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Carbone A, Flacco ME, Manzoli L, Lamberti N, Pigazzani F, Rega S, Migliarino S, Ferrara F, Citro R, Manfredini R, Bossone E. Chronobiological variation in takotsubo syndrome: an updated systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102804. [PMID: 39163922 DOI: 10.1016/j.cpcardiol.2024.102804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Accepted: 08/16/2024] [Indexed: 08/22/2024]
Abstract
Takotsubo syndrome (TTS) might exhibit particular chronobiological patterns in its onset, characterized by variations according to time of the day, day of the week, and month of the year. The aim of this study was to fully explore the temporal patterns (circadian, weekly and seasonal) in the onset of TTS. A systematic review and meta-analysis of literature were conducted for studies (2006-2024) reporting the temporal patterns (circadian, weekly and/or seasonal) in the onset of TTS. Among the 4257 studies retrieved, 20 (including 64,567 subjects) fulfilled all eligibility criteria. Data were aggregated used random effects model as pooled risk ratio and the attributable risk (AR). The proportion analysis (including 8 studies; n=853) showed a decreasing pattern of the pooled rates of TTS shifting from the morning to the night (pooled TTS rates: 34.0%; 32.1%; 21.7%; 12.7% in the morning, afternoon, evening and night, respectively). The same pattern was observed stratifying by type of preceding stressful factor or event, considering physical stressors (pooled rates in the morning and night: 37.6% and 9.8%, respectively), and also in case no event could be identified. The pooled rates of TTS onset peaked on Monday and Tuesday (17.3% and 18.4% respectively), then declined during the week, reaching the lowest rates on Friday and Saturday (10.6% and 10.8%, respectively), with no sex differences. TTS onset reached the highest values on summer, and the lowest in winter (27.9% versus 21.7% in summer and winter, respectively). The TTS morning peak based analyses (∼33% of all the registered events) account for a RR of 1.46 (95% CI: 1.38-1.54), the week-based for a RR of 1.26 (1.16-1.35), the season-based for a RR of 1.04 (1.04-1.05). TTS onset exhibits specific chronobiological patterns, characterized by a peak during the morning hours, and on Monday and Tuesday. Differing from other cardiovascular emergencies TTS was more frequent during summer. Further studies are needed to fully understand the underlying pathophysiological mechanisms in order to tailor relative management and preventive strategies.
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Affiliation(s)
- Andreina Carbone
- Department of Public Health, University of Naples "Federico II", Naples, Italy; Unit of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Elena Flacco
- Department of Environmental Sciences and Prevention, University of Ferrara, Ferrara, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Filippo Pigazzani
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, UK
| | - Salvatore Rega
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | | | | | - Rodolfo Citro
- Clinical Cardiology Unit Medicine and Health Science "V. Tiberio" Department, University of Molise Responsible Research Hospital, Campobasso, Italy
| | - Roberto Manfredini
- Clinical Medicine Unit, Department of Medical Sciences, University of Ferrara, Italy
| | - Eduardo Bossone
- Department of Public Health, University of Naples "Federico II", Naples, Italy.
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Kadoya Y, Chong AY, Small GR, Chow B, deKemp R, Ruddy TD, Beanlands R, Crean AM. Myocardial flow reserve recovery in patients with Takotsubo syndrome: Insights from positron emission tomography. J Nucl Cardiol 2024; 37:101869. [PMID: 38685396 DOI: 10.1016/j.nuclcard.2024.101869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/07/2024] [Accepted: 04/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) has been implicated in the pathogenesis of Takotsubo syndrome (TTS). Positron emission tomography (PET) plays a key role in the assessment of CMD through myocardial flow reserve (MFR). However, there is limited information on the temporal progression of MFR and its relationship to coronary artery disease (CAD) in TTS patients. METHODS This study evaluated patients with TTS who underwent cardiac catheterization and PET within one year of hospitalization. Patients were categorized into acute (≤10 days), subacute (11-30 days), and chronic (≥31 days) stages based on post-onset time of PET assessment. MFR values and prevalence of abnormal MFR (<2.0) were compared between stages. Temporal MFR changes in patients with obstructive CAD (≥70% stenosis by coronary angiography), non-obstructive CAD, and normal coronaries were compared. RESULTS Of the 88 patients studied (mean age 70; 96% female), 52 (59%) were in the acute, 17 (19%) in the subacute, and 19 (22%) in the chronic stage. Median MFR in the acute stage was 2.0 (1.5-2.3), with 58% of patients showing abnormal MFR. A significant time-dependent improvement in MFR was observed (P = 0.002), accompanied by a decreased prevalence of abnormal MFR (P = 0.016). While patients with normal coronaries showed significant MFR improvement over time (P = 0.045), patients with obstructive or non-obstructive CAD demonstrated no improvement across three stages (P = 0.346 and 0.174, respectively). CONCLUSION PET-derived MFR was impaired in TTS patients during the acute phase, with improvement suggesting potential recovery from CMD over time. The concurrent presence of obstructive CAD might impede this recovery process.
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Affiliation(s)
- Yoshito Kadoya
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun Yeong Chong
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Gary R Small
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Benjamin Chow
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Robert deKemp
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rob Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andrew M Crean
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Wang Y, Tang X, Cui J, Wang P, Yang Q, Chen Y, Zhang T. Ginsenoside Rb1 mitigates acute catecholamine surge-induced myocardial injuries in part by suppressing STING-mediated macrophage activation. Biomed Pharmacother 2024; 175:116794. [PMID: 38776673 DOI: 10.1016/j.biopha.2024.116794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/14/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Stress cardiomyopathy (SCM) is associated with cardiovascular mortality rates similar to acute coronary syndrome. Myocardial injuries driven by inflammatory mechanisms may in part account for the dismal prognosis of SCM. Currently, no inflammation-targeted therapies are available to mitigate SCM-associated myocardial injuries. In this study, acute catecholamine surge-induced SCM was modeled by stimulating the ovariectomized (OVX) mice with isoproterenol (ISO). The effects of ginsenoside Rb1 (Rb1) on SCM-associated myocardial injuries were assessed in the OVX-ISO compound mice. RAW 264.7 macrophages stimulated with calf thymus DNA (ctDNA) or STING agonist DMXAA were adopted to further understand the anti-inflammatory mechanisms of Rb1. The results show that estrogen deprivation increases the susceptibility to ISO-induced myocardial injuries. Rb1 mitigates myocardial injuries and attenuates cardiomyocyte necrosis as well as myocardial inflammation in the OVX-ISO mice. Bioinformatics analysis suggests that cytosolic DNA-sensing pathway is closely linked with ISO-triggered inflammatory responses and cell death in the heart. In macrophages, Rb1 lowers ctDNA-stimulated production of TNF-α, IL-6, CCL2 and IFN-β. RNA-seq analyses uncover that Rb1 offsets DNA-stimulated upregulation in multiple inflammatory response pathways and cytosolic DNA-sensing pathway. Furthermore, Rb1 directly mitigates DMXAA-stimulated STING activation and inflammatory responses in macrophages. In conclusion, the work here demonstrates for the first time that Rb1 protects against SCM-associated myocardial injuries in part by counteracting acute ISO stress-triggered cardiomyocyte necrosis and myocardial inflammation. Moreover, by evidencing that Rb1 downregulates cytosolic DNA-sensing machineries in macrophages, our findings warrant further investigation of therapeutic implications of the anti-inflammatory Rb1 in the treatment of SCM.
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Affiliation(s)
- Yujue Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Xinmiao Tang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Jingang Cui
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Peiwei Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Qinbo Yang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Yu Chen
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Laboratory of Clinical and Molecular Pharmacology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China.
| | - Teng Zhang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China.
