Enfermedad de Tako-Tsubo / The Tako-Tsubo disease

La enfermedad de “Tako-Tsubo”, conocida también como miocardiopatía de Tako-Tsubo o miocardiopatía por estrés, está caracterizada por dolor torácico, anormalidades del segmento ST-onda T en el ecosonograma, niveles séricos elevados de enzimas cardíacas y alteraciones en la motilidad del VI consistentes en acinesia apical extensa de carácter reversible. Describir las características clínicas y la experiencia del Centro Cardiovascular La Floresta en pacientes con miocardiopatía de Tako-Tsubo. Se realizó el diagnóstico de miocardiopatía de Tako-Tsubo en función de los criterios mayores y menores a pacientes ingresados a la sala de emergencia en el contexto de síndrome coronario agudo, sometidos a evaluación angiográfica, ecocardiográfica y egresados con seguimiento clínico y ecocardiográfico entre enero de 2006 a enero de 2008. De 288 pacientes 14 (5 %) cumplieron con criterios diagnósticos para miocardiopatía de Tako-Tsubo, todos refirieron estrés psicológico como desencadenante, cinco de estos 14 pacientes (36%), padecían de neoplasias malignas bajo tratamiento con quimioterapia, con edades promedio de 62 ± 12 años, de los cuales 9 (64%) fueron mujeres, todos con elevación de marcadores enzimáticos. Al ecosonograma presentaron alteraciones. En el ecocardiograma los pacientes tuvieron evidencia de acinesia apical y la fracción de eyección que estuvo por encima del límite inferior. Todos fueron sometidosa angiografía coronaria convencional y ventriculografía. La miocardiopatía de Tako-Tsubo es una entidad bien definida que imita a un síndrome coronario agudo. La estrategia diagnóstica está basada en la angiografía coronaria precoz sin omitir la ventriculografía. Especial interés debe ser puesto en pacientes con enfermedades neoplásicas que reciban quimioterapia.

Tako-Tsubo” disease, also known as apical ballooning of the left ventricle or stress cardiomyopathy, is characterized by resting chest pain, ST-T changes on the ECG, elevated cardiac biomarkers and reversible extensive apical akinesis which mimics, at end systole, a japanese jar used to trap octopodes called “Tako-Tsubo”. To describe our experience at the “Instituto Médico La Floresta” in patients with Tako-Tsubo disease. The diagnosis of Tako-Tsubo disease was made based on major and minor criteria to patients admitted to the emergency department with the diagnosis of acute coronary syndrome, between january 2006 and january 2008. All patients underwent cardiac catheterization, coronary angiography, left ventriculography and transthoracic echocardiography and were followed-up clinically and with echocardiography for 6 months. Of 288 patients, 14 (5%) met the criteria for Tako-Tsubo disease, all had emotional stress as a trigger, 5 of these 14 pts (36%) had malignancies on chemotherapy. The age range was 62±12 years, 9 patients (64%) were women, all with elevated CK and CK-MB and 7 (50%) had also increased troponin levels. On the ECG 11 patients (79%) had inverted T waves and 3 (21%) showed ST segment elevation. One patient (7%) developed non-sustained ventricular tachycardia. On the echocardiogram and left ventriculography all showed the typical pattern of Tako-Tsubo disease at end systole and none had neither evidence of left ventricular outflow tract obstruction nor coronary artery disease. Tako-Tsubo disease is a distinct entity which mimics an ACS. The suggested approach is an early diagnostic coronary angiography with left ventriculography. Patients with malignancies on chemotherapy deserve special attention.

Subtle neurological deficits and psychopathological findings in substance-abusing homeless and non-homeless veterans.

This study evaluated the hypothesis that homeless individuals would display higher levels of neurological deficits than non-homeless individuals, particularly in frontal lobe or executive functions. Eighteen acutely homeless, 15 chronically homeless, and 20 non-homeless individuals admitted to an inpatient psychiatric service received a battery of neurological and psychosocial measures. In comparison to non-homeless subjects with comparable levels of psychopathology, homeless individuals showed higher levels of hostility, prior criminal activity, and family history of psychiatric illness, but lower levels of depression. A positive relationship between hostility and neurological soft signs was observed among chronically homeless subjects. These results suggest that a substantial subset of nonpsychotic homeless veterans suffers from "occult" neurological deficits.

Cardiac manifestations of cocaine abuse: a cross-sectional study of asymptomatic men with a history of long-term abuse of "crack" cocaine.

