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Clinical features of takotsubo cardiomyoathy in north america
The 8th Annual Scientific Meeting
•
HFSA
S41
084
086
Clinical Features of Takotsubo Cardiomyoathy in North America Roopinder Sandhu,1 Mazen Hanna,1 Robert C. Bahler1; 1Heart and Vascular Center at MetroHealth, Case University School of Medicine, Cleveland, OH
Plasma Nt-proBNP is Elevated in Adults with Sickle Cell Disease without Clinical Heart Failure Aloir Q. Araujo,1 Edmundo Arteaga,1 Paula Buck,1 Jose Leao,1 Charles Mady1; 1 Cardiomyopathies Unity, Heart Institute (INCOR) - University of Sao Paulo Medical School, Sao paulo, SP, Brazil
Background: Tako-tsubo (octopus trap) cardiomyopathy (TTC), first described in Japan, refers to an acute, novel form of left ventricular (LV) systolic dysfunction with a unique LV configuration due to the combination of apical akinesis yet preserved basal function. This clinical syndrome, initiated by an acute stress, is not widely recognized in North America. Purpose: We report the clinical features of 10 patients seen in our community hospital over 22 months. Methods: Patients were identified from the consultation, cardiac catherization and echocardiography services. Inclusion criteria were an acute stress, abnormal repolarization on the electrocardiogram (ECG), abnormal cardiac enzymes, abnormal left ventricular (LV) systolic function with apical akinesis/hypokinesis and partial or full resolution. Patients with a clinical presentation consistent with acute myocarditis, an acute coronary syndrome or obstructive coronary artery disease were excluded. Clinical data abstracted from the medical record included the precipitating event, treatment modalities and time course of illness, laboratory data, ECGs and imaging data. Results: Most patients were women (8/10) with mean age of 59 years (range 40–79). None had prior cardiac disease. A precipitating event could be identified in all as either a physical stress (9), most commonly respiratory failure, or emotional stress (1). Initial ECG changes were sinus tachycardia in 7 with ST elevation in 4 and depression in 1. T wave inversions developed in all 10 patients, 5 with changes only in anterolateral leads, 4 with anterolateral and inferior inversions and 1 with lateral changes only. Initial QTc was prolonged in 6 patients with a group mean of 475 msec (range 430–590). Cardiac enzymes were elevated: median troponin I ⫽ 3.4 IU (range 2–164) and median CKMB% ⫽ 5.1 (range 1.3–10.9). Echocardiography showed a characteristic LV wall motion pattern with marked apical dysfunction and preserved basal function in all patients. Right ventricular wall motion was abnormal in 4/6. The LV ejection fraction initially was 27% ⫾ 7 and at follow up 53% ⫾ 8 with a mean elapsed time of 17 days. Coronary angiography showed no CAD in 6 and ⬍ 70% stenoses in 2; adenosine nuclear scan was normal in 1 patient. Conclusions: TTC is a distinctive yet under recognized cardiac syndrome. The discordance between the initial severity of LV dysfunction and the minimal elevations of cardiac enzymes is striking. Recovery of ventricular function begins within days of the inciting event. Increased awareness of this novel cardiomyopathy will advance our ability to investigate the pathophysiology.
Background: NT-proBNP (amino-terminal pro-brain natriuretic peptide) is elevated in the plasma of patients with cardiac disfunctions Objectives: To evaluate the plasmatic levels of NT-proBNP in adult patients (pts) with sickle cell disease (SCD), normotensive, without symptoms or signs of heart failure. Population and Methods: 18 pts with SCD in NYHA class I, mean age 37.6 years, and 20 normal volunteers, sex and age matched. The plasmatic quantification of NT-proBNP was made through electrochemiluminescense immunoassay Roche. Patients and control group were studied by Doppler echocardiography. Results: In comparison with normals, pts with SCD presented larger left atria (p ⬍ 0.0001), increased left ventricular mass and mass index (p ⬍ 0.001), slight decrease in systolic fractional shortening (p ⬍ 0.15), and mild systolic and diastolic dysfunctions according to Doppler tissue imaging. NTproBNP (table): SCD pts had elevated plasma concentrations of the peptide in comparison to the control group. Univariate analysis did not demonstrate significant correlations between the plasmatic values and anemia severity, cardiac dimensions and mass, or left ventricular function. Conclusions: Adults (4th decade) with SCD and no signs of heart failure, present cardiac remodeling and elevation of plasmatic concentrations of NT-proBNP. The prognostic value of these findings warrant more investigation.