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Chitturi KR, Bhogal S, Kassaian SE, Merdler I, Abusnina W, Chaturvedi A, Ben-Dor I, Waksman R, Case BC, Barac A, Hashim HD. Coronary microvascular dysfunction and cancer therapy-related cardiovascular toxicity. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00459-7. [PMID: 38789343 DOI: 10.1016/j.carrev.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) has been implicated as a potential mechanism in the pathophysiology of different clinical presentations, including ischemia and no obstructive coronary artery disease (INOCA), myocardial infarction and nonobstructive coronary arteries (MINOCA), stress cardiomyopathy, heart failure, and myocarditis. There are limited data about the role of CMD in cancer therapy-related cardiovascular toxicities. CASE PRESENTATIONS Four women with a diagnosis of active cancer receiving treatment who developed subsequent MINOCA or INOCA presented for cardiac catheterization. Upon coronary angiography showing no obstructive coronary arteries, coronary function testing was performed to evaluate for CMD. METHODS Coronary physiology was assessed measuring non-hyperemic (resting full-cycle ratio [RFR]) and hyperemic (fractional flow reserve [FFR]) indices using a physiologic pressure wire. The wire also measured coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and RFR using thermodilution technology. CMD was confirmed if the CFR was <2.5 and the IMR was >25. RESULTS Among 4 patients with diagnosis of active cancer presenting with chest pain, there was no evidence of obstructive coronary artery disease, leading to separate diagnoses of INOCA, MINOCA, stress cardiomyopathy, and myocarditis. We found CMD in 2 patients (1 with INOCA and 1 with immune checkpoint inhibitor-related myocarditis). CONCLUSIONS CMD may play a role in cardiovascular toxicities. Further coronary physiology studies are needed to understand the mechanisms of cancer therapy-related cardiovascular toxicity and CMD, as well as optimal preventive and treatment options.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Sukhdeep Bhogal
- Section of Cardiology, Sovah Health, Martinsville, VA, United States of America
| | | | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Abhishek Chaturvedi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ana Barac
- Section of Cardio-Oncology, Inova Schar Heart and Vascular, Falls Church, VA, United States of America
| | - Hayder D Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
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Couch LS, Garrard JW, Henry JA, Kotronias RA, Alaour B, De Maria GL, Channon KM, Banning AP, Lyon AR, Marber M, Kaier TE. Comparison of troponin and natriuretic peptides in Takotsubo syndrome and acute coronary syndrome: a meta-analysis. Open Heart 2024; 11:e002607. [PMID: 38508657 PMCID: PMC10952941 DOI: 10.1136/openhrt-2024-002607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/16/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Takotsubo syndrome (TTS) is an acute heart failure syndrome which resembles acute coronary syndrome (ACS) at presentation. Differentiation requires coronary angiography, but where this does not occur immediately, cardiac biomarkers may provide additional utility. We performed a meta-analysis to compare troponin and natriuretic peptides (NPs) in TTS and ACS to determine if differences in biomarker profile can aid diagnosis. METHODS We searched five literature databases for studies reporting NPs (Brain NP (BNP)/NT-pro-BNP) or troponin I/T in TTS and ACS, identifying 28 studies for troponin/NPs (5618 and 1145 patients, respectively). RESULTS Troponin was significantly lower in TTS than ACS (standardised mean difference (SMD) -0.86; 95% CI, -1.08 to -0.64; p<0.00001), with an absolute difference of 75 times the upper limit of normal (×ULN) higher in ACS than TTS. Conversely, NPs were significantly higher in TTS (SMD 0.62; 95% CI, 0.44 to 0.80; p<0.00001) and 5.8×ULN greater absolutely. Area under the curve (AUC) for troponin in ACS versus TTS was 0.82 (95% CI, 0.70 to 0.93), and 0.92 (95% CI, 0.80 to 1.00) for ST-segment elevation myocardial infarction versus TTS. For NPs, AUC was 0.69 (95% CI, 0.48 to 0.89). Combination of troponin and NPs with logistic regression did not improve AUC. Recursive Partitioning and Regression Tree analysis calculated a troponin threshold ≥26×ULN that identified 95% cases as ACS where and specificity for ACS were 85.71% and 53.57%, respectively, with 94.32% positive predictive value and 29.40% negative predictive value. CONCLUSIONS Troponin is lower and NPs higher in TTS versus ACS. Troponin had greater power than NPs at discriminating TTS and ACS, and with troponin ≥26×ULN patients are far more likely to have ACS.
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Affiliation(s)
- Liam Steven Couch
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - James W Garrard
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - John A Henry
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Rafail A Kotronias
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Bashir Alaour
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Giovanni Luigi De Maria
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Keith M Channon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Adrian P Banning
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | | | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Thomas Edward Kaier
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
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Couch LS, Banning AP. Takotsubo syndrome or Takotsubo-like contractile dysfunction? Eur Heart J 2023; 44:5167. [PMID: 37978875 DOI: 10.1093/eurheartj/ehad745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Affiliation(s)
- Liam S Couch
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Adrian P Banning
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
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D'Amario D, Borovac JA, Patti G. A machine-learning-based prediction model in patients with takotsubo syndrome: 'You can't stop change any more than you can stop the suns from setting!'. Eur J Heart Fail 2023; 25:2312-2315. [PMID: 37975147 DOI: 10.1002/ejhf.3069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Domenico D'Amario
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
| | - Josip Angelo Borovac
- Division of Interventional Cardiology, Cardiovascular Diseases Department, University Hospital of Split, Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Giuseppe Patti
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
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Citro R, Bellino M, Merli E, Di Vece D, Sherrid MV. Obstructive Hypertrophic Cardiomyopathy and Takotsubo Syndrome: How to Deal With Left Ventricular Ballooning? J Am Heart Assoc 2023; 12:e032028. [PMID: 37889174 PMCID: PMC10727392 DOI: 10.1161/jaha.123.032028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Currently, there are 2 proposed causes of acute left ventricular ballooning. The first is the most cited hypothesis that ballooning is caused by direct catecholamine toxicity on cardiomyocytes or by microvascular ischemia. We refer to this pathogenesis as Takotsubo syndrome. More recently, a second cause has emerged: that in some patients with underlying hypertrophic cardiomyopathy, left ventricular ballooning is caused by the sudden onset of latent left ventricular outflow tract obstruction. When it becomes severe and unrelenting, severe afterload mismatch and acute supply-demand ischemia appear and result in ballooning. In the context of 2 causes, presentations might overlap and cause confusion. Knowing the pathophysiology of each mechanism and how to determine a correct diagnosis might guide treatment.
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Affiliation(s)
- Rodolfo Citro
- Cardio‐Thorax‐Vascular DepartmentUniversity Hospital San Giovanni di Dio e Ruggi d’AragonaSalernoItaly
- Department of Vascular PhysiopathologyIRCCS NeuromedPozzilliItaly
| | - Michele Bellino
- Department of Medicine, Surgery and DentistryUniversity of SalernoSalernoItaly
| | - Elisa Merli
- Department of CardiologyOspedale per gli InfermiFaenzaItaly
| | - Davide Di Vece
- Department of CardiologyUniversity Hospital ZurichZurichSwitzerland
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Vriz O, Mushtaq AH, Elshaer AN, Shaik A, Landi I, Alzahrani T. Takotsubo Syndrome in Black Americans: Insights From the National Inpatient Sample. Tex Heart Inst J 2023; 50:e228055. [PMID: 37853912 PMCID: PMC10658156 DOI: 10.14503/thij-22-8055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Data on race-related differences in the clinical outcomes of Takotsubo syndrome are limited, particularly for Black patients. This study aimed to assess whether race and sex may have an additional impact on the inpatient mortality of patients with Takotsubo syndrome. METHODS A total of 4,628 patients from the United States' National Inpatient Sample from 2012 to 2016 were identified; propensity score analysis revealed a similar propensity score between Black patients (n = 2,314) and White patients (n = 2,314), which was used to balance observed covariates. Sex and age distributions were identical between the 2 groups. The groups were also similar in baseline characteristics, including cardiovascular risk factors. White patients were compared with Black patients on in-hospital outcomes and inpatient mortality. A logistic regression analysis was conducted to measure the difference in mortality based on race and sex. RESULTS Compared with White patients, Black patients had a higher percentage of in-hospital complications, including cerebrovascular accidents (4.9% vs 2.5%, P ≤ .01), acute kidney injury (25% vs 19%, P ≤ .01); longer lengths of stay (8 vs 7 days, P ≤ .01); and higher inpatient mortality (6.1% vs 4.5%, P < .01). When analysis was conducted with race and sex combined, inpatient mortality was higher among Black men than among White women (odds ratio, 2.7 [95% CI, 1.80-3.95]; P ≤ .01). CONCLUSION This study showed that Black patients with Takotsubo syndrome have higher in-hospital complications and inpatient mortality rates. When race and sex were combined, inpatient mortality was significantly higher among Black men than among either White men and women or Black women.
