Takotsubo cardiomyopathy: queries of the current era

: Takotsubo cardiomyopathy (TTS), also known as left ventricular apical ballooning syndrome, is an acute, usually reversible heart failure syndrome that most often affects postmenopausal women experiencing an emotionally stressful event. It is characterized by sudden left ventricular dysfunction and wall motion abnormalities involving the apical and mid segments. TTS has been increasingly recognized in recent years, and more and more information about the pathophysiology, diagnosis, and treatment of these patients has been reported. However, much is still unknown. TTS has a wide variety of clinical subtypes and has been described in several clinical contexts. Moreover, TTS simulates ST-segment elevation myocardial infarction and acute myocarditis, and it can be difficult to obtain a certain diagnosis. As a result, clinical decisions are challenging, and many patients currently receive an inappropriate management strategy. The aim of this review is to critically analyze the evidence about this disease reported in the literature, with particular focus on the pathophysiological processes, the diagnostic elements that can help the clinician differentiate it from other diseases, and the best management of these patients.

Value of ejection fraction/velocity ratio in the prognostic stratification of patients with asymptomatic aortic valve stenosis

BACKGROUND

The ejection fraction/velocity ratio (EFVR) is a simple function-corrected index of aortic stenosis severity with a good correlation with aortic valve area measured using the Gorlin formula at cardiac catheterization. It is calculated by dividing left ventricular ejection fraction (LVEF) to 4 × (peak jet velocity)² .

OBJECTIVE

Our aim was to evaluate the value of EFVR in predicting adverse events in patients with asymptomatic aortic stenosis.

METHODS

We analyzed the clinical and echocardiographic data of 216 asymptomatic patients with at least moderate aortic stenosis (AVA ≤ 1.5 cm² ). The primary end-point was cardiovascular death or aortic valve replacement.

RESULTS

There were 119 (55%) men and mean age was 68 ± 10 years. The mean follow-up time was 4.2 ± 1.6 years (median 4.3 years). During follow-up, the composite end-point of death or aortic valve replacement was reached in 105 patients (49%). Using multivariate Cox regression analysis, EFVR and valvulo-arterial impedance emerged as independent variables associated with outcome (P < 0.001 and P = 0.001, respectively). In the subgroup of patients with severe aortic stenosis (AVA < 1 cm² ), EFVR ≤ 0.9 was associated with an increased hazard ratio for the composite end-point of mortality and aortic valve replacement (HR 2.14, 95% CI: 1.15-4.0, P = 0.017), even after adjusting for aortic valve area.

CONCLUSIONS

In patients with asymptomatic moderate to severe aortic stenosis, EFVR is useful for risk stratification. Our results suggest that incorporating EFVR in the evaluation of patients with asymptomatic aortic stenosis might help identify those who are most likely to benefit from early elective aortic replacement.

Arterial stiffness and mitral regurgitation in arterial hypertension: an intriguing pathophysiological link

BACKGROUND

We examined the relative impact of arterial stiffness on the presence and/or severity of chronic mitral regurgitation (MR) in hypertensive patients.

METHODS

We prospectively enrolled 141 untreated hypertensive patients (mean age 56.6 ± 11.5 years): 94 with MR, 47 without MR. As a measure of arterial stiffness, pulse wave velocity (PWV) was assessed by applanation tonometry. Assessment of MR severity was obtained through calculation of effective regurgitant orifice area (EROA) and vena contracta by standard two-dimensional transthoracic echocardiography.

RESULTS

PWV appears to progressively increase according to the presence and severity of MR (no MR = 7.3 ± 1.1 m/s, mild MR = 7.9 ± 1.3 m/s, moderate MR = 9.0 ± 1.7 m/s, severe MR = 13.3 ± 4.1 m/s; P < 0.001 for all comparisons). EROA was positively correlated with age (P = 0.011), left atrial volume index (P = 0.023), PWV (P < 0.001) and augmentation index (P < 0.001), and negatively correlated with left ventricular ejection fraction (P = 0.002) and heart rate (HR) (P = 0.018). On stepwise multivariate logistic regression analysis, only PWV (OR = 2.87, 95% CI 1.750-4.738, P < 0.001) and HR (OR = 0.94, 95% CI 0.895-0.994, P = 0.02) appeared to be independent predictors of severe MR. Receiver operating characteristic curves showed that a cutoff of 9 m/s for PWV provided the best sensitivity/specificity for predicting both the presence of any degree of MR (sensitivity 73%, specificity 87%, AUC = 0.863; P < 0.001) and MR severity (sensitivity 100%, specificity 81%, AUC = 0.954; P < 0.001).