Plasmatic NT-proBNP (pg/ml)
SCD Control p
Mean ⫾ SD
Median
Interval
195 ⫾ 116 41 ⫾ 28 ⬍0.0001
156 30.2 ⬍0.001
28–365 5–114
087 Doppler Tissue Imaging Identifies Altered Activation Sequences in Stable Heart Transplant Recipients Adam E. Berman, Sammy Khatib, Mandeep R. Mehra; Cardiology, Ochsner Clinic Foundation, New Orleans, LA
085 The Importance of Geometric Configuration in Predicting Ventricular Arrhythmias in Left Ventricular Dysfunction Jason A. Mitchell,1 Richard V. Milani,1 Mandeep R. Mehra1; 1Department of Cardiovascular Medicine, Ochsner Clinic Foundation, New Orleans, LA Background: Conventional dogma focuses on left ventricular ejection fraction (LVEF) as the marker for increased propensity for ventricular arrhythmias in patients with cardiomyopathy. Whether assessments of geometric adaptive changes in cardiomyopathic ventricles incrementally contribute to the elucidation of ventricular arrhythmias beyond the simple evaluation of ejection fraction, remains unknown. Methods: To evaluate the relationship of ventricular geometry and non-sustained ventricular tachyarrhythmias, we retrospectively analyzed our database from 1998 to 2003. We included all patients who underwent an echocardiogram (LVEF ⱕ 35%) and a holter monitor within a 12-month period. Patients were grouped based on left ventricular geometry into either concentric remodeling (CR, normal LV mass index but increased relative wall thickness) or ventricular hypertrophy (including concentric or eccentric hypertrophy). Primarily, we sought to analyze the relationship of geometric configuration and freedom from runs of non-sustained VT (NSVT). Results: 467 patients met the inclusion criteria. Age (67 ⫾ 12 vs. 69 ⫾ 13 years), body mass index (28 ⫾ 6 vs. 27 ⫾ 6 kg/m2) and LVEF (22 ⫾ 8 vs. 24 ⫾ 8%) were not significant predictors of occurrence of or absence of NSVT (all p ⫽ ns). Patients with NSVT were more likely to have larger dimension ventricles (LV end diastolic diameter 6.2 ⫾ 1 vs. 5.7 ⫾ 1 cm, p ⫽ 0.002). Those patients who demonstrated hypertrophic response (n ⫽ 416) had a 14.2% rate of NSVT, while the CR group (n ⫽ 51) only exhibited a rate of 2.0% (p ⫽ 0.012). Conclusions: This investigation suggests that the geometric configuration provides incremental information for predicting ventricular arrhythmias in cardiomyopathy, beyond that provided by LVEF alone. We suggest that parameters of structural remodeling and not simply contractile function as measured by LVEF, should be taken into consideration when assessing predilection for serious ventricular arrhythmias.