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Affiliation(s)
- Olga Vriz
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Cardiology and Sport Medicine, San Antonio Hospital, San Daniele del Friuli, Udine, Italy
| | - Ali Hassan Mushtaq
- School of Medicine, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed Nahid Elshaer
- School of Medicine, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah Shaik
- School of Medicine, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Irene Landi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Talal Alzahrani
- Department of Medicine, College of Medicine, Taibah University, Medina, Saudi Arabia
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Liu Y, Chen Q, Yang JZ, Li XW, Chen LJ, Zhang KK, Liu JL, Li JH, Hsu C, Chen L, Zeng JH, Wang Q, Zhao D, Xu JT. Multi-Omics Analysis Reveals the Role of Sigma-1 Receptor in a Takotsubo-like Cardiomyopathy Model. Biomedicines 2023; 11:2766. [PMID: 37893138 PMCID: PMC10604683 DOI: 10.3390/biomedicines11102766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that presents with sudden onset of chest pain and dyspneic and cardiac dysfunction as a result of extreme physical or emotional stress. The sigma-1 receptor (Sigmar1) is a ligand-dependent molecular chaperone that is postulated to be involved in various processes related to cardiovascular disease. However, the role of Sigmar1 in TTS remains unresolved. In this study, we established a mouse model of TTS using wild-type and Sigmar1 knockout mice to investigate the involvement of Sigmar1 in TTS development. Our results revealed that Sigmar1 knockout exacerbated cardiac dysfunction, with a noticeable decrease in ejection fraction (EF) and fractional shortening (FS) compared to the wild-type model. In terms of the gut microbiome, we observed regulation of Firmicutes and Bacteroidetes ratios; suppression of probiotic Lactobacillus growth; and a rise in pathogenic bacterial species, such as Colidextribacter. Metabolomic and transcriptomic analyses further suggested that Sigmar1 plays a role in regulating tryptophan metabolism and several signaling pathways, including MAPK, HIF-1, calcium signaling, and apoptosis pathways, which may be crucial in TTS pathogenesis. These findings offer valuable insight into the function of Sigmar1 in TTS, and this receptor may represent a promising therapeutic target for TTS.
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Affiliation(s)
- Yi Liu
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Qing Chen
- Key Laboratory of Evidence Science, China University of Political Science and Law, Ministry of Education, Beijing 100088, China
- Beijing Municipal Public Security Judicial Appraisal Center, Beijing 100142, China
| | - Jian-Zheng Yang
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Xiu-Wen Li
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Li-Jian Chen
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Kai-Kai Zhang
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Jia-Li Liu
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Jia-Hao Li
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Clare Hsu
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Long Chen
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Jia-Hao Zeng
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Qi Wang
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
| | - Dong Zhao
- Key Laboratory of Evidence Science, China University of Political Science and Law, Ministry of Education, Beijing 100088, China
| | - Jing-Tao Xu
- Guangzhou Key Laboratory of Forensic Multi-Omics for Precision Identification, School of Forensic Medicine, Southern Medical University, Guangzhou 510515, China (Q.W.)
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Oliveira GMMD, Almeida MCCD, Rassi DDC, Bragança ÉOV, Moura LZ, Arrais M, Campos MDSB, Lemke VG, Avila WS, Lucena AJGD, Almeida ALCD, Brandão AA, Ferreira ADDA, Biolo A, Macedo AVS, Falcão BDAA, Polanczyk CA, Lantieri CJB, Marques-Santos C, Freire CMV, Pellegrini D, Alexandre ERG, Braga FGM, Oliveira FMFD, Cintra FD, Costa IBSDS, Silva JSN, Carreira LTF, Magalhães LBNC, Matos LDNJD, Assad MHV, Barbosa MM, Silva MGD, Rivera MAM, Izar MCDO, Costa MENC, Paiva MSMDO, Castro MLD, Uellendahl M, Oliveira Junior MTD, Souza OFD, Costa RAD, Coutinho RQ, Silva SCTFD, Martins SM, Brandão SCS, Buglia S, Barbosa TMJDU, Nascimento TAD, Vieira T, Campagnucci VP, Chagas ACP. Position Statement on Ischemic Heart Disease - Women-Centered Health Care - 2023. Arq Bras Cardiol 2023; 120:e20230303. [PMID: 37556656 PMCID: PMC10382148 DOI: 10.36660/abc.20230303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Andreia Biolo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | | | | | | | - Celi Marques-Santos
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Hospital São Lucas Rede D'Or São Luis, Aracaju, SE - Brasil
| | | | - Denise Pellegrini
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | - Fabiana Goulart Marcondes Braga
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Lara Terra F Carreira
- Cardiologia Nuclear de Curitiba, Curitiba, PR - Brasil
- Hospital Pilar, Curitiba, PR - Brasil
| | | | | | | | | | | | | | | | | | | | | | - Marly Uellendahl
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
| | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | - Ricardo Quental Coutinho
- Faculdade de Ciências Médicas da Universidade de Pernambuco (UPE), Recife, PE - Brasil
- Hospital Universitário Osvaldo Cruz da Universidade de Pernambuco (UPE), Recife, PE - Brasil
| | | | - Sílvia Marinho Martins
- Pronto Socorro Cardiológico de Pernambuco da Universidade de Pernambuco (PROCAPE/UPE), Recife, PE - Brasil
| | | | - Susimeire Buglia
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | - Thais Vieira
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Rede D'Or, Aracaju, SE - Brasil
- Hospital Universitário da Universidade Federal de Sergipe (UFS), Aracaju, SE - Brasil
| | | | - Antonio Carlos Palandri Chagas
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Centro Universitário Faculdade de Medicina ABC, Santo André, SP - Brasil
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12
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Ruddy TD, Tavoosi A, Taqueti VR. Role of nuclear cardiology in diagnosis and risk stratification of coronary microvascular disease. J Nucl Cardiol 2023; 30:1327-1340. [PMID: 35851643 DOI: 10.1007/s12350-022-03051-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/22/2022] [Indexed: 10/17/2022]
Abstract
Coronary flow reserve (CFR) with positron emission tomography/computed tomography (PET/CT) has an important role in the diagnosis of coronary microvascular disease (CMD), aids risk stratification and may be useful in monitoring therapy. CMD contributes to symptoms and a worse prognosis in patients with coronary artery disease (CAD), nonischemic cardiomyopathies, and heart failure. CFR measurements may improve our understanding of the role of CMD in symptoms and prognosis in CAD and other cardiovascular diseases. The clinical presentation of CAD has changed. The prevalence of nonobstructive CAD has increased to about 50% of patients with angina undergoing angiography. Ischemia with nonobstructive arteries (INOCA) is recognized as an important cause of symptoms and has an adverse prognosis. Patients with INOCA may have ischemia due to CMD, epicardial vasospasm or diffuse nonobstructive CAD. Reduced CFR in patients with INOCA identifies a high-risk group that may benefit from management strategies specific for CMD. Although measurement of CFR by PET/CT has excellent accuracy and repeatability, use is limited by cost and availability. CFR measurement with single-photon emission tomography (SPECT) is feasible, validated, and would increase availability and use of CFR. Patients with CMD can be identified by reduced CFR and selected for specific therapies.
