Documentation of dynamic electrocardiographic changes shortly after the onset of tako-tsubo cardiomyopathy

A 76-year-old female with atrial fibrillation and prior cerebral infarction had chest discomfort during rehabilitation for left hemiparesis, and visited the nearby hospital. Her ECG, which was obtained 10 min after the onset, showed marked ST-segment elevation in leads I, II, III, aV(F) and V(2-6), and she was referred to our hospital for cardiac examination. On admission, her ECG, which was obtained 50 min after the onset, showed poor R wave progression and mild ST-segment elevation in leads V(5-6). During only 10 min after the admission, the ST-segment level increased dynamically, and it decreased spontaneously again. Left ventriculography showed akinesia of the mid-to-distal portion and hyperkinesia of the basal portion of the left ventricular chamber, and coronary angiography showed no significant coronary artery disease despite of significant ST-segment elevation. We diagnosed her as having tako-tsubo cardiomyopathy. She was discharged well 10 days later.

Variant form of tako-tsubo cardiomyopathy

We report a female case of variant form of tako-tsubo cardiomyopathy in which wall motion of the distal segment was preserved. In the current case, left ventriculography showed akinesia of the mid portion and normokinesia of the distal and basal portions of the left ventricular chamber. ST-segment elevation was obvious in leads V1-3 rather than in leads V4-6. Because ST-segment elevation is absent in left precordial leads, cardiologists should take care not to fail to diagnose variant form of tako-tsubo cardiomyopathy.

Impact of admission hyperglycemia and diabetes mellitus on short- and long-term mortality after acute myocardial infarction in the coronary intervention era

The influence of admission hyperglycemia and diabetes on short- and long-term mortality of patients with acute myocardial infarction (AMI) in the percutaneous coronary intervention (PCI) era was investigated. From 1996 to 2003, a total of 802 consecutive patients with AMI underwent coronary angiography. Primary PCI was performed in 724 patients (90%). Three-year mortality curves were constructed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors of 30-day mortality and mortality from 30 days to 3 years. There were 261 patients with admission hyperglycemia (admission glucose>or=11.1 mmol/L) and 212 patients with diabetes. Admission hyperglycemia was associated with a significantly higher 30-day mortality rate (8.4% vs 2.4%, p<0.001). However, there was no significant difference in 30-day mortality rates between diabetic and nondiabetic patients (5.7% vs 3.9%, p=0.29). Conversely, diabetes significantly increased mortality from 30 days to 3 years (10.0% vs 5.5%, p=0.03), but admission hyperglycemia did not (8.4% vs 5.9%, p=0.19). Multivariate analysis showed that hyperglycemia was an independent predictor of 30-day mortality (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.13 to 2.61, p=0.01), but diabetes was not (OR 0.84, 95% CI 0.55 to 1.27, p=0.42). Diabetes was independently associated with mortality from 30 days to 3 years (OR 1.43, 95% CI 1.02 to 1.97, p=0.04), but hyperglycemia had a neutral effect (OR 0.98, 95% CI 0.70 to 1.36, p=0.92). In conclusion, in the PCI era, admission hyperglycemia was associated with short-term mortality, whereas diabetes increased long-term mortality after convalescence in patients with AMI. Admission hyperglycemia and diabetes should be treated as 2 distinct disease states.

Tako-tsubo cardiomyopathy after automobile accident

A 53-year-old woman was involved in a traffic accident while driving her car. She had chest oppressive sensation 6 h after the accident, and was admitted to our hospital. On admission, she had no external injury. She was fully conscious, and felt anxiety about the accident. Twelve-lead electrocardiogram showed mild ST-segment elevation in leads II, III, aVF and V2-5. Chest X-ray did not show pneumothorax, rib fracture or pulmonary congestion. Emergency coronary angiography showed no significant coronary artery disease. However, left ventriculography showed akinesia of the mid-to-distal portion of the left ventricular chamber and hyperkinesia of the basal portion (ejection fraction=45%). She was diagnosed as having tako-tsubo cardiomyopathy. Follow-up left ventriculography 11 days later showed normal wall motion of the left ventricular chamber (ejection fraction=62%). Clinicians should recognize that tako-tsubo cardiomyopathy is one of etiologies of chest symptom after automobile accident. It can occur due to emotional stress even if patients have no external injury.

