2016 Vol. 13, No. 11
Optimizing Care for ST-elevation Myocardial Infarction Patients: Application of Systems Engineering
Background Recurrence of takotsubo cardiomyopathy (TTC) is a well-known complication. However, current literature lists only a few isolated cases. We aimed to determine the incidence and clinical significance of recurrent TTC. Methods & Results Our institutional database constituted a collective of 114 patients diagnosed with TTC since 2003. Close follow-up of these patients revealed a recurrence of TTC in seven of these (6.1%). The time interval between the index event and its recurrence varied between six months and six years. Arterial hypertension was more revealed in the recurrence group of TTC compared to non-recurrence group, (P = 0.02). Chronic obstructive pulmonary disease and/or asthma was more diagnosed in the recurrence group, (P = 0.04). Clinical events like right ventricular involvement, TTC related complications such as life-threatening arrhythmias, pulmonary congestion and in hospital death were observed more frequently in the recurrent episode. Over a mean follow-up of one year the mortality rate was similar in both groups. Conclusions Recurrence of TTC with?in six years after index event is not an uncommon phenomenon. In the event of right ventricular involvement in the relapse phase, it might be associated with a higher complication rate. TTC recurrence should be the first differential diagnosis in patients with a past history of TTC.
Objectives To investigate the prevalence and characteristics of pulmonary embolism (PE) at autopsy in a Chinese general hospital over a period of 10 years, and to evaluate the antemortem achievement of the prophylaxis, diagnosis, and treatment of PE. Methods All medical records of deaths from the West Branch of the Chinese People’s Liberation Army (PLA) General Hospital were retrospectively reviewed, for the period of January 1, 2006 to December 31, 2015. Cases in which autopsies had been performed were identified and further analyzed. The numbers and detailed characteristics of patients who had PEs were noted. Prophylactic measures, along with diagnosis and treatment of PE, were recorded, if performed. Results During the 10-year period, 1057 patients died in the study hospital and 278 necropsies were performed (autopsy rate: 26.3%). Nine patients were found to have PE (3.2%), and in seven of these patients (2.5%), the PE was considered to be fatal. Embolisms were found in the trunk and bilateral main branches of the pulmonary artery tree in all seven of the fatal PE cases. Right intracardiac thrombosis was detected in five of the nine PE patients (55.6%). All patients with PE had been hospitalized in medical departments, and only one had undergone surgery during hospitalization. Antemortem prophylaxis was performed in two of the nine PE cases (22.2%). None of the 9 patients had received a clinical diagnosis of PE before death. Conclusions The incidence of and death rate associated with PE may vary among different races and regions. Continuous monitoring of PE by means of necropsy in certain representative medical institutions is necessary.
Background This prospective study integrated multiple clinical indexes and inflammatory markers associated with coronary atherosclerotic vulnerable plaque to establish a risk prediction model that can evaluate a patient with certain risk factors for the likelihood of the occurrence of a coronary heart disease event within one year. Methods This study enrolled in 2686 patients with mild to moderate coronary artery lesions. Eighty-five indexes were recorded, included baseline clinical data, laboratory studies, and procedural characteristics. During the 1-year follow-up, 233 events occurred, five patients died, four patients suffered a nonfatal myocardial infarction, four patients underwent revascularization, and 220 patients were readmitted for angina pectoris. The Risk Estimation Model and the Simplified Model were conducted using Bayesian networks and compared with the Single Factor Models. Results The area under the curve was 0.88 for the Bayesian Model and 0.85 for the Simplified Model, while the Single Factor Model had a maximum area under the curve of 0.65. Conclusion The new models can be used to assess the short-term risk of individual coronary heart disease events and may assist in guiding preventive care.
In recent decades, the outcomes of coronary heart disease (CHD) have markedly improved, which can be partly attributed to the use of novel drugs (especially statins and antiplatelet drugs) and partly to the evolution of percutaneous coronary intervention (PCI). From percutaneous transluminal coronary angioplasty to bare-metal stent and then to drug-eluting stent, every step of PCI is attractive to interventional cardiologist, great progress has been made for patients with CHD. In the past few years, some successor devices for treating CHD have emerged. Undoubtedly, drug-coated balloon (DCB), which was recommended by 2014 ESC Guidelines on myocardial revascularization, is a “shining star” among them. DCB involves a semi-compliant angioplasty balloon coated with an anti-proliferative agent that can exert antirestenotic efficacy by permeating into the vessel wall during balloon contact. This review discusses the conception and merits, preclinical data, emerging clinical indications, and results from clinical trials of this novel interventional technology. Although DCB has shown authentic efficacy in the treatment of in-stent restenosis, its use in de novo coronary lesions is still in dispute. Hence, concerns and the future direction of DCB are also covered in this paper.