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Affiliation(s)
- Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
| | - Anahita Tavoosi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Viviany R Taqueti
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Polednikova K, Kozel M, Linkova H, Novackova M, Trinh MD, Tousek P. Triggers, characteristics, and hospital outcome of patients with Takotsubo syndrome: 10 years experience in a large university hospital centre. Eur Heart J Suppl 2023; 25:E10-E16. [PMID: 37234233 PMCID: PMC10206857 DOI: 10.1093/eurheartjsupp/suad105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A unique clinical feature of Takotsubo syndrome (TTS) is the stress trigger factor. Different types of triggers exist, generally divided into emotional and physical stressor. The aim was to create long-term registry of all consecutive patients with TTS across all disciplines in our large university hospital. We enrolled patients on the basis of meeting the diagnostic criteria of the international InterTAK Registry. We aimed to determine type of triggers, clinical characteristics, and outcome of TTS patients during 10 years period. In our prospective, academic, single centre registry, we enrolled 155 consecutive patients with diagnoses of TTS between October 2013 and October 2022. The patients were divided into three groups, those having unknown (n = 32; 20.6%), emotional (n = 42; 27.1%), or physical (n = 81; 52.3%) triggers. Clinical characteristics, cardiac enzyme levels, echocardiographic findings, including ejection fraction, and TTS type did not differ among the groups. Chest pain was less common in the group of patients with a physical trigger. On the other hand, arrhythmogenic disorders such as prolonged QT intervals, cardiac arrest requiring defibrillation, and atrial fibrillation were more common among the TTS patients with unknown triggers compared with the other groups. The highest in-hospital mortality was observed between patients having physical trigger (16% vs. 3.1% in TTS with emotional trigger and 4.8% in TTS with unknown trigger; P = 0.060). Conclusion: More than half of the patients with TTS diagnosed in a large university hospital had a physical trigger as a stress factor. An essential part of caring for these types of patients is the correct identification of TTS in the context of severe other conditions and the absence of typical cardiac symptoms. Patients with physical trigger have a significantly higher risk of acute heart complications. Interdisciplinary cooperation is essential in the treatment of patients with this diagnosis.
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Affiliation(s)
| | - Martin Kozel
- Cardiocentre of University Hospital Kralovske Vinohrady, Srobarova 1150/50, Prague 100 34, Czechia
- Third Faculty of Medicine, Charles University, Ruska 2411, Prague 100 00, Czechia
| | - Hana Linkova
- Cardiocentre of University Hospital Kralovske Vinohrady, Srobarova 1150/50, Prague 100 34, Czechia
- Third Faculty of Medicine, Charles University, Ruska 2411, Prague 100 00, Czechia
| | - Marketa Novackova
- Cardiocentre of University Hospital Kralovske Vinohrady, Srobarova 1150/50, Prague 100 34, Czechia
- Third Faculty of Medicine, Charles University, Ruska 2411, Prague 100 00, Czechia
| | - Minh Duc Trinh
- Cardiocentre of University Hospital Kralovske Vinohrady, Srobarova 1150/50, Prague 100 34, Czechia
- Third Faculty of Medicine, Charles University, Ruska 2411, Prague 100 00, Czechia
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14
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Vriz O, Alzahrani T, Landi I, Mushtaq AH, Shaik A, Elshaer AN. Age-sex effect on in-hospital complications and mortality in patients with Takotsubo syndrome. Insights from the National Inpatient Sample. Monaldi Arch Chest Dis 2023; 94. [PMID: 37070781 DOI: 10.4081/monaldi.2023.2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/29/2023] [Indexed: 04/19/2023] Open
Abstract
Age and sex differences in Takotsubo syndrome (TTS) are still a matter of debate. The present study aimed to evaluate the difference in cardiovascular (CV) risk factors, CV disease, in-hospital complications, and death within different sex-age groups. Using the National Inpatient Sample database between 2012 and 2016, 32,474 patients older than 18 years of age hospitalized with the primary diagnosis of TTS were identified. A total of 32,474 patients were enrolled; 27,611 (85.04%) were female. CV risk factors were higher in females, while CV diseases and in-hospital complications were significantly higher in males. The mortality in males was twice as high as that of female patients (9.83% versus 4.58%, p<0.01), and in the logistic regression model after adjustment for confounders, the odds ratio (OR) was 1.79, the confidence interval was 1.60-2.02, and p<0.01. After dividing the group based on age, in-hospital complications were inversely related to age in both sexes, and the length of in-hospital stay was double in the youngest group compared to the oldest one. Mortality increased progressively with age in both groups but was constantly higher in males for each age group. Multiple logistic regression analysis for mortality was performed for the two sexes separately and for the three age groups, considering the youngest one as the reference group. In females, the OR was 1.59 and 2.88, respectively, for groups 2 and 3; for males, the OR was 1.92 and 3.15, all of them statistically significant (p<0.01). In-hospital complications were more common in younger patients with TTS, particularly in males. Mortality was positively correlated with age for both sexes, but mortality was higher in males compared to females in all age groups.
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Affiliation(s)
- Olga Vriz
- Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh.
| | - Talal Alzahrani
- Department of Medicine, College of Medicine, Taibah University, Madinah.
| | - Irene Landi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara.
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15
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Wu H, Su H, Zhu C, Wu S, Cui S, Zhou M. Establishment and effect evaluation of a stress cardiomyopathy mouse model induced by different doses of isoprenaline. Exp Ther Med 2023; 25:166. [PMID: 36936708 PMCID: PMC10015318 DOI: 10.3892/etm.2023.11865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 02/01/2023] [Indexed: 03/04/2023] Open
Abstract
The optimum dose of isoprenaline (ISO) required to induce stress cardiomyopathy (SC) in mice is not known. The present study aimed to investigate the dose-response association and determine the optimum dose of ISO to establish a high-morbidity/low-mortality SC mouse model to simulate the clinical symptoms of SC. A total of 72 6-week-old wild-type female mice (C57BL/6) were randomly divided into control mice administered normal saline and mice treated with increasing ISO concentrations (5, 10, 25, 50 and 100 mg/kg ISO intraperitoneal injections daily for 14 consecutive days). All mice were analysed by body weight assessment, open field test (OFT), echocardiography (Echo), electrocardiogram (ECG), assessment of myocardial pathology and quantification of cortisol, brain natriuretic peptide (BNP), cardiac troponin T (cTnT), catecholamine (CA) and C-reactive protein (CRP). Compared with the control group, the 25 and 50 mg/kg ISO groups exhibited the most prominent weight changes and lower mortality. The open-field test showed a significant decrease in autonomous activity behaviour in the 25 and 50 mg/kg ISO groups compared with the control group (P<0.05). Echo revealed that the apex of the heart was balloon-like in the 25 and 50 mg/kg ISO groups, along with prominent left ventricular dyskinesia. ECG showed a significant increase in ST segment amplitude, QT interval and Q amplitude (P<0.05) in the 25 and 50 mg/kg ISO group compared with the control group. Haematoxylin and eosin staining of heart tissue showed a disordered arrangement of myocardial cells, dissolution of myocardial fibres and cytoplasm, notable widening of myocardial cell space, oedema and hyperaemia of the interstitium, whereas heart tissue of the control group was structurally intact. Compared with the control group, the 25 and 50 mg/kg ISO groups exhibited significantly higher levels of cortisol, BNP, cTNT, CA and CRP (P<0.05). A high-incidence low-mortality SC model was successfully and stably developed by administration of 25 and 50 mg/kg ISO. Such models may provide a basis for the development of other animal models of SC.
