Preadmission beta-blockers are associated with decreased incidence of neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage

Subarachnoid haemorrhage-induced reversible cardiac dysfunction: time course and potential mechanisms

AIMS

Cardiac dysfunction is commonly observed in patients with subarachnoid haemorrhage (SAH). However, the specific timeline of cardiac remodelling and the underlying mechanisms responsible for this effect following SAH remain unknown. This study aims to explore the impact of SAH on cardiac dysfunction and its potential mechanisms over time.

METHODS AND RESULTS

In Protocol 1, we investigated cardiac function and potential mechanisms in a Sprague-Dawley rat model of SAH at six time points (baseline and Days 1, 3, 7, 14, and 28) while exploring the underlying mechanisms. Our assessments included the haemodynamic profile, echocardiography, and the concentrations of plasma biomarkers at various time points post-SAH. We determined neuropeptide Y (NPY) 1-5 receptor protein expression levels through western blotting. In Protocol 2, we administered an NPY1 receptor antagonist to evaluate the effects of cardiac dysfunction induced by SAH on Day 3. In Protocol 1, SAH gradually provoked cardiac systolic dysfunction during the acute phase, reaching its peak on Day 3 without concurrent alterations in wall thickness. However, no significant changes were observed from Days 14 to 28 compared with Day 0. The changes in cardiac dysfunction were consistent with myocardial injury, inflammatory biomarkers, and NPY levels. SAH resulted in a heightened heart rate and systolic blood pressure, correlating with elevated epinephrine and norepinephrine levels. In Protocol 2, the administration of the NPY1 receptor antagonist effectively ameliorated cardiac dysfunction.

CONCLUSIONS

SAH induces transient cardiac dysfunction in the acute phase, and the underlying mechanisms for this response involve the NPY-NPY1 receptor pathway, otherwise known as catecholamines.

Case report: Naturally occurring neurogenic stunned myocardium in a dog secondary to status epilepticus

A 4-year-old male neutered Boston Terrier was presented with status epilepticus. He was diagnosed with idiopathic epilepsy and hospitalized with supportive care. During hospitalization, the patient developed both supraventricular and ventricular arrhythmias as well as focal left ventricular dyskinesis. Cardiac troponin I was significantly increased, which was supportive of myocardial damage. Neurogenic stunned myocardium was suspected, and the patient was treated and responded to esmolol. Follow-up echocardiography demonstrated the resolution of the ventricular dyskinesia. This report describes the clinical presentation, diagnostic findings, treatment, management, and outcome of the first reported case of naturally occurring neurogenic stunned myocardium in a dog. Electrocardiogram monitoring, cardiac troponin I, and echocardiography should be considered in patients presenting with seizure activity, especially when exhibiting cluster seizures or in status epilepticus.

Sex-specific extracerebral complications in patients with aneurysmal subarachnoid hemorrhage

Background

Extracerebral complications in patients with aneurysmal subarachnoid hemorrhage (aSAH) often occur during their stay at the neurocritical care unit (NCCU). Their influence on outcomes is poorly studied. The identification of sex-specific extracerebral complications in patients with aSAH and their impact on outcomes might aid more personalized monitoring and therapy strategies, aiming to improve outcomes.

Methods

Consecutive patients with aSAH admitted to the NCCU over a 6-year period were evaluated for the occurrence of extracerebral complications (according to prespecified criteria). Outcomes were assessed with the Glasgow Outcome Scale Extended (GOSE) at 3 months and dichotomized as favorable (GOSE 5-8) and unfavorable (GOSE 1-4). Sex-specific extracerebral complications and their impact on outcomes were investigated. Based on the results of the univariate analysis, a multivariate analysis with unfavorable outcomes or the occurrence of certain complications as dependent variables was performed.