CONCLUSION

Reduced arterial elasticity because of increased stiffness may be an important marker for the presence and severity of MR in hypertensive patients.

Multimodality imaging for thromboembolic risk assessment in atrial fibrillation

: Atrial fibrillation is the most widely represented sustained arrhythmia in the world. Thromboembolic risk assessment represents the main clinical challenge associated with this condition, requiring enormous medical, social and economical efforts. Several pieces of evidence in literature highlight how clinical risk factors are not enough for a correct thromboembolic risk stratification of patients with atrial fibrillation, since thromboembolic events have been proven to occur even in patients with low clinical risk scores. A comprehensive multimodality imaging approach, with special regard to echocardiography and new technologies seems to be the best method for this purpose. The aim of this review is to propose a hybrid thromboembolic risk stratification system that combinines clinical evaluation with instrumental clues on left atrial remodeling, fibrosis and deformation which, could be useful especially for patients classified at low thromboembolic risk according to clinical scores.

Left ventricular endocardial longitudinal dysfunction persists after acute myocarditis with preserved ejection fraction

BACKGROUND

The aim of present study was to assess left ventricular (LV) myocardial deformation and changes over time in patients with acute myocarditis (AM) with preserved ejection fraction detected by late gadolinium enhancement (LGE) magnetic resonance imaging.

METHODS

Thirty-five male patients with AM diagnoses and preserved systolic function based on cardiac magnetic resonance imaging (MRI) were prospectively enrolled. On admission, echocardiography with measurements of global and segmental longitudinal (LS) strains was performed both at the endocardial (ENDO) and epicardial (EPI) levels. Findings were compared to 25 control subjects. Twenty-six patients were also monitored over a 22-month follow-up (FU group).

RESULTS

On admission, global ENDO-LS was poorer in magnitude in AM (-19.2 ± 3.1) than in controls (-24.0 ± 1.05) (P < 0.0001), whereas EPI-LS was not different (-20.6 ± 3.4 vs -19.7 ± 6 P = NS). A functional increase in magnitude in both ENDO-LS (-20.8 ± 5.4, P = NS) and EPI-LS (-22.6 ± 4.6, P = 0.02) was found in FU vs AM patients.

CONCLUSIONS

The present study demonstrates a steady ENDO-LS impairment in infarct-like AM during a 2-year follow-up period, despite a preserved LV ejection fraction.

New classification of geometric ventricular patterns in severe aortic stenosis: Could it be clinically useful?

BACKGROUND

In severe aortic stenosis, different left ventricle (LV) remodeling patterns as a response to pressure overload have distinct hemodynamic profiles, cardiac function, and outcomes. The most common classification considers LV relative wall thickness and LV mass index to create 4 different groups. A new classification including also end-diastolic volume index has been recently proposed.

AIM

To describe the prevalence of the newly identified remodeling patterns in patients with severe aortic stenosis and to evaluate their clinical relevance according to symptoms.

METHODS

We analyzed 286 consecutive patients with isolated severe aortic stenosis. Current guidelines were used for echocardiographic evaluation. Symptoms were defined as the presence of angina, syncope, or NYHA class III-IV.

RESULTS

The mean age was 75 ± 9 years, 156 patients (54%) were men, while 158 (55%) were symptomatic. According to the new classification, the most frequent remodeling pattern was concentric hypertrophy (57.3%), followed by mixed (18.9%) and dilated hypertrophy (8.4%). There were no patients with eccentric remodeling; only 4 patients had a normalLV geometry. Symptomatic patients showed significantly more mixed hypertrophy (P < .05), while the difference regarding the prevalence of the other patterns was not statistically significant. When we analyzed the distribution of the classic 4 patterns stratified by the presence of symptoms, however, we did not find a significant difference (P = .157).

CONCLUSIONS

The new classification had refined the description of different cardiac geometric phenotypes that develop as a response to pressure overload. It might be superior to the classic 4 patterns in terms of association with symptoms.