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Affiliation(s)
- Haosheng Wu
- Graduate School, Anhui University of Traditional Chinese Medicine, Hefei, Anhui 230000, P.R. China
| | - Hang Su
- Graduate School, Anhui University of Traditional Chinese Medicine, Hefei, Anhui 230000, P.R. China
| | - Chao Zhu
- Graduate School, Anhui University of Traditional Chinese Medicine, Hefei, Anhui 230000, P.R. China
| | - Shengbing Wu
- Research Institute of Acupuncture and Meridian, Anhui University of Chinese Medicine, Hefei, Anhui 230000, P.R. China
- College of Acupuncture and Massage, Anhui University of Chinese Medicine, Hefei, Anhui 230000, P.R. China
| | - Shuai Cui
- Research Institute of Acupuncture and Meridian, Anhui University of Chinese Medicine, Hefei, Anhui 230000, P.R. China
- College of Acupuncture and Massage, Anhui University of Chinese Medicine, Hefei, Anhui 230000, P.R. China
- Correspondence to: Professor Meiqi Zhou or Dr Shuai Cui, Research Institute of Acupuncture and Meridian, Anhui University of Chinese Medicine, 103 Meishan Road, Shushan, Hefei, Anhui 230000, P.R. China
| | - Meiqi Zhou
- Research Institute of Acupuncture and Meridian, Anhui University of Chinese Medicine, Hefei, Anhui 230000, P.R. China
- Correspondence to: Professor Meiqi Zhou or Dr Shuai Cui, Research Institute of Acupuncture and Meridian, Anhui University of Chinese Medicine, 103 Meishan Road, Shushan, Hefei, Anhui 230000, P.R. China
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16
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Ferreira C. Takotsubo syndrome: We are still "halfway". A complex heart-brain duality? Rev Port Cardiol 2023; 42:247-249. [PMID: 36639105 DOI: 10.1016/j.repc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Catarina Ferreira
- Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal; Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal; Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal.
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17
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Exploring the Cardiotoxicity Spectrum of Anti-Cancer Treatments: Definition, Classification, and Diagnostic Pathways. J Clin Med 2023; 12:jcm12041612. [PMID: 36836147 PMCID: PMC9962102 DOI: 10.3390/jcm12041612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Early detection and treatment of cancer have led to a noticeable reduction in both mortality and morbidity. However, chemotherapy and radiotherapy could exert cardiovascular (CV) side effects, impacting survival and quality of life, independent of the oncologic prognosis. In this regard, a high clinical index of suspicion is required by the multidisciplinary care team in order to trigger specific laboratory tests (namely natriuretic peptides and high-sensitivity cardiac troponin) and appropriate imaging techniques (transthoracic echocardiography along with cardiac magnetic resonance, cardiac computed tomography, and nuclear testing (if clinically indicated)), leading to timely diagnosis. In the near future, we do expect a more tailored approach to patient care within the respective community along with the widespread implementation of digital health tools.
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18
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Angiography-derived index of microvascular resistance in takotsubo syndrome. Int J Cardiovasc Imaging 2023; 39:233-244. [PMID: 36336756 PMCID: PMC9813145 DOI: 10.1007/s10554-022-02698-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/20/2022] [Indexed: 11/09/2022]
Abstract
Coronary microvascular dysfunction (CMD) has been proposed as a key driver in the etiopathogenesis of Takotsubo syndrome (TTS), likely related to an "adrenergic storm" upon a susceptible microvascular circulation. The aim of our manuscript was to assess CMD in patients with TTS through the computation of the angiography-derived index of microcirculatory resistance (IMR) and its correlation with clinical presentation. Coronary angiograms of 41 consecutive TTS patients were retrospectively analyzed to derive angiography-based indices of CMD. Three indices (NH-IMRangio, AngioIMR and A-IMR) were calculated based on quantitative flow ratio. CMD was defined as an IMRangio value ≥ 25 units. The correlation between CMD and clinical presentation was then assessed. Median age was 76 years, 85.7% were women and mean left ventricular ejection fraction (LVEF) at first echocardiogram was 41.2%. Angiography-derived IMR was higher in left anterior descending artery (LAD) than circumflex and right coronary artery with either NH-IMRangio (53.9 ± 19.8 vs 35.8 ± 15.4 vs 40.8 ± 18.5, p-value < 0.001), AngioIMR (47.2 ± 17.3 vs 31.8 ± 12.2 vs 37.3 ± 13.7, p-value < 0.001) or A-IMR (52.7 ± 19 vs 36.1 ± 14.1 vs 41.8 ± 16.1, p-value < 0.001). All patients presented CMD with angiography-derived IMR ≥ 25 in at least one territory with each formula. Angiography-derived IMR in LAD territory was significantly higher in patients presenting with LVEF impairment (≤ 40%) than in those with preserved ventricular global function (NH-IMRangio: 59.3 ± 18.1 vs 46.3 ± 16.0 p-value = 0.030; AngioIMR: 52.9 ± 17.8 vs 41.4 ± 14.2, p-value = 0.037; A-IMR: 59.2 ± 18.6 vs 46.3 ± 17.0, p-value = 0.035). CMD assessed with angiography-derived IMR is a common finding in TTS and it is inversely correlated with LV function. The available formulas have a substantial superimposable diagnostic performance in assessing coronary microvascular function.
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19
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Wang T, Xiong T, Yang Y, Zuo B, Chen X, Wang D. Metabolic remodeling in takotsubo syndrome. Front Cardiovasc Med 2022; 9:1060070. [PMID: 36505375 PMCID: PMC9729286 DOI: 10.3389/fcvm.2022.1060070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
The heart requires a large and constant supply of energy that is mainly the result of an efficient metabolic machinery that converges on mitochondrial oxidative metabolism to maintain its continuous mechanical work. Perturbations in these metabolic processes may therefore affect energy generation and contractile function directly. Metabolism characteristics in takotsubo syndrome (TTS) reveals several metabolic alterations called metabolic remodeling, including the hyperactivity of sympathetic metabolism, derangements of substrate utilization, effector subcellular dysfunction and systemic metabolic disorders, ultimately contributing to the progression of the disease and the development of a persistent and long-term heart failure (HF) phenotype. In this review, we explore the current literature investigating the pathological metabolic alterations in TTS. Although the metabolic dysfunction in takotsubo hearts is initially recognized as a myocardial metabolic inflexibility, we suggest that the widespread alterations of systemic metabolism with complex interplay between the heart and peripheral tissues rather than just cardiometabolic disorders per se account for long-term maladaptive metabolic, functional and structural impairment under this condition. Therapeutic strategies with the recent evidence from small clinical and animal researches, especially for targeting substrate utilization and/or oxidative stress, might be promising tools to improve the outcome of patients with TTS beyond that achieved with traditional sympathetic inhibition and symptomatic therapies.
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Affiliation(s)
- Ti Wang
- The Hospital Affiliated to Medical School of Yangzhou University (Taizhou People’s Hospital), Taizhou, Jiangsu, China
| | - Ting Xiong
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuxue Yang
- The Hospital Affiliated to Medical School of Yangzhou University (Taizhou People’s Hospital), Taizhou, Jiangsu, China
| | - Bangyun Zuo
- The Hospital Affiliated to Medical School of Yangzhou University (Taizhou People’s Hospital), Taizhou, Jiangsu, China
| | - Xiwei Chen
- The Hospital Affiliated to Medical School of Yangzhou University (Taizhou People’s Hospital), Taizhou, Jiangsu, China
| | - Daxin Wang
- The Hospital Affiliated to Medical School of Yangzhou University (Taizhou People’s Hospital), Taizhou, Jiangsu, China,*Correspondence: Daxin Wang, ,
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20
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Acevedo-Mendez BA, Ye Y, Makaryus JN, Hirsh B. De novo ulcerative colitis and Takotsubo cardiomyopathy following sleeve gastrectomy. BMJ Case Rep 2022; 15:e251519. [PMID: 36400719 PMCID: PMC9677032 DOI: 10.1136/bcr-2022-251519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The increasing prevalence of severe obesity is a major public health concern. Bariatric surgery is an important treatment option for severe obesity due to its long-term sustained result. Multiple studies have shown that patients have an increased risk of developing inflammatory bowel disease following bariatric surgery. Takotsubo syndrome usually presents as acute left ventricular systolic dysfunction without corresponding obstructive coronary artery disease after an acute stress episode. We describe a unique case of a patient who developed de novo ulcerative colitis and takotsubo cardiomyopathy shortly after sleeve gastrectomy. The patient made a successful recovery due to prompt recognition and appropriate treatment.