Introduction: Whether myocardial activation sequences in heart transplant (HT) recipients differ from non-transplanted structurally normal hearts is unknown. We performed a case control study to determine baseline myocardial activation sequences in stable heart transplant recipients utilizing Doppler tissue imaging (DTI) techniques. We then compared them to non-HT patients with structurally normal hearts to assess for potential differences between the two groups. Methods: We retrospectively reviewed our echocardiographic database and identified 11 HT recipients (8 males, 59 ⫾ 7 yrs) with normal LV systolic function. All transplants were performed ⬎ 6 months from the time of the echocardiogram. We then analyzed DTI in these patients and compared them to 11 age matched controls (7 males, 64 ⫾ 10 yrs) with no evidence of structural heart disease. Patients with LV ejection fractions (LVEF) ⬍ 55%, atrial fibrillation, permanent pacemakers, QRS duration ⬎ 120 msec, or moderate or greater valvular heart disease were excluded. We analyzed DTI time intervals and peak velocities (GE Vivid 7). In DTI, onset of (ECG) Q wave to peak (DTI) S and E waves (Q-S, Q-E) was measured. An 8 segment global LV score was created by averaging 8 data points from the basal and mid-positions of the respective LV wall. Results: Baseline characteristics including age, sex, heart rate, LVEF, LV mass index, QRS duration and peak DTI velocities were not significantly different between the two groups. Conclusions: 1) DTI techniques allow detailed investigation into myocardial mechanics in HT recipients. 2) Stable HT recipients display altered patterns of ventricular activation sequences when compared to age matched non-HT recipients with normal LV systolic function. 3) Stable HT recipients demonstrated earlier activation and relaxation within the cardiac cycle as assessed by DTI. We speculate that the role of DTI in HT patients may expand, with potential applications including detection of rejection and allograft vasculopathy. Results
Mean 4 chamber DTI Q-S (msec) Mean 2 chamber DTI Q-S (msec) Mean 4 chamber DTI Q-E (msec) Mean 2 chamber DTI Q-E (msec) 8 segment DTI Q-S(msec) 8 segment DTI Q-E (msec)
HT (n⫽11)
Control (n⫽11)
p value
145 ⫾ 26 126 ⫾ 14 448 ⫾ 26 446 ⫾ 28 136 ⫾ 18 447 ⫾ 24
179 ⫾ 30 167 ⫾ 35 548 ⫾ 49 550 ⫾ 49 173 ⫾ 30 549 ⫾ 56
0.01 0.007 0.0002 0.0001 0.006 0.0001
•
HFSA
S41
084
086
Clinical Features of Takotsubo Cardiomyoathy in North America Roopinder Sandhu,1 Mazen Hanna,1 Robert C. Bahler1; 1Heart and Vascular Center at MetroHealth, Case University School of Medicine, Cleveland, OH
Plasma Nt-proBNP is Elevated in Adults with Sickle Cell Disease without Clinical Heart Failure Aloir Q. Araujo,1 Edmundo Arteaga,1 Paula Buck,1 Jose Leao,1 Charles Mady1; 1 Cardiomyopathies Unity, Heart Institute (INCOR) - University of Sao Paulo Medical School, Sao paulo, SP, Brazil
Background: Tako-tsubo (octopus trap) cardiomyopathy (TTC), first described in Japan, refers to an acute, novel form of left ventricular (LV) systolic dysfunction with a unique LV configuration due to the combination of apical akinesis yet preserved basal function. This clinical syndrome, initiated by an acute stress, is not widely recognized in North America. Purpose: We report the clinical features of 10 patients seen in our community hospital over 22 months. Methods: Patients were identified from the consultation, cardiac catherization and echocardiography services. Inclusion criteria were an acute stress, abnormal repolarization on the electrocardiogram (ECG), abnormal cardiac enzymes, abnormal left ventricular (LV) systolic function with apical akinesis/hypokinesis and partial or full resolution. Patients with a clinical presentation consistent with acute myocarditis, an acute coronary syndrome or obstructive coronary artery disease were excluded. Clinical data abstracted from the medical record included the precipitating event, treatment modalities and