Antineoplastic Drug-Induced Cardiotoxicity: A Redox Perspective

Antineoplastic drugs can be associated with several side effects, including cardiovascular toxicity (CTX). Biochemical studies have identified multiple mechanisms of CTX. Chemoterapeutic agents can alter redox homeostasis by increasing the production of reactive oxygen species (ROS) and reactive nitrogen species RNS. Cellular sources of ROS/RNS are cardiomyocytes, endothelial cells, stromal and inflammatory cells in the heart. Mitochondria, peroxisomes and other subcellular components are central hubs that control redox homeostasis. Mitochondria are central targets for antineoplastic drug-induced CTX. Understanding the mechanisms of CTX is fundamental for effective cardioprotection, without compromising the efficacy of anticancer treatments. Type 1 CTX is associated with irreversible cardiac cell injury and is typically caused by anthracyclines and conventional chemotherapeutic agents. Type 2 CTX, associated with reversible myocardial dysfunction, is generally caused by biologicals and targeted drugs. Although oxidative/nitrosative reactions play a central role in CTX caused by different antineoplastic drugs, additional mechanisms involving directly and indirectly cardiomyocytes and inflammatory cells play a role in cardiovascular toxicities. Identification of cardiologic risk factors and an integrated approach using molecular, imaging, and clinical data may allow the selection of patients at risk of developing chemotherapy-related CTX. Although the last decade has witnessed intense research related to the molecular and biochemical mechanisms of CTX of antineoplastic drugs, experimental and clinical studies are urgently needed to balance safety and efficacy of novel cancer therapies.

A recommended practical approach to the management of anthracycline-based chemotherapy cardiotoxicity: an opinion paper of the working group on drug cardiotoxicity and cardioprotection, Italian Society of Cardiology

Anthracyclines are the mainstay of treatment of a variety of haematological malignancies and solid tumours. Unfortunately, the clinical use of these drugs is limited by cumulative, dose-related cardiotoxicity which may ultimately lead to a severe and irreversible form of cardiomyopathy. Thus, there is an increasing need for close cooperation among cardiologists, oncologists and haemato-oncologists. As anthracyclines save lives, the logical goal of this cooperation, besides preventing or mitigating cardiotoxicity, is to promote an acceptable balance between the potential cardiac side effects and the vital benefit of anticancer treatment. This manuscript, which is specifically addressed to the cardiologist who has not accumulated much experience in the field of cancer therapy, focuses on several topics, that is old and new mechanisms of cardiac toxicity, late cardiac toxicity, the importance of overall risk assessment, the key role of a cardiology consult before starting cancer therapy, and the pros and cons of primary and secondary prevention programmes.

Risk Stratification Using the CHA2DS2-VASc Score in Takotsubo Syndrome: Data From the Takotsubo Italian Network

Background

The CHA₂DS₂‐VASc score predicts stroke in patients with atrial fibrillation and has been reported to have a prognostic role even in acute coronary syndrome patients. The Takotsubo syndrome is a condition that mimics acute coronary syndrome and may present several complications including stroke. We sought to assess the ability of CHA₂DS₂‐VASc score to predict adverse events in Takotsubo syndrome patients.

Methods and Results

Overall, 371 Takotsubo syndrome patients were enrolled in a prospective registry. Patients were divided into 3 groups according to the CHA₂DS₂‐VASc score: Group A (≤1), B (2–3), and C (≥4). The median CHA₂DS₂‐VASc score was 3 (interquartile range: 2–4). Overall, 9%, 42%, and 49% were included in Group A, B, and C, respectively. Follow‐up length was 26±20 months. The mortality rate was 6%, 7%, and 17% in Group A, B, and C, respectively (P=0.011). The stroke rate was 3% and not different among the 3 groups. Estimated major adverse cardiac and cerebrovascular events (the composite of death, myocardial infarction, and stroke) rates in the 3 groups were 6%, 9%, and 17% in Group A, B, and C, respectively (P=0.033). The CHA₂DS₂‐VASc score resulted as a predictor of major adverse cardiac and cerebrovascular events (odds ratio 2.1, 95% confidence interval, 1.2–3.6; P=0.01) and all‐cause mortality (odds ratio 1.5, 95% confidence interval, 1.2–1.9; P=0.001).

Conclusions

In Takotsubo syndrome, the CHA₂DS₂‐VASc score allows prediction of cardiovascular events and mortality at long‐term follow‐up.