Right bundle-branch block in anterior acute myocardial infarction in the coronary intervention era: Acute angiographic findings and prognosis

BACKGROUND

Previous studies in the prethrombolytic or thrombolytic era have reported that right bundle-branch block (RBBB) is associated with poor clinical outcome in patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

The purpose of this study was to examine the relations between RBBB and angiographic findings or clinical outcomes in patients with AMI in the coronary intervention era. A total of 430 patients with a first anterior AMI who underwent coronary angiography within 12 h after the onset were enrolled in this study. Seventy-one patients (17%) had RBBB documented during their hospital stay. RBBB was documented on admission in 35 patients. Patients with RBBB were older (p<0.01) and had prodromal angina less frequently (p=0.03) than those without. On the initial angiograms, patients with RBBB had an occluded left anterior descending artery (p<0.01) and multivessel disease (p=0.01) more frequently than those without. Thirty-day mortality rate was significantly higher in patients with RBBB than in those without (14.0% vs 1.9%, p<0.01). Multiple logistic-regression analysis demonstrated that RBBB (odds ratio 5.89, p<0.01) and multivessel disease (odds ratio 4.36, p=0.01) were independent predictors of 30-day mortality.

CONCLUSIONS

Our data suggested that RBBB was still associated with poor clinical outcome in patients with anterior AMI even in the coronary intervention era.

Documentation of early improvement of left ventricular function in tako-tsubo cardiomyopathy

An 86-year-old woman was admitted to our hospital because of chest pain after a heated argument with her daughter. Electrocardiogram showed ST-segment elevation in leads V2-3 and T wave inversion in leads V3-6. Emergency cardiac catheterization was performed 2 h after the onset of chest pain. Coronary angiography showed no significant coronary artery disease. However, left ventriculography showed apical akinesis and basal hyperkinesis (ejection fraction=42%). She was diagnosed as having tako-tsubo cardiomyopathy. Follow-up left ventriculography showed marked improvement of the left ventricular function (ejection fraction=74%) during only 41 h. She was discharged 3 days later.

Novel percutaneous catheter thrombectomy in acute massive pulmonary embolism: rotational bidirectional thrombectomy (ROBOT)

BACKGROUND

Although thrombolysis is a standard therapy in cases of pulmonary embolism (PE), fatal outcome is often observed. We designed and investigated the efficacy of a novel percutaneous catheter therapy, rotational bidirectional thrombectomy (ROBOT), for PE.

METHODS AND RESULTS

Eighteen patients with acute massive PE (Miller score > or = 20) were included in this study. We separated them into two groups [group A (n = 10), thrombolysis; group B (n = 8): thrombolysis and ROBOT or ROBOT alone]. There was no difference in the hemodynamic indices between the groups at diagnosis. ROBOT was designed to fragment emboli by rotating a regular pigtail catheter. Three deaths occurred in group A because of hemodynamic impairment, but there was no death in group B. One day after treatment, systolic pulmonary artery pressure had decreased from 53 +/- 8 to 30 +/- 8 mm Hg (P < 0.05) in group B and from 54 +/- 5 to 42 +/- 19 mm Hg (NS) in group A. The hospitalization period in group B was shorter than that in group A (17 +/- 6 vs. 27 +/- 10 days, P < 0.05).

CONCLUSION

ROBOT therapy results in a significant, rapid improvement in the hemodynamic situation and in a better outcome than conventional therapy in patients with acute massive pulmonary embolism.

Pathophysiological role of endothelin in ectopic ossification of human spinal ligaments induced by mechanical stress

Ossification of the posterior longitudinal ligament (OPLL) of the spine is characterized by progressive ectopic bone formation in the spinal ligament. To identify the genes related to ossification affected by mechanical stress during OPLL, analyses using cDNA microarray were carried out using cultured human spinal ligament cells that had been subjected to uniaxial cyclic stretching. Samples were obtained from a total of 14 patients: seven cervical or thoracic OPLL patients and seven control patients. Spinal ligament cells derived from tissues of OPLL (OPLL cells) and control (non-OPLL cells) patients were subjected to uniaxial sinusoidal cyclic stretching (0.5 Hz, 20% stretch) for various time periods (0-9 hours). cDNA microarrays revealed that ranges of distribution of both up- and downregulated genes evoked by cyclic stretching were significantly wider in OPLL cells than in non-OPLL cells. Increases in the mRNA expression of endothelin-1 (ET-1) as well as various marker genes related to ossification were also observed. mRNA expression of ET-1 and alkaline phosphatase was increased by mechanical stress in a time-dependent manner, while addition of ET-1 to static cultures of OPLL cells increased mRNA expression of alkaline phosphatase in a dose-dependent manner. During 9 hours of cyclic stretching, ET-1 release increased to about sixfold the amount observed in nonstretched cells. In non-OPLL cells, neither cyclic stretching nor ET-1 induced any increase in alkaline phosphatase expression. These results suggest that mechanical stress promotes the progression of ossification in OPLL cells through autocrine and/or paracrine mechanisms of ET-1.