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Affiliation(s)
- Bernardo Andres Acevedo-Mendez
- Department of Medicine, North Shore University Hospital, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Yuting Ye
- Department of Medicine, North Shore University Hospital, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - John Nihad Makaryus
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
| | - Benjamin Hirsh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
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21
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Yildiz M, Ashokprabhu N, Shewale A, Pico M, Henry TD, Quesada O. Myocardial infarction with non-obstructive coronary arteries (MINOCA). Front Cardiovasc Med 2022; 9:1032436. [PMID: 36457805 PMCID: PMC9705379 DOI: 10.3389/fcvm.2022.1032436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is evident in up to 15% of all acute myocardial infarctions (AMI) and disproportionally affects females. Despite younger age, female predominance, and fewer cardiovascular risk factors, MINOCA patients have a worse prognosis than patients without cardiovascular disease and a similar prognosis compared to patients with MI and obstructive coronary artery disease (CAD). MINOCA is a syndrome with a broad differential diagnosis that includes both ischemic [coronary artery plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection (SCAD), and coronary embolism/thrombosis] and non-ischemic mechanisms (Takotsubo cardiomyopathy, myocarditis, and non-ischemic cardiomyopathy)-the latter called MINOCA mimickers. Therefore, a standardized approach that includes multimodality imaging, such as coronary intravascular imaging, cardiac magnetic resonance, and in selected cases, coronary reactivity testing, including provocation testing for coronary vasospasm, is necessary to determine underlying etiology and direct treatment. Herein, we review the prevalence, characteristics, prognosis, diagnosis, and treatment of MINOCA -a syndrome often overlooked.
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Namrita Ashokprabhu
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Aarushi Shewale
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Madison Pico
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Odayme Quesada
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
- Women’s Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, OH, United States
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22
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Knez R, Niksic M, Omerovic E. Orexin/hypocretin system dysfunction in patients with Takotsubo syndrome: A novel pathophysiological explanation. Front Cardiovasc Med 2022; 9:1016369. [PMID: 36407467 PMCID: PMC9670121 DOI: 10.3389/fcvm.2022.1016369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/05/2022] [Indexed: 09/19/2023] Open
Abstract
Takotsubo syndrome (TTS) is an acute heart failure syndrome. Emotional or physical stressors are believed to precipitate TTS, while the pathophysiological mechanism is not yet completely understood. During the coronavirus disease (COVID-19) pandemic, an increased incidence of TTS has been reported in some countries; however, the precise pathophysiological mechanism for developing TTS with acute COVID-19 infection is unknown. Nevertheless, observing the symptoms of COVID-19 might lead to new perspectives in understanding TTS pathophysiology, as some of the symptoms of the COVID-19 infection could be assessed in the context of an orexin/hypocretin-system dysfunction. Orexin/hypocretin is a cardiorespiratory neuromodulator that acts on two orexin receptors widely distributed in the brain and peripheral tissues. In COVID-19 patients, autoantibodies against one of these orexin receptors have been reported. Orexin-system dysfunction affects a variety of systems in an organism. Here, we review the influence of orexin-system dysfunction on the cardiovascular system to propose its connection with TTS. We propose that orexin-system dysfunction is a potential novel explanation for the pathophysiology of TTS due to direct or indirect dynamics of orexin signaling, which could influence cardiac contractility. This is in line with the conceptualization of TTS as a cardiovascular syndrome rather than merely a cardiac abnormality or cardiomyopathy. To the best of our knowledge, this is the first publication to present a plausible connection between TTS and orexin-system dysfunction. We hope that this novel hypothesis will inspire comprehensive studies regarding orexin's role in TTS pathophysiology. Furthermore, confirmation of this plausible pathophysiological mechanism could contribute to the development of orexin-based therapeutics in the treatment and prevention of TTS.
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Affiliation(s)
- Rajna Knez
- Gillberg Neuropsychiatry Centre, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Development, Department of Women's and Child Health, Skaraborg Hospital, Skövde, Sweden
- Institution for Health, School of Health Sciences, University of Skövde, Skövde, Sweden
| | - Milan Niksic
- Department of Cardiology, Skaraborg Hospital, Skövde, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 797] [Impact Index Per Article: 398.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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24
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Couch LS, Channon K, Thum T. Molecular Mechanisms of Takotsubo Syndrome. Int J Mol Sci 2022; 23:12262. [PMID: 36293121 PMCID: PMC9603071 DOI: 10.3390/ijms232012262] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 12/04/2022] Open
Abstract
Takotsubo syndrome (TTS) is a severe but reversible acute heart failure syndrome that occurs following high catecholaminergic stress. TTS patients are similar to those with acute coronary syndrome, with chest pain, dyspnoea and ST segment changes on electrocardiogram, but are characterised by apical akinesia of the left ventricle, with basal hyperkinesia in the absence of culprit coronary artery stenosis. The pathophysiology of TTS is not completely understood and there is a paucity of evidence to guide treatment. The mechanisms of TTS are thought to involve catecholaminergic myocardial stunning, microvascular dysfunction, increased inflammation and changes in cardiomyocyte metabolism. Here, we summarise the available literature to focus on the molecular basis for the pathophysiology of TTS to advance the understanding of the condition.