Results

Overall, 343 patients were included. Most of them were women (63.6%), and they were older than men. Demographics, presence of comorbidities, radiological findings, severity of bleeding, and aneurysm-securing strategies were compared among the sexes. More women than men suffered from cardiac complications (p = 0.013) and infection (p = 0.048). Patients with unfavorable outcomes were more likely to suffer from cardiac (p < 0.001), respiratory (p < 0.001), hepatic/gastrointestinal (p = 0.023), and hematological (p = 0.021) complications. In the multivariable analysis, known factors including age, female sex, increasing number of comorbidities, increasing World Federation of Neurosurgical Societies (WFNS), and Fisher grading were expectedly associated with unfavorable outcomes. When adding complications to these models, these factors remained significant. However, when considering the complications, only pulmonary and cardiac complications remained independently associated with unfavorable outcomes.

Conclusion

Extracerebral complications after aSAH are frequent. Cardiac and pulmonary complications are independent predictors of unfavorable outcomes. Sex-specific extracerebral complications in patients with aSAH exist. Women suffered more frequently from cardiac and infectious complications potentially explaining the worse outcomes.

Subarachnoidal hemorrhage related cardiomyopathy: an overview of Tako-Tsubo cardiomyopathy and related cardiac syndromes

INTRODUCTION

Subarachnoid hemorrhage (SAH) is caused by a ruptured intracranial aneurysm leading to acute extravasation of blood into the subarachnoid space. SAH has an incidence of 6.3 per 100,000 persons per year in Europe and accounts for 5% of all strokes. SAH occurs at a relatively young age and has poor clinical outcomes and high mortality rates. Cardiac syndromes are regularly seen in patients with acute neurologic disease including SAH. These cardiac complications of SAH are associated with increased morbidity and mortality and present in a large variety and severity.

AREAS COVERED

The main goal of this review is to describe the SAH-related cardiac syndromes. Secondly, we will provide an overview of the underlying pathophysiology regarding the development of cardiac syndromes. Thirdly, we will describe the impact of cardiac syndromes on patient outcome.

EXPERT OPINION

Of all neurology patients, SAH patients have the highest risk of developing takotsubo syndrome (TTS), occurring in about 0.8-30% of patients. Both TTS and neurogenic stunned myocardium have many similarities on echocardiographic evaluation. In European Cardiology consensus, SAH is recognized as a primary cause of TTS.

Association of pre-admission antihypertensive agents and outcomes in aneurysmal subarachnoid hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI) and poor functional outcome are common complications in patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). It has been proposed that pre-admission beta-blocker therapy may lower cerebral vasospasm (cVSP) risk after aSAH; however, this association with other antihypertensives is unknown. We sought to determine the association between antihypertensives and clinical outcomes in aSAH patients.

METHODS

We performed a retrospective study on a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2021. Association between pre-admission use of antihypertensives and patient outcomes was determined. Primary outcomes included DCI and poor functional outcome at 3 months after discharge defined as modified Rankin scale [mRS] 4-6. The secondary outcome was cVSP identified using transcranial Doppler (TCD).

RESULTS

The cohort consisted of 306 aSAH patients with mean age 57.1 (SD 13.6) years with 187 females (61 %). Although pre-admission use of beta-blockers (OR 0.40, 95 % CI 0.21-80, p = 0.02), calcium channel blockers (OR 0.43, 95 % CI 0.19-0.93, p = 0.035), and thiazide (OR 0.31, 95 % CI 0.11-0.86, p = 0.025) were associated with lower risk of cVSP in univariate analysis, we did not find any association in a multivariate model after adjusting for age. There was no association between any class of antihypertensives and DCI or functional outcome.

CONCLUSION

Pre-admission use of antihypertensive agents may affect TCD findings, however, none of them appear to be independently associated with DCI or functional outcome. Larger prospective studies are needed to establish any potential association.

