Cardiac tamponade leading to the diagnosis of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome): a case report and review of the literature

Eosinophilic granulomatosis with polyangiitis (EGPA), which was previously called Churg-Strauss syndrome, is a necrotizing systemic vasculitis of unknown cause accompanied by prominent eosinophilia. Cardiovascular complications, including eosinophilic myocarditis, are a major cause of mortality in this disorder. Acute pericarditis with slight pericardial effusion is a typical manifestation in EGPA, though hemodynamically significant pericardial effusion has been reported in a few cases. We report a case that initially presented with isolated cardiac tamponade, which was followed by systemic manifestations of EGPA over 3 weeks. Including the present case, previous EGPA cases with cardiac tamponade are reviewed to delineate its clinical characteristics.

"Ballooning" patterns in takotsubo cardiomyopathy reflect different clinical backgrounds and outcomes: a BOREAS-TCM study

Whether different patterns of ventricular ballooning in takotsubo cardiomyopathy (TCM) reflect differences in trigger mechanisms or clinical outcomes is unclear. Here we examined differences in the clinical characteristics of typical and atypical forms of TCM. TCM patients (n = 251) in the BOREAS Registry were enrolled for comparison of TCM with apical ballooning (type A, n = 217) and TCM with non-apical ballooning (type non-A, n = 34). The percentage of females was significantly lower in the type non-A group (58.8 vs. 75.6 %), while other demographic parameters and triggers of TCM were similar in the two groups. Rate of mid-ventricular obstruction (MVO) was lower (2.9 vs. 14.3 %) in the type non-A group than in the type A group, though left ventricular ejection fractions in the two groups were comparable. During a follow-up period of 2.6 ± 2.8 years, TCM recurred in 2.9 % of the patients and cardiac death occurred in 4.0 %. Cox proportional hazard analysis indicated that body mass index (hazard ratio [HR]: 0.75, 95 % confidence interval [CI] 0.54-0.99) and MVO (HR: 14.71, CI 1.87-304.66) were determinants of TCM recurrence and that advanced age (HR: 1.09, CI 1.02-1.17) and cardiogenic shock (HR: 4.27, CI 1.07-18.93) were significantly associated with cardiac death. In conclusion, approximately 20 % of TCM patients show non-apical left ventricular ballooning, and female sex and MVO are less frequent in this type than in apical ballooning type TCM. Low body mass index and MVO are risk factors of recurrence, and advanced age and cardiogenic shock are risk factors of cardiac death in TCM.

Cardiac metaiodobenzylguanidine imaging and heart failure

The autonomic nervous system has pivotal roles in pathophysiology and prognosis in patients with heart failure. Cardiac (123)I-labeled metaiodobenzylguanidine (MIBG) imaging enables noninvasive and quantitative assessment of cardiac sympathetic innervation in cardiology practice. Several investigations have demonstrated independent and incremental prognostic values of this imaging technique in combination with clinical information in patients with heart failure. Cardiac MIBG imaging may help cardiologists evaluate cardiac sympathetic nerve function and predict lethal event risk in heart failure. It can contribute not only to the identification of low-risk or high-risk probability for lethal events but also to the selection of the appropriate therapeutic strategy, such as medical and device therapy in patients at greater risk for lethal outcomes due to pump failure or sudden arrhythmic events. Thus, precise risk stratification through cardiac MIBG imaging may contribute to more effective use of medical resources and more appropriate selection of therapeutic strategy in heart failure patients.

Association of a single nucleotide polymorphism in the SH2D1A intronic region with systemic lupus erythematosus

SH2D1A, also known as signaling lymphocytic activation molecule (SLAM)-associated protein (SAP), is an adaptor protein. Recently, it was reported that SAP deficient mice were protected from systemic lupus erythematosus (SLE). In this study, we postulated SH2D1A gene to be a candidate susceptibility gene for SLE and analyzed its association with SLE. A case-control association study was conducted on 5 tag single nucleotide polymorphisms (SNPs) in SH2D1A region in 506 Japanese female SLE patients and 330 healthy female controls. The luciferase assay was performed to determine the functional role of the SNP associated with SLE. One SNP in the intron 2, rs2049995, showed association with SLE (p=0.0110, odds ratio (OR) 1.97, 95% confidence interval (CI) 1.16-3.34, under the dominant model). The association of rs2049995 seemed to be stronger in the subset with the age of onset less than 20 years (p=0.0067, OR 2.65, 95% CI 1.28-5.46). Functional evaluation of rs2049995 showed that reporter gene activity was increased 1.9-fold for the susceptible allele compared with the resistant allele. An intronic SNP of SH2D1A is associated with SLE.