Is admission hyperglycaemia in non-diabetic patients with acute myocardial infarction a surrogate for previously undiagnosed abnormal glucose tolerance?

AIMS

To investigate whether admission hyperglycaemia in non-diabetic patients with acute myocardial infarction (AMI) is a surrogate for previously undiagnosed abnormal glucose tolerance.

METHODS AND RESULTS

Two hundred non-diabetic patients with AMI were divided into three groups: 81 patients with admission glucose < 7.8 mmol/L (group 1), 83 patients with admission glucose > or = 7.8 mmol/L and < 11.1 mmol/L (group 2), and 36 patients with admission glucose > or = 11.1 mmol/L (group 3). Abnormal glucose tolerance, diabetes, or impaired glucose tolerance (IGT) was diagnosed by oral glucose tolerance test (OGTT). OGTT identified diabetes in 53 patients (27%) and IGT in 78 patients (39%). When the fasting glucose criteria were applied, however, only 14 patients (7%) were diagnosed as having diabetes. The prevalence of abnormal glucose tolerance was similar among the three groups: 67% in group 1, 63% in group 2, and 69% in group 3 (P = 0.74). The relation of fasting glucose (r2 = 0.50, P < 0.001) and HbA1c (r2 = 0.34, P < 0.001) to 2-h post-load glucose was significant, but the relation of admission glucose to 2-h post-load glucose was not significant (r2 = 0.02, P = 0.08). Multivariable analysis showed that fasting glucose and HbA1c were independent predictors of abnormal glucose tolerance, but admission glucose was not.

CONCLUSION

Admission hyperglycaemia in non-diabetic patients with AMI does not represent previously undiagnosed abnormal glucose tolerance. Fasting glucose and HbA1c, rather than admission glucose, may be useful to predict abnormal glucose tolerance. However, these parameters lacked sensitivity. OGTT should be considered in all non-diabetic patients with AMI.

Persistent left ventricular dysfunction in takotsubo cardiomyopathy after pacemaker implantation

Two cases of takotsubo cardiomyopathy occurred after pacemaker implantation, both in elderly women who received a dual-chamber pacemaker for complete atrioventricular block. They had persistent left ventricular dysfunction even during their convalescence.

Acute Pericarditis Unmasks ST-Segment Elevation in Asymptomatic Brugada Syndrome

A 26-year-old man was admitted to our hospital because of acute pericarditis. The current patient had a saddle-back type ST-segment elevation shortly after the onset of acute pericarditis. Interestingly, it converted into a coved type ST-segment elevation, subsequently regressed gradually as acute inflammation improved. After 3 months, right ventricular rapid pacing induced ventricular fibrillation, and intravenous sodium channel blocker induced a coved type ST-segment elevation. The current case implies that a Brugada-type ST-segment elevation, which is thought to be false in acute pericarditis, may be true in some patients with asymptomatic Brugada syndrome.

Right atrial thrombosis as a complication of arrhythmogenic right ventricular cardiomyopathy

A 65-year-old woman was admitted to our hospital due to palpitation. Electrocardiogram (ECG) showed ventricular tachycardia originating from the right ventricle, and transthoracic echocardiography revealed dilatations of the right atrium and ventricle. The diagnosis of arrhythmogenic right ventricular cardiomyopathy was made. Eleven months later, echocardiography revealed a solid thrombus (36x32 mm) attached to the free wall of the right atrium, and it was surgically resected. Four months after the operation, a solid thrombus (48x30 mm) appeared again at the same site despite anticoagulant treatment. The patient died of both left and right heart failure 33 months after the operation.