time course of illness, laboratory data, ECGs and imaging data. Results: Most patients were women (8/10) with mean age of 59 years (range 40–79). None had prior cardiac disease. A precipitating event could be identified in all as either a physical stress (9), most commonly respiratory failure, or emotional stress (1). Initial ECG changes were sinus tachycardia in 7 with ST elevation in 4 and depression in 1. T wave inversions developed in all 10 patients, 5 with changes only in anterolateral leads, 4 with anterolateral and inferior inversions and 1 with lateral changes only. Initial QTc was prolonged in 6 patients with a group mean of 475 msec (range 430–590). Cardiac enzymes were elevated: median troponin I ⫽ 3.4 IU (range 2–164) and median CKMB% ⫽ 5.1 (range 1.3–10.9). Echocardiography showed a characteristic LV wall motion pattern with marked apical dysfunction and preserved basal function in all patients. Right ventricular wall motion was abnormal in 4/6. The LV ejection fraction initially was 27% ⫾ 7 and at follow up 53% ⫾ 8 with a mean elapsed time of 17 days. Coronary angiography showed no CAD in 6 and ⬍ 70% stenoses in 2; adenosine nuclear scan was normal in 1 patient. Conclusions: TTC is a distinctive yet under recognized cardiac syndrome. The discordance between the initial severity of LV dysfunction and the minimal elevations of cardiac enzymes is striking. Recovery of ventricular function begins within days of the inciting event. Increased awareness of this novel cardiomyopathy will advance our ability to investigate the pathophysiology.
Background: NT-proBNP (amino-terminal pro-brain natriuretic peptide) is elevated in the plasma of patients with cardiac disfunctions Objectives: To evaluate the plasmatic levels of NT-proBNP in adult patients (pts) with sickle cell disease (SCD), normotensive, without symptoms or signs of heart failure. Population and Methods: 18 pts with SCD in NYHA class I, mean age 37.6 years, and 20 normal volunteers, sex and age matched. The plasmatic quantification of NT-proBNP was made through electrochemiluminescense immunoassay Roche. Patients and control group were studied by Doppler echocardiography. Results: In comparison with normals, pts with SCD presented larger left atria (p ⬍ 0.0001), increased left ventricular mass and mass index (p ⬍ 0.001), slight decrease in systolic fractional shortening (p ⬍ 0.15), and mild systolic and diastolic dysfunctions according to Doppler tissue imaging. NTproBNP (table): SCD pts had elevated plasma concentrations of the peptide in comparison to the control group. Univariate analysis did not demonstrate significant correlations between the plasmatic values and anemia severity, cardiac dimensions and mass, or left ventricular function. Conclusions: Adults (4th decade) with SCD and no signs of heart failure, present cardiac remodeling and elevation of plasmatic concentrations of NT-proBNP. The prognostic value of these findings warrant more investigation.
Plasmatic NT-proBNP (pg/ml)
SCD Control p
Mean ⫾ SD
Median
Interval
195 ⫾ 116 41 ⫾ 28 ⬍0.0001
156 30.2 ⬍0.001
28–365 5–114
087 Doppler Tissue Imaging Identifies Altered Activation Sequences in Stable Heart Transplant Recipients Adam E. Berman, Sammy Khatib, Mandeep R. Mehra; Cardiology, Ochsner Clinic Foundation, New Orleans, LA
085 The Importance of Geometric Configuration in Predicting Ventricular Arrhythmias in Left Ventricular Dysfunction Jason A. Mitchell,1 Richard V. Milani,1 Mandeep R. Mehra1; 1Department of Cardiovascular Medicine, Ochsner Clinic Foundation, New Orleans, LA Background: Conventional dogma focuses on left ventricular ejection fraction (LVEF) as the marker for increased propensity for ventricular arrhythmias in patients with cardiomyopathy. Whether assessments of geometric adaptive changes in cardiomyopathic ventricles incrementally contribute to the elucidation of ventricular arrhythmias beyond the simple evaluation of ejection fraction, remains