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Affiliation(s)
- Liam S. Couch
- Department of Cardiovascular Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Keith Channon
- Department of Cardiovascular Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, 30625 Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, 30625 Hannover, Germany
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25
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Januszewicz A, Mulatero P, Dobrowolski P, Monticone S, Van der Niepen P, Sarafidis P, Reincke M, Rexhaj E, Eisenhofer G, Januszewicz M, Kasiakogias A, Kreutz R, Lenders JW, Muiesan ML, Persu A, Agabiti-Rosei E, Soria R, Śpiewak M, Prejbisz A, Messerli FH. Cardiac Phenotypes in Secondary Hypertension. J Am Coll Cardiol 2022; 80:1480-1497. [DOI: 10.1016/j.jacc.2022.08.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/06/2022]
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26
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Palazzuoli A, Metra M, Collins SP, Adamo M, Ambrosy AP, Antohi LE, Ben Gal T, Farmakis D, Gustafsson F, Hill L, Lopatin Y, Tramonte F, Lyon A, Masip J, Miro O, Moura B, Mullens W, Radu RI, Abdelhamid M, Anker S, Chioncel O. Heart failure during the COVID-19 pandemic: clinical, diagnostic, management, and organizational dilemmas. ESC Heart Fail 2022; 9:3713-3736. [PMID: 36111511 PMCID: PMC9773739 DOI: 10.1002/ehf2.14118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/13/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023] Open
Abstract
The coronavirus 2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF). Several consensus documents describe the appropriate diagnostic algorithm and treatment approach for patients with HF and associated COVID-19 infection. However, few questions about the mechanisms by which COVID can exacerbate HF in patients with high-risk (Stage B) or symptomatic HF (Stage C) remain unanswered. Therefore, the type of HF occurring during infection is poorly investigated. The diagnostic differentiation and management should be focused on the identification of the HF phenotype, underlying causes, and subsequent tailored therapy. In this framework, the relationship existing between COVID and onset of acute decompensated HF, isolated right HF, and cardiogenic shock is questioned, and the specific management is mainly based on local hospital organization rather than a standardized model. Similarly, some specific populations such as advanced HF, heart transplant, patients with left ventricular assist device (LVAD), or valve disease remain under investigated. In this systematic review, we examine recent advances regarding the relationships between HF and COVID-19 pandemic with respect to epidemiology, pathogenetic mechanisms, and differential diagnosis. Also, according to the recent HF guidelines definition, we highlight different clinical profile identification, pointing out the main concerns in understudied HF populations.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte HospitalUniversity of Siena53100SienaItaly
| | - Marco Metra
- Cardiology, Cardio‐Thoracic Department, Civil Hospitals, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Sean P. Collins
- Department of Emergency MedicineVanderbilt University Medical CentreNashvilleTNUSA
| | - Marianna Adamo
- Cardiology, Cardio‐Thoracic Department, Civil Hospitals, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA,Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Laura E. Antohi
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C.Iliescu” BucharestBucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Dimitrios Farmakis
- Cardio‐Oncology Clinic, Heart Failure Unit, “Attikon” University HospitalNational and Kapodistrian University of Athens Medical SchoolAthensGreece,University of Cyprus Medical SchoolNicosiaCyprus
| | | | - Loreena Hill
- School of Nursing and MidwiferyQueen's UniversityBelfastUK
| | - Yuri Lopatin
- Volgograd Medical UniversityCardiology CentreVolgogradRussia
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte HospitalUniversity of Siena53100SienaItaly
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari IntegralUniversity of BarcelonaBarcelonaSpain,Department of CardiologyHospital Sanitas CIMABarcelonaSpain
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Brenda Moura
- Armed Forces Hospital, Porto, & Faculty of MedicineUniversity of PortoPortoPortugal
| | - Wilfried Mullens
- Cardiovascular PhysiologyHasselt University, Belgium, & Heart Failure and Cardiac Rehabilitation Specialist, Ziekenhuis Oost‐LimburgGenkBelgium
| | - Razvan I. Radu
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C.Iliescu” BucharestBucharestRomania
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityNew Cairo, 5th settlementCairo11865Egypt
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu” Bucharest; University for Medicine and Pharmacy “Carol Davila” BucharestBucharestRomania
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27
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 98] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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28
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Srinivasan A, Wong F, Couch LS, Wang BX. Cardiac Complications of COVID-19 in Low-Risk Patients. Viruses 2022; 14:1322. [PMID: 35746793 PMCID: PMC9228093 DOI: 10.3390/v14061322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has resulted in over 6 million deaths and significant morbidity across the globe. Alongside common respiratory symptoms, COVID-19 is associated with a variety of cardiovascular complications in the acute and post-acute phases of infection. The suggested pathophysiological mechanisms that underlie these complications include direct viral infection of the myocardium via the angiotensin-converting enzyme 2 (ACE2) protein and a cytokine release syndrome that results in indirect inflammatory damage to the heart. Patients with pre-existing cardiovascular disease and co-morbidities are generally more susceptible to the cardiac manifestations of COVID-19. However, studies have identified a variety of complications in low-risk individuals, including young adults and children. Myocarditis and paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS) are among the adverse events reported in the acute phase of infection. Furthermore, patients have reported cardiac symptoms persisting beyond the acute phase in post-COVID syndrome. This review summarises the acute and chronic cardiac consequences of COVID-19 in low-risk patients, explores the pathophysiology behind them, and discusses new predictive factors for poor outcomes.
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Affiliation(s)
- Akash Srinivasan
- Department of Medicine, Faculty of Medicine, Imperial College London, London SW7 2AD, UK; (A.S.); (F.W.)
| | - Felyx Wong
- Department of Medicine, Faculty of Medicine, Imperial College London, London SW7 2AD, UK; (A.S.); (F.W.)
| | - Liam S. Couch
- King’s College London BHF Centre, The Rayne Institute, St Thomas’ Hospital, London SE1 7EH, UK;
| | - Brian X. Wang
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
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29
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Arcari L, Musumeci MB, Cacciotti L. The Swiss cheese model in takotsubo syndrome. Eur Heart J Case Rep 2022; 6:ytac235. [PMID: 35734631 PMCID: PMC9210939 DOI: 10.1093/ehjcr/ytac235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Luca Arcari
- Cardiology Unit, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Maria Beatrice Musumeci
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Luca Cacciotti
- Cardiology Unit, Madre Giuseppina Vannini Hospital, Rome, Italy
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30
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Arcari L, Núñez Gil IJ, Stiermaier T, El-Battrawy I, Guerra F, Novo G, Musumeci B, Cacciotti L, Mariano E, Caldarola P, Parisi G, Montisci R, Vitale E, Sclafani M, Volpe M, Corbì-Pasqual M, Martinez-Selles M, Almendro-Delia M, Sionis A, Uribarri A, Akin I, Thiele H, Brunetti ND, Eitel I, Santoro F. Gender Differences in Takotsubo Syndrome. J Am Coll Cardiol 2022; 79:2085-2093. [PMID: 35618345 DOI: 10.1016/j.jacc.2022.03.366] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Male sex in takotsubo syndrome (TTS) has a low incidence and it is still not well characterized. OBJECTIVES The aim of the present study is to describe TTS sex differences. METHODS TTS patients enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry were analyzed. Comparisons between sexes were performed within the overall cohort and using an adjusted analysis with 1:1 propensity score matching for age, comorbidities, and kind of trigger. RESULTS In total, 286 (11%) of 2,492 TTS patients were men. Male patients were younger (age 69 ± 13 years vs 71 ± 11 years; P = 0.005), with higher prevalence of comorbid conditions (diabetes mellitus 25% vs 19%; P = 0.01; pulmonary diseases 21% vs 15%; P = 0.006; malignancies 25% vs 13%; P < 0.001) and physical trigger (55 vs 32% P < 0.01). Propensity-score matching yielded 207 patients from each group. After 1:1 propensity matching, male patients had higher rates of cardiogenic shock and in-hospital mortality (16% vs 6% and 8% vs 3%, respectively; both P < 0.05). Long-term mortality rate was 4.3% per patient-year (men 10%, women 3.8%). Survival analysis showed higher mortality rate in men during the acute phase in both cohorts (overall: P < 0.001; matched: P = 0.001); mortality rate after 60 days was higher in men in the overall (P = 0.002) but not in the matched cohort (P = 0.541). Within the overall population, male sex remained independently associated with both in-hospital (OR: 2.26; 95% CI: 1.16-4.40) and long-term mortality (HR: 1.83; 95% CI: 1.32-2.52). CONCLUSIONS Male TTS is featured by a distinct high-risk phenotype requiring close in-hospital monitoring and long-term follow-up.
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Affiliation(s)
- Luca Arcari
- Institute of Cardiology, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Iván J Núñez Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology, University of Mannheim, Mannheim, Germany; Department of Cardiology and Angiology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Giuseppina Novo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Cardiology Unit, University of Palermo, University Hospital P. Giaccone, Palermo, Italy
| | - Beatrice Musumeci
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Luca Cacciotti
- Institute of Cardiology, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Enrica Mariano
- Division of Cardiology, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Enrica Vitale
- University of Foggia, Department of Medical and Surgical Sciences, Foggia, Italy
| | - Matteo Sclafani
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Massimo Volpe
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | | | - Manuel Martinez-Selles
- Department of Cardiology, Hospital General Universitario Gregorio Marañon, CIBERCV, and Universidad Europea, Universidad Complutense, Madrid, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Aitor Uribarri
- Department of Cardiology, Hospital vall d'hebron, Barcelona, Spain
| | - Ibrahim Akin
- Department of Cardiology, University of Mannheim, Mannheim, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Department of Internal Medicine/Cardiology, Leipzig, Germany
| | | | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Francesco Santoro
- University of Foggia, Department of Medical and Surgical Sciences, Foggia, Italy
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31
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Citro R, Silverio A, Bellino M, Parodi G, Bossone E. Response to: Correspondence on 'Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome' by John E Madias. Heart 2022; 108:1242-1243. [PMID: 35606111 DOI: 10.1136/heartjnl-2022-321278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rodolfo Citro
- Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy .,Vascular Physiopathology Unit, IRCCS Neuromed, Pozzilli, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Guido Parodi
- Department of Cardiology, ASL4 Liguria, Lavagna, Italy
| | - Eduardo Bossone
- Division of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
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32
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A Case Series of Concomitant Cardiac Electrical Disease among Takotsubo Syndrome Patients and Literature Review. J Cardiovasc Dev Dis 2022; 9:jcdd9030079. [PMID: 35323627 PMCID: PMC8955983 DOI: 10.3390/jcdd9030079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 01/06/2023] Open
Abstract
The pathophysiology of Takotsubo Syndrome (TTS) is not completely understood and the trigger of sudden cardiac death (SCD) in TTS is not clear either. We therefore sought to find an association between TTS and primary electrical diseases. A total of 148 TTS patients were analyzed between 2003 and 2017 in a bi-centric manner. Additionally, a literature review was performed. The patients were included in an ongoing retrospective cohort database. The coexistence of TTS and primary electrical diseases was confirmed in five cases as the following: catecholaminergic polymorphic ventricular tachycardia (CPVT, 18-year-old female) (n = 1), LQTS 1 (72-year-old female and 65-year-old female) (n = 2), LQTS 2 (17-year-old female) (n = 1), and LQTS in the absence of mutations (22-year-old female). Four patients suffered from malignant tachyarrhythmia and recurrent syncope after TTS. Except for the CPVT patient and one LQTS 1 patient, all other cases underwent subcutaneous ICD implantation. An event recorder of the CPVT patient after starting beta-blocker did not detect arrhythmias. The diagnosis of primary electrical disease was in 80% of cases unmasked on a TTS event. This diagnosis triggered a family clinical and genetic screening confirming the diagnosis of primary electrical disease. A subsequent literature review identified five cases as the following: a congenital atrioventricular block (n = 1), a Jervell and Lange-Nielsen Syndrome (n = 1), and a family LQTS in the absence of a mutation (n = 2), LQTS 2 (n = 1). A primary electrical disease should be suspected in young and old TTS patients with a family history of sudden cardiac death. In suspected cases, e.g., ongoing QT interval prolongation, despite recovery of left ventricular ejection fraction a family screening is recommended.
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33
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Tomasoni D, Adamo M, Metra M. February 2022 at a glance: focus on pathophysiology and acute heart failure. Eur J Heart Fail 2022; 24:243-244. [PMID: 35199407 DOI: 10.1002/ejhf.2224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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34
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Omerovic E, Citro R, Bossone E, Redfors B, Backs J, Bruns B, Ciccarelli M, Couch LS, Dawson D, Grassi G, Iacoviello M, Parodi G, Schneider B, Templin C, Ghadri JR, Thum T, Chioncel O, Tocchetti CG, Van Der Velden J, Heymans S, Lyon AR. Pathophysiology of Takotsubo Syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 1: Overview and the central role for catecholamines and sympathetic nervous system. Eur J Heart Fail 2021; 24:257-273. [PMID: 34907620 DOI: 10.1002/ejhf.2400] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/11/2022] Open
Abstract
This is the first part of a scientific statement from the Heart Failure Association of the European Society of Cardiology focused upon the pathophysiology of Takotsubo syndrome and is complimentary to the previous HFA Position Statement on Takotsubo syndrome which focused upon clinical management. In part 1 we provide an overview of the pathophysiology of Takotsubo syndrome and fundamental questions to consider. We then review and discuss the central role of catecholamines and the sympathetic nervous system in the pathophysiology, and the direct effects of high surges in catecholamines upon myocardial biology including β-adrenergic receptor signaling, G protein coupled receptor kinases, cardiomyocyte calcium physiology, myofilament physiology, cardiomyocyte gene expression, myocardial electrophysiology and arrhythmogenicity, myocardial inflammation, metabolism and energetics. The integrated effects upon ventricular haemodynamics are discussed and integrated into the pathophysiological model. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Rodolfo Citro
- Heart Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, A. Cardarelli Hospital, Naples, Italy
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Johannes Backs
- Institute of Experimental Cardiology, Heidelberg University, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Germany
| | - Bastian Bruns
- Institute of Experimental Cardiology, Heidelberg University, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Germany.,Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Heidelberg, Germany
| | - Michele Ciccarelli
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno, Italy
| | - Liam S Couch
- National Heart and Lung Institute, Imperial College, London, UK
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK
| | - Guido Grassi
- Clinica Medica, University of Milano Bicocca, Milan, Italy
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, University Hospital, Bari, Italy
| | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | | | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jelena R Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania and University of Medicine Carol Davila, Bucharest, Romania
| | - C Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | | | - Stephane Heymans
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, The Netherlands and Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology and Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
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35
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Madias JE. Pathophysiology of Takotsubo syndrome: still a puzzle. Letter regarding the article 'Pathophysiology of Takotsubo syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 2: vascular pathophysiology, gender and sex hormones, genetics, chronic cardiovascular problems and clinical implications'. Eur J Heart Fail 2021; 24:1323. [PMID: 34816553 DOI: 10.1002/ejhf.2390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/19/2021] [Indexed: 01/04/2023] Open
Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA
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36
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Omerovic E, Citro R, Bossone E, Redfors B, Backs J, Bruns B, Ciccarelli M, Couch LS, Dawson D, Grassi G, Iacoviello M, Parodi G, Schneider B, Templin C, Ghadri JR, Thum T, Chioncel O, Tocchetti CG, Van Der Velden J, Heymans S, Lyon AR. Pathophysiology of Takotsubo syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 2: vascular pathophysiology, gender and sex hormones, genetics, chronic cardiovascular problems and clinical implications. Eur J Heart Fail 2021; 24:274-286. [PMID: 34655287 DOI: 10.1002/ejhf.2368] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 01/09/2023] Open
Abstract
While the first part of the scientific statement on the pathophysiology of Takotsubo syndrome was focused on catecholamines and the sympathetic nervous system, in the second part we focus on the vascular pathophysiology including coronary and systemic vascular responses, the role of the central and peripheral nervous systems during the acute phase and abnormalities in the subacute phase, the gender differences and integrated effects of sex hormones, genetics of Takotsubo syndrome including insights from microRNA studies and inducible pluripotent stem cell models of Takotsubo syndrome. We then discuss the chronic abnormalities of cardiovascular physiology in survivors, the limitations of current clinical and preclinical studies, the implications of the knowledge of pathophysiology for clinical management and future perspectives and directions of research.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Rodolfo Citro
- Heart Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, A. Cardarelli Hospital, Naples, Italy
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Johannes Backs
- Institute of Experimental Cardiology, Heidelberg University, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Bastian Bruns
- Institute of Experimental Cardiology, Heidelberg University, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Heidelberg, Germany.,Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Heidelberg, Germany
| | - Michele Ciccarelli
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno, Italy
| | - Liam S Couch
- National Heart and Lung Institute, Imperial College, London, UK
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK
| | - Guido Grassi
- Clinica Medica, University of Milano Bicocca, Milan, Italy
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, University Hospital, Bari, Italy
| | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | | | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jelena R Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania and University of Medicine Carol Davila, Bucharest, Romania
| | - C Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Jolanda Van Der Velden
- Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stephane Heymans
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Cardiology, Royal Brompton Hospital, London, UK
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