Inter-vendor variability of left ventricular volumes and strains determined by three-dimensional speckle tracking echocardiography

BACKGROUND

Inter-vendor discordance in three-dimensional speckle-tracking echocardiography (3DS) remains uncharacterized. We aimed to examine inter-vendor discordance of left ventricular (LV) volumes, and functional parameters and their reproducibilities between two commercially available 3DS systems.

METHODS

Echocardiographic examinations with 3DS were performed in 26 healthy subjects (age 34 ± 13 years, 85% men) using a Vivid E9 system (V1) with 4V probe (GE Health Care) and Artida (V2) with PST-25SX probe (Toshiba Medical Systems) on the same day. LV variables and global LV longitudinal, circumferential, radial, and area strains were measured by vendor-specific softwares, 4D strain EchoPAC BT11 (for V1) and 3D WMT (for V2), respectively. Reproducibility of data was assessed by an intra-class correlation coefficient (ICC).

RESULTS

The mean time required for 3DS analysis was 5.4 ± 1.5 min for V1, being 21% less than that for V2 (6.8 ± 1.9 min, P < 0.01). Reproducibilities of all LV strains were comparable between V1 (ICC 0.50-0.82) and V2 (ICC 0.51-0.76), except for intra-observer and inter-observer reproducibilities of radial strain being lower in V2 (ICC for V1 0.82 and 0.82 and ICC for V2 0.44 and 0.40, respectively). LV strains in all directions and area were significantly different between V1 and V2, though LV volumes and ejection fraction were comparable.

CONCLUSIONS

Global longitudinal, circumferential, and area LV strains are reproducible in both 3DS vendors. However, values of three-dimensional LV strains by 3DS are highly vendor-dependent.

Rationale and design of J-ACCESS 4: prognostic impact of reducing myocardial ischemia identified using ECG-gated myocardial perfusion SPECT in Japanese patients with coronary artery disease

BACKGROUND

The findings of our recent study entitled, "Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (J-ACCESS)" showed that myocardial perfusion single photon emission computed tomography (MPS) can detect coronary artery disease (CAD) and help to predict future cardiac events in patients with suspected or extant CAD. However, the extent of the benefit conferred by percutaneous coronary intervention (PCI) as an initial management strategy compared with optimal medical therapy remains controversial. Little evidence supports the notion that myocardial ischemia identified using MPS is an alternative target of coronary revascularization to reduce the likelihood of developing cardiac events.

METHODS

The multicenter, prospective cohort J-ACCESS 4 study aims to clarify the prognostic impact of reducing myocardial ischemia determined using electrocardiogram-gated MPS in Japanese patients with coronary artery disease. We started to register patients in J-ACCESS 4 at 74 facilities during June 2012 and will continue to do so until December 2013 or until the cohort comprises 500 patients who will participate in the study from one month before, until two months after stress/rest MPS assessment. Imaging data, the background of the patients including coronary risk factors and treatment before MPS assessments will be analyzed. The patients will undergo coronary revascularization within two months after MPS and/or receive appropriate medical therapy. The second stress/rest MPS will be performed from 4 to 10 months after coronary revascularization or registration. They will be followed up for over one year after the second MPS assessment. The primary endpoints will be cardiac death, sudden death of unknown cause, non-fatal myocardial infarction, and hospitalization for heart failure. The secondary endpoints will comprise death due to all causes including non-cardiac death and any cardiovascular events. This study will be completed in 2015. Here, we describe the design of the J-ACCESS 4 study.

Prognostic value of automated SPECT scoring system for coronary artery disease in stress myocardial perfusion and fatty acid metabolism imaging

Quantitative SPECT analysis contributes to the diagnostic and prognostic assessment of coronary artery disease. A novel automated scoring system (heart score view) can provide identical quantitative information to that determined by expert visual analysis. The aim of the present study is to evaluate the prognostic value of the automated SPECT scoring system when applied to stress thallium and resting beta-methyl-iodophenyl pentadecanoic acid (BMIPP) SPECT images. After a preliminary validation of the automated system by comparison with expert visual analyses, outcome data from 151 consecutive patients with suspected or known coronary artery disease without prior myocardial infarction were analyzed using automated SPECT scores on stress thallium and resting BMIPP images. The software quantified abnormalities as summed stress (SSS), summed rest and summed difference scores for stress thallium and as summed BMIPP scores (SBS). Cardiac events occurred over a period of 48 months in 29 (19.2%) patients with diabetes mellitus, a lower left ventricular ejection fraction (LVEF) and more abnormal scores for thallium and BMIPP. Multivariate predictors of all cardiac events included diabetes mellitus and thallium SSS. The global Chi-square value was significantly increased when SSS was added to the clinical information (diabetes mellitus and LVEF). Negative predictive values of thallium SSS and SBS were almost identical at 84% for all cardiac events and 98% for hard cardiac events. Automatically quantified perfusion and BMIPP scores are related to cardiac events and these values can improve the risk stratification of coronary patients particularly when stress thallium imaging is combined with clinical information.

Synergistic prognostic values of cardiac sympathetic innervation with left ventricular hypertrophy and left atrial size in heart failure patients without reduced left ventricular ejection fraction: a cohort study

OBJECTIVES

This study tested whether cardiac sympathetic innervation assessed by metaiodobenzylguanidine (MIBG) activity has long-term prognostic value in combination with left ventricular hypertrophy (LVH) and left atrial size in heart failure (HF) patients without reduced left ventricular ejection fraction (LVEF).

DESIGN

A single-centre prospective cohort study.

SETTING/PARTICIPANTS

With primary endpoints of cardiac death and rehospitalisation due to HF progression, 178 consecutive symptomatic HF patients with 74% men, mean age of 56 years and mean LVEF of 64.5% were followed up for 80 months. The entry criteria consisted of LVEF more than 50%, completion of predischarge clinical evaluations including cardiac MIBG and echocardiographic studies and at least more than 1-year follow-up when survived.

RESULTS

Thirty-four patients with cardiac evens had larger left atrial dimension (LAD), increased LV mass index, reduced MIBG activity quantified as heart-to-mediastinum ratio (HMR) than did the others. Multivariable Cox analysis showed that LAD and HMR were significant predictors (HR of 1.080 (95% CI 1.00 to 1.16, p=0.044) and 0.107 (95% CI 0.01 to 0.61, p=0.012, respectively). Thresholds of HMR (1.65) and LAD (37 mm) were closely related to identification of high-risk patients. In particular, HMR was a significant determinant of cardiac events in both patients with and without LV hypertrophy. Reduced HMR with enlarged LAD or LV hypertrophy identified patients at most increased risk; overall log-rank value, 11.5, p=0.0032 for LAD and 17.5, p=0.0002, respectively.

CONCLUSIONS

In HF patients without reduced LV ejection fraction, impairment of cardiac sympathetic innervation is related to cardiac outcomes independently and synergistically with LA size and LV hypertrophy. Cardiac sympathetic innervation assessment can contribute to better risk-stratification in combination with evaluation of LA size and LV mass but is needed to be evaluated for establishing aetiology-based risk assessment in HF patients at increased risk.

Validation of automated quantitation of myocardial perfusion and fatty acid metabolism abnormalities on SPECT images

BACKGROUND

Myocardial perfusion and fatty acid imaging have played important roles in the risk stratification of patients with coronary artery disease (CAD). However, visual image assessment requires considerable experience and training. Therefore, an automated program has been developed that can quantify perfusion and fatty acid uptake on myocardial single emission computed tomography (SPECT). The present study aimed to validate the automated quantitative program.

METHODS AND RESULTS

A total of 50 patients were studied with known or suspected CAD who underwent stress ²⁰¹Thallium (²⁰¹Tl) and resting ¹²³I-labelled β-methyl iodophenyl pentadecanoic acid (BMIPP) SPECT. The SPECT images were quantified in 17 segments visually and using our Heart Score View software. Values were compared with those in a normal Japanese database and calculated summed stress (SSS), summed rest (SRS), summed difference (SDS), and summed BMIPP scores for each modality. Summed scores obtained using standard visual analysis and Heart Score View significantly correlated (²⁰¹Tl: SSS: r=0.934; SRS: r=0.827; SDS: r=0.743 summed BMIPP score: r=0.913) (each P<0.001) and Bland-Altman analysis revealed good agreement between the 2 approaches.

CONCLUSIONS

Correlations between scores determined using Heart Score View software and standard visual interpretation were linear for both perfusion and fatty acid images. Thus, our new automated program might be useful for the risk stratification of patients with CAD in the clinical setting.