unknown. Methods: To evaluate the relationship of ventricular geometry and non-sustained ventricular tachyarrhythmias, we retrospectively analyzed our database from 1998 to 2003. We included all patients who underwent an echocardiogram (LVEF ⱕ 35%) and a holter monitor within a 12-month period. Patients were grouped based on left ventricular geometry into either concentric remodeling (CR, normal LV mass index but increased relative wall thickness) or ventricular hypertrophy (including concentric or eccentric hypertrophy). Primarily, we sought to analyze the relationship of geometric configuration and freedom from runs of non-sustained VT (NSVT). Results: 467 patients met the inclusion criteria. Age (67 ⫾ 12 vs. 69 ⫾ 13 years), body mass index (28 ⫾ 6 vs. 27 ⫾ 6 kg/m2) and LVEF (22 ⫾ 8 vs. 24 ⫾ 8%) were not significant predictors of occurrence of or absence of NSVT (all p ⫽ ns). Patients with NSVT were more likely to have larger dimension ventricles (LV end diastolic diameter 6.2 ⫾ 1 vs. 5.7 ⫾ 1 cm, p ⫽ 0.002). Those patients who demonstrated hypertrophic response (n ⫽ 416) had a 14.2% rate of NSVT, while the CR group (n ⫽ 51) only exhibited a rate of 2.0% (p ⫽ 0.012). Conclusions: This investigation suggests that the geometric configuration provides incremental information for predicting ventricular arrhythmias in cardiomyopathy, beyond that provided by LVEF alone. We suggest that parameters of structural remodeling and not simply contractile function as measured by LVEF, should be taken into consideration when assessing predilection for serious ventricular arrhythmias.
Introduction: Whether myocardial activation sequences in heart transplant (HT) recipients differ from non-transplanted structurally normal hearts is unknown. We performed a case control study to determine baseline myocardial activation sequences in stable heart transplant recipients utilizing Doppler tissue imaging (DTI) techniques. We then compared them to non-HT patients with structurally normal hearts to assess for potential differences between the two groups. Methods: We retrospectively reviewed our echocardiographic database and identified 11 HT recipients (8 males, 59 ⫾ 7 yrs) with normal LV systolic function. All transplants were performed ⬎ 6 months from the time of the echocardiogram. We then analyzed DTI in these patients and compared them to 11 age matched controls (7 males, 64 ⫾ 10 yrs) with no evidence of structural heart disease. Patients with LV ejection fractions (LVEF) ⬍ 55%, atrial fibrillation, permanent pacemakers, QRS duration ⬎ 120 msec, or moderate or greater valvular heart disease were excluded. We analyzed DTI time intervals and peak velocities (GE Vivid 7). In DTI, onset of (ECG) Q wave to peak (DTI) S and E waves (Q-S, Q-E) was measured. An 8 segment global LV score was created by averaging 8 data points from the basal and mid-positions of the respective LV wall. Results: Baseline characteristics including age, sex, heart rate, LVEF, LV mass index, QRS duration and peak DTI velocities were not significantly different between the two groups. Conclusions: 1) DTI techniques allow detailed investigation into myocardial mechanics in HT recipients. 2) Stable HT recipients display altered patterns of ventricular activation sequences when compared to age matched non-HT recipients with normal LV systolic function. 3) Stable HT recipients demonstrated earlier activation and relaxation within the cardiac cycle as assessed by DTI. We speculate that the role of DTI in HT patients may expand, with potential applications including detection of rejection and allograft vasculopathy. Results
Mean 4 chamber DTI Q-S (msec) Mean 2 chamber DTI Q-S (msec) Mean 4 chamber DTI Q-E (msec) Mean 2 chamber DTI Q-E (msec) 8 segment DTI Q-S(msec) 8 segment DTI Q-E (msec)
HT (n⫽11)
Control (n⫽11)
p value
145 ⫾ 26 126 ⫾ 14 448 ⫾ 26 446 ⫾ 28 136 ⫾ 18 447 ⫾ 24
179 ⫾ 30 167 ⫾ 35 548 ⫾ 49 550 ⫾ 49 173 ⫾ 30 549 ⫾ 56
0.01 0.007 0.0002 0.0001 0.006 0.0001