The association of Takotsubo cardiomyopathy and aneurysmal subarachnoid hemorrhage: A U.S. nationwide analysis

OBJECTIVE

Takotsubo cardiomyopathy (TC) is a stress-induced cardiomyopathy that can be precipitated by aneurysmal subarachnoid hemorrhage (aSAH). Several studies have shown patients who develop TC following aSAH have an increased risk of disability and mortality. The goal of this study is to examine the incidence of TC in aSAH, identify its risk factors, and analyze its impact on patient outcomes.

METHODS

Data for patients with aSAH between the years of 2009 and 2018 were extracted from the Nationwide Inpatient Sample (NIS) and stratified based on the diagnosis of TC. Univariate analysis was used to assess the incidence of TC and covariates including patient demographics, aneurysmal treatment, in-hospital mortality rate, length of stay and costs. Multivariate logistic regression models analyzed the relationship between TC and these variables RESULTS: 80,915 aSAH patient-discharges were included in this study, 673 (0.83%) of which, developed TC. Females (OR 3.49, CI [2.82-4.33], P < 0.001), white ethnicity (69% vs 63%, P = 0.003) and patients with certain comorbidities including smoking (OR 1.64, CI [1.38-1.95], P < 0.0001) and seizures (OR 1.32, CI [1.07, 1.64], P = 0.01) were most likely to develop TC. Patients who developed TC had significantly increased mortality (OR 1.36, CI [1.13-1.65], P = 0.001), hospital stays (mean days of 19.4 vs 11.5, P < 0.0001), and costs ($104,111 vs $48,734, P < 0.0001). Hypertension (OR 0.63, CI [0.54-0.74], P < 0.0001) and hyperlipidemia (OR 0.63, CI [0.51-0.77], P < 0.0001) were found to be protective against TC. Patients with TC after acute SAH were more likely to undergo endovascular coiling (OR 1.68, CI [1.327-2.127], P < 0.001) rather than surgical clipping (OR 0.66, CI [0.52-0.83], P < 0.0001).

CONCLUSIONS

Female sex, white ethnicity, smoking and seizures represented significant predictors of developing TC after aSAH, while hypercholesterolemia and hypertension were protective.

Experimental Subarachnoid Hemorrhage Drives Catecholamine-Dependent Cardiac and Peripheral Microvascular Dysfunction

Subarachnoid hemorrhage (SAH) is a devastating cerebral event caused by an aneurysmal rupture. In addition to neurological injury, SAH has significant effects on cardiac function and the peripheral microcirculation. Since these peripheral complications may exacerbate brain injury, the prevention and management of these peripheral effects are important for improving the overall clinical outcome after SAH. In this investigation, we examined the effects of SAH on cardiac function and vascular reactivity in a well-characterized blood injection model of SAH. Standard echocardiographic and blood pressure measurement procedures were utilized to assess cardiac function and hemodynamic parameters in vivo; we utilized a pressure myography approach to assess vascular reactivity in cremaster skeletal muscle resistance arteries ex vivo. We observed that elevated catecholamine levels in SAH stun the myocardium, reduce cardiac output and augment myogenic vasoconstriction in isolated cremaster arteries. These cardiac and vascular effects are driven by beta- and alpha-adrenergic receptor signaling, respectively. Clinically utilized adrenergic receptor antagonists can prevent cardiac injury and normalize vascular function. We found that tumor necrosis factor (TNF) gene deletion prevents the augmentation of myogenic reactivity in SAH: since membrane-bound TNF serves as a mechanosensor in the arteries assessed, alpha-adrenergic signaling putatively augments myogenic vasoconstriction by enhancing mechanosensor activity.

Beta-Blockade in Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVE

Sympathetic nervous system activation after aneurysmal subarachnoid hemorrhage (aSAH) is associated with complications and poor outcome. In this systematic review and meta-analysis, we investigate the effect of beta-blockers on outcome after aSAH.