OBJECTIVES: The objective of this study was to evaluate the prevalence of cardiac abnormalities in young, asymptomatic long-term "crack" cocaine abusers. BACKGROUND: Although the cardiac complications of cocaine abuse have received widespread attention, the prevalence of cardiac abnormalities in asymptomatic long-term cocaine abusers is unknown. METHODS: History, physical examination, electrocardiogram (ECG) and echocardiogram were performed in 52 consecutive long-term cocaine abusers admitted to a drug rehabilitation program. Findings were compared with those in 14 age-matched normal volunteers and 14 age-matched normotensive patients admitted to a psychiatric service who had a pattern of smoking and alcohol consumption similar to that of the study patients. RESULTS: The ECG findings were abnormal in 29% of cocaine abusers, and included nonspecific ST-T wave changes in 15%, abnormal ST segment elevation in 10%, old inferior infarction in 2%, old anteroseptal infarction in 2% and abnormal precordial R wave progression in 10%. When compared with normal volunteers and control patients, cocaine abusers had increased left ventricular posterior wall thickness (1.12 vs. 0.76 and 0.85 cm, respectively, p < 0.0001), increased septal thickness (1.13 vs. 0.76 and 0.86 cm, p < 0.001) and higher left ventricular mass index (142 vs. 84 and 94 g/m2, p < 0.0001). Left ventricular diastolic filling variables did not differ significantly among the three groups. Diastolic filling variables were similar in cocaine abusers with and without left ventricular hypertrophy, and the prevalence of left ventricular hypertrophy did not differ significantly between those who used no alcohol or < 35 ml/week of alcohol and those who consumed > or = 500 ml/week of alcohol. Left ventricular segmental wall motion abnormalities were present in 11 subjects (21%) and the ejection fraction was decreased (< 0.45) in 2 (4%). CONCLUSIONS: Electrocardiographic and echocardiographic abnormalities are common in long-term cocaine abusers. Despite the frequent occurrence of left ventricular hypertrophy, Doppler-derived diastolic filling pattern was not altered. Concomitant alcohol use did not affect the prevalence of these abnormalities.

Phenomenology and course of psychiatric disorders associated with combat-related posttraumatic stress disorder.

OBJECTIVE: Studies indicate that chronic combat-related posttraumatic stress disorder (PTSD) is frequently associated with other psychiatric disorders. Questions regarding the nature and interrelationships of these conditions require clarification. The purpose of this study was to address primary and secondary illness relationships by focusing on the specific phenomenology and course of illness onset of PTSD comorbidity. METHOD: In order to minimize confounding factors, only outpatients without recent substance use disorders were included. Sixty subjects who had been exposed to severe combat stress including veterans of Vietnam and veterans of World War II or Korea, 15 of whom were former prisoners of war, received structured assessments over serial evaluations. RESULTS: PTSD was the most prevalent lifetime disorder followed by major depression, panic disorder, generalized anxiety disorder, and phobic disorder or symptoms. Endogenous-appearing features overlapping other clinical populations were common; however, some specific symptom patterns also were suggestive of traumatic influence. Unlike generalized anxiety disorder and past substance use, the mean onset of phobias, major depression, and panic disorder, respectively, occurred later than PTSD. CONCLUSIONS: These observations suggest that persistent conditions related to PTSD progress toward symptoms that are increasingly autonomous in their pattern of occurrence.

Patient noncompliance and overcompliance. Behavior patterns underlying a patient's failure to 'follow doctor's orders'.

The vicissitudes of medical treatment are affected in large part by patient compliance. Noncompliance can be caused by a variety of psychological, somatic, and socioeconomic factors. Overcompliance would seem on the surface to be less of a problem, but it too can have serious consequences in terms of treatment success. Several psychological factors account for overcompliance. The physician's best defenses against both noncompliance and overcompliance are to listen carefully to the patient for clues to one of these impending behaviors and to establish good rapport with the patient. An individualized approach is important, and in some cases participation in organized self-help groups is of benefit.

Influence of age on lithium therapy.

Contradictory information exists with respect to lithium dosage in elderly patients with affective disorders. To determine the relationship between age and lithium blood levels, we studied 66 outpatients in stable condition and receiving maintenance lithium therapy. The salient question was whether the same dosage of lithium will produce similar blood levels in both old and young adults. Our results revealed no significant correlation between age and dosage. The data suggest that the dosage of lithium required to maintain a therapeutic blood level is the same regardless of age. We therefore suggest that lithium therapy be individualized according to the total clinical picture rather than chronologic age.