Despite significant therapeutic advances, patients with chronic heart failure (HF) remain at high risk of morbidity and mortality. Sacubitril valsartan (previously known as LCZ696) is a new oral agent approved for the treatment of symptomatic chronic heart failure in adults with reduced ejection fraction. It is described as the first in class angiotensin receptor neprilysin inhibitor (ARNI) since it incorporates the neprilysin inhibitor, sacubitril and the angiotensin II receptor antagonist, valsartan. Neprilysin is an endopeptidase that breaks down several vasoactive peptides including natriuretic peptides (NPs), bradykinin, endothelin and angiotensin II (Ang-II). Therefore, a natural consequence of its inhibition is an increase of plasmatic levels of both, NPs and Ang-II (with opposite biological actions). So, a combined inhibition of these both systems (Sacubitril / valsartan) may enhance the benefits of NPs effects in HF (natriuresis, diuresis, etc) while Ang-II receptor is inhibited (reducing vasoconstriction and aldosterone release). In a large clinical trial (PARADIGM-HF with 8442 patients), this new agent was found to significantly reduce cardiovascular and all cause mortality as well as hospitalizations due to HF (compared to enalapril). This manuscript reviews clinical evidence for sacubitril valsartan, dosing and cautions, future directions and its considered place in the therapy of HF with reduced ejection fraction.
The primary cardiac tumors are extremely rare tumors that arise from the normal cardiac tissues. There are benign variants (mostly myxoma) and malignant tumors. Fibroelastoma (FE) is the most common primary tumor, of which myxoma is the most common subtype followed by papillary fibroelastomas (PFE). They account for the majority of primary heart valvular tumors that mainly involve the left (mitral and aortic) valves, and only few cases reported pulmonary valve PFE . We present a case of 61 year old female who had incidental pulmonary valve papillary fibroelastoma finding on echo along with anomalous coronary arteries.
Dermatomyositis is an idiopathic systemic inflammatory disorder that rarely affects the cardiac muscles. It has shown to be associated with various arrhythmias frequently manifesting as conduction disturbances. There are few case reports regarding dermatomyositis and ventricular tachyarrhythmias. Moreover, data regarding clinical experiences and outcome of radiofrequency catheter ablation (RFCA) for ventricular tachycardia (VT) in dermatomyositis is limited. We report a 51-year old male patient with dermatomyositis presented at our hospital for recurrent palpitation caused by VT.The VT was isoproterenol-triggered, adenosine-suppressed, and focally originating from the posteroinferior right ventricular septal area. The most likely mechanism is abnormal automaticity. A successful 3D-electroanatomical mapping-guided RFCA at the earliest activation sites cured VTs with no recurrence. It suggests that RFCA is safe and effective for focal VTs in dermatomyositis patients.
Letter to the Editor
A 76 year old female patient with chronic polydipsia and abnormal circadian blood pressure oscillations with periodic daily hypertension in the afternoon despite antihypertensive treatment is described. The abnormal diurnal blood pressure rise spontaneously disappeared when her daily drinking volume was reduced to normal. She began voluntary polydipsia after an episode of painful urolithiasis 12 years ago when she was advised to maintain a high daily fluid intake to prevent a relapse. During clinical workup, no other etiologic factor could be detected to explain the high diurnal blood pressure changes. Four years earlier, she had suffered an ischemic stroke in the vertebrobasilar territory caused by cerebral microangiopathy. She showed mild renal insufficiency, a residual neurologic syndrome after stroke and hypertensive heart disease with normal left ventricular ejection fraction. Plasma Na and other electrolytes were normal. A renal ultrasound exam was unremarkable and excluded renal artery stenosis. Extended laboratory investigations including plasma and urinary glucocorticoids, mineralocorticoids, metanephrins, thyroid function tests and the plasma aldosterone/renin ratio were also normal. We discuss abnormal control of volume homeostasis by hormonal and renal mechanisms and abnormal central blood pressure regulation following brain stem infarction as potential causal mechanisms to explain the association of polydipsia with the recurrent diurnal hypertension in our patient. Although chronic polydipsia may be rare, it may occasionally be a modifiable cause contributing to blood pressure elevations and treatment resistance of hypertension particularly when volume handling is impaired by concomitant disease.
In the emergency department, early diagnosis and detection is required as delays in treatment can result in lives lost. Acute coronary syndrome (ACS) and acute aortic syndrome (AAS) are different disease entities with some similar pathophysiology and rarely occur in a single scenario. A 61-year-old female presented to the emergency room with dull, anterior chest pain of one day duration. She had a past history of Type 2 diabetes mellitus, essential hypertension and dyslipidemia. Her initial electrocardiogram (EKG) demonstrated 0.5 mm/mV ST-segment elevation in leads III and aVF and 0.5 mm/mV ST-segment depression in leads I, aVL, V4 - V6. Her chest CT scan demonstrated blood leaks through the wall but contained by the adventitia at anteromedial portion of upper descending thoracic aorta. We performed percutaneous coronary artery intervention (PCI) of right coronary artery and thoracic endovascular aneurysm repair (TEVAR) in one procedural time. It is important to exclude acute aortic syndromes before reperfusion therapy in patients presenting with AMI. And commonly one disease entity is the cause of the symptom and is given focus; however, as seen in this case, two disease entities are involved and happening concomitantly.
I have read the article entitled “Is cardiac resynchronisation therapy feasible, safe and beneficial in the very elderly?” by Olechowski et al. (1) with great interest, recently published in Journal of Geriatric Cardiology 2015; 12: 497-501. The investigators reported that implantation of CRT is feasible and safe in very elderly despite extensive co-morbidity (1).