METHODS

The review was prospectively registered with PROSPERO (CRD42019111784). We performed a systematic literature search of MEDLINE, EMBASE, the Cochrane Library, published conference proceedings, and abstracts. Eligible studies included both randomized controlled trials and observational studies up to October 2018, reporting the effect of beta-blocker therapy on the following outcomes in aSAH: mortality, vasospasm, delayed cerebral ischemia, infarction or stroke, cardiac dysfunction, and functional outcomes. Studies involving traumatic SAH were excluded. Citations were reviewed, and data extracted independently by two investigators using a standardized proforma.

RESULTS

We identified 819 records with 16 studies (four were randomized controlled trials) including 6702 patients selected for analysis. Exposure to beta-blockade either before or after aSAH was associated with a significant reduction in unadjusted mortality (RR 0.63, 95% CI 0.42-0.93, p = 0.02). A significant reduction in unadjusted mortality was also seen in prospective trials of post-event beta-blockade (RR 0.51, 95% CI 0.28-0.93, p = 0.03). Statistically significant differences were not seen for other outcomes investigated.

CONCLUSIONS

In adult patients with aSAH, beta-blocker therapy is associated with a mortality benefit. Studies are generally of a low quality with considerable clinical heterogeneity. Prospective large interventional trials with patient centered outcomes are required to validate this finding.

Neurogenic Stunned Myocardium: A Case Report and Brief Review

BACKGROUND

Neurogenic stunned myocardium (NSM) is a condition in a group of stress cardiomyopathies with evolving nomenclature that includes Takotsubo cardiomyopathy. It manifests through electrocardiogram changes, cardiac enzyme elevation, and regional or global kinetic wall motion abnormalities.

CASE REPORT

We present a 43-year-old female with a subarachnoid hemorrhage who developed persistent hypotension and tachycardia secondary to neurogenic stress cardiomyopathy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to consider NSM in any patient with neurologic pathology and undifferentiated shock. Early recognition in the emergency department setting can yield valuable data to guide the treatment and improve clinical outcomes in these patients.

Prognostic Value of Echocardiography for Left Ventricular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

Cardiac dysfunction may worsen outcomes after aneurysmal subarachnoid hemorrhage (SAH). This study quantitatively assessed the prognostic value of left ventricular dysfunction with respect to functional outcomes and mortality in patients with aneurysmal SAH.

METHODS

We searched MEDLINE and EMBASE databases to retrieve relevant studies evaluating echocardiographic left ventricular dysfunction following aneurysmal SAH. Fourteen relevant observational studies evaluating 2234 patients were finally included in this study.

RESULTS

Echocardiographic regional wall motion abnormalities (RWMA) and neurogenic cardiomyopathy (NCM) of the left ventricle occurring after SAH were significantly related to an increase of in-hospital mortality (in 8 studies for RWMA, odds ratio [OR] 2.37; 95% confidence interval [CI] 1.74-3.25 and in 5 studies for NCM, OR 2.82; 95% CI 1.2-6.6). Decreased ejection fraction on echocardiography was not associated with the increase of in-hospital mortality (in 4 studies, OR 1.76; 95% CI 0.86-3.61). The heterogeneities of decreased ejection fraction and NCM were significantly resolved by analyzing only the studies based on echocardiogram measurements obtained within 72 hours after admission.

CONCLUSIONS

The present meta-analysis suggests that the identification of echocardiographic left ventricular dysfunction identified by RWMA and NCM after SAH could provide better prognostic information for in-hospital mortality.

Acute Brain Diseases as Triggers for Stress Cardiomyopathy: Clinical Characteristics and Outcomes

OBJECTIVE

To determine the clinical characteristics and outcomes of patients with neurogenic stress cardiomyopathy (NSC) among patients admitted to our neuroscience intensive care unit (NICU).

METHODS

Following institutional review board approval, consecutive adult patients admitted to the NICU between 2009 and 2013 with definite and possible NSC were included. Data on patient demographics, baseline clinical information, cardiac function, and laboratory values were collected. Outcomes included length of stay, modified Rankin Scale (mRS) at discharge and long-term follow-up. Continuous variables were compared