were the only parameters related to the presence of HF symptoms.

Takotsubo cardiomyopathy caused by epinephrine-treated bee sting anaphylaxis: a case report.

INTRODUCTION: Stress-induced cardiomyopathy (Takotsubo) after bee stings in patients who have received catecholamines is rare. Endogenous as well as exogenous administration of catecholamines is thought to trigger stress-induced cardiomyopathy. CASE PRESENTATION: A 37-year-old healthy white woman was stung by an unknown Hymenoptera that resulted in an anaphylactic reaction. Intravenous adrenaline (0.9 mg) was administered at a nearby clinic; she was transferred to our emergency room. Cardiogenic shock was diagnosed and mechanical ventilation commenced. Hemodynamic stabilization was not achieved by inotropic support and intra-aortic balloon pump insertion. Initial coronary angiography did not demonstrate any coronary obstructive lesions while her left ventricular systolic function was severely depressed. Peripheral femoral venoarterial extracorporeal membrane oxygenation was inserted as a bridge to recovery assuming possible reversible cause of the cardiogenic shock. Over the following 48 hours she was extubated and gradually weaned off venoarterial extracorporeal membrane oxygenation and inotropic support. She was discharged with a near normal left ventricular ejection fraction and in 3 weeks she was asymptomatic with normal electrocardiographic and echocardiographic examinations (left ventricular ejection fraction >65 %). CONCLUSIONS: A Hymenoptera sting may be a specific cause of catecholamine cardiac depression. The presence of cardiogenic shock and its etiology should prompt aggressive management including extracorporeal membrane oxygenation as a bridge to cardiac functional recovery in such rare scenarios.

Serum corin is reduced and predicts adverse outcome in non-ST-elevation acute coronary syndrome.

BACKGROUND AND OBJECTIVES: The aim of the current study was to describe the role of corin, an enzyme that cleaves pro-atrial natriuretic peptide and pro-brain natriuretic peptide into their active peptides, in patients with acute coronary syndrome (ACS). METHODS: Serum corin level was studied in patients with non-ST-elevation ACS who underwent percutaneous coronary intervention (n=152) and in control volunteers (n=103). RESULTS: The corin level was lower in acute coronary syndrome patients (798±288 pg/ml) than in the controls (1165±613 pg/ml, p<0.0001). Those acute coronary syndrome patients who developed major adverse cardiovascular events (MACE; 60.9%) within 3 years of discharge had lower corin levels than the patients who did not experience major adverse cardiovascular events (698.16±233.67 vs. 952.1±297.81 pg/ml, p<0.0001). Using a multiple logistic regression model, corin level was a significant predictor of post-ACS MACE: p=0.0004 for 50 pg/ml steps, AUC 0.791, while p<0.0001, and AUC 0.804 using corin and brain natriuretic peptide as predictors. CONCLUSIONS: Patients with non-ST-elevation ACS have lower serum corin levels than controls. Corin levels are lower in ACS patients who later experience MACE and thus might be predictor for MACE. This new putative biomarker may be useful, either alone or in combination with other biomarkers, for cardiovascular risk stratification assessment and outcome prediction in ACS patients.