Influence of Genetics and Gender in Takotsubo Syndrome: Unexplored Areas of an Incompletely Understood Disease

Stress cardiomyopathy, also known as “Takotsubo syndrome” (TS), is a complex disease that typically affects postmenopausal women. The pathophysiology is still largely unknown, but evidence of a frequent association between TS and stressful events has evoked the hypothesis of a pathophysiologic role of sympathetic overdrive in the myocardial dysfunction. However, despite several studies, the role gender plays in TS onset remains unclear because stress cardiomyopathy also has been described in young women and in men. Moreover, although several cases of a familial cluster of TS have been reported, no responsible gene mutations or polymorphisms have been clearly identified so far, and neither the modality of transmission or the true impact of genetic background. In this review, we discuss the role of gender in the onset, course, and outcomes of TS and we report the available data about polymorphisms and gene mutations so far investigated, trying to critically analyze the evidence reported in the literature.

Takotsubo syndrome and estrogen receptor genes: partners in crime?

AIMS

We aimed to analyze genetic polymorphism of estrogen receptor (ESR) 1 and ESR2 in a series of postmenopausal women with Takotsubo syndrome (TS).

METHODS

In total, 81 consecutive white women were prospectively enrolled: 22 with TS (TS group; mean age 71.2 ± 9.8 years), 22 with acute myocardial infarction (MI group; mean age 73.2 ± 8 years), and 37 asymptomatic healthy controls (CTRL group; mean age 69 ± 4.2 years). Genotyping of ESR1 -397C>T (rs2234693) and -351A>G (rs9340799) and ESR2 -1839G>T (rs 1271572) and 1082G>A (rs1256049) genetic variants was performed. We estimated the odds ratio (OR) between the genotype of each examined locus with the occurrence of TS or MI.

RESULTS

The risk of experiencing TS was higher for those study participants carrying the T allele at the rs2234693 locus of the ESR1 gene [OR: 2.0, 95% confidence interval (CI): 0.973-4.11, P = 0.04, TS vs. MI + CTRL; OR: 2.79, 95% CI: 1.17-6.64, P = 0.016, TS vs. MI alone]. Women carrying a T allele at the rs1271572 locus of the ESR2 gene demonstrated an even higher risk (OR: 3.23, 95% CI: 1.55-6.73, P = 0.0019, TS vs. MI + CTRL; OR: 9.13, 95% CI: 2.78-29.9, P = 0.0001, TS vs. MI alone).

CONCLUSION

The study reports preliminary findings suggesting a possible link between ESR polymorphisms and the occurrence of TS. Larger studies are needed to confirm our results.

The Diagnostic Challenge of Dipyridamole-atropine Stress Echocardiography in a Patient with Myocardial Bridge

A 60-year-old male patient was submitted to dipyridamole-atropine stress echocardiography (DSE) for chest pain during exertion. At rest, no electrocardiographic (ECG) and transthoracic echocardiographic (TTE) abnormalities were observed. After dipyridamole infusion, the patient complained a mild chest discomfort, without ECG changes and TTE wall-motion abnormalities. Subsequently, worsening of the anginal symptoms combined with descending ST-depression and T-negative waves occurred after atropine and unexpectedly, aminophylline administration. Coronary angiography was performed showing a myocardial bridge (MB) of the left anterior descending artery. The occurrence, during DSE, of worsening ischemic abnormalities after atropine and aminophylline administration may be a particular diagnostic feature of MB.

Cardiovascular imaging in the diagnosis and monitoring of cardiotoxicity: role of echocardiography

The evaluation by cardiovascular imaging of chemotherapy patients became a central topic in the last several years. The use of drugs for the treatment of cancers increased, and new molecules and protocols were developed to improve outcomes in these patients. Although, these novel approaches also produced a progressive increase in side effects, particularly myocardial dysfunction. Imaging of the heart was highly accurate in the early diagnosis of cancer therapeutics related-cardiac dysfunction. Echocardiography is the first-line method to assess ventricular function alterations, and it is required to satisfy the need for an early, easy and accurate diagnosis to stratify the risk of heart failure and manage treatments. A careful monitoring of cardiac function during the course of therapy should prevent the onset of severe heart impairment. This review provides an overview of the most important findings of the role of echocardiography in the management of chemotherapy-treated patients to create a clear and complete description of the efficacy of conventional measurements, the importance of comprehensive heart evaluations, the additional role of new echocardiographic techniques, the utility of integrated studies using other imaging tools and the positions of the most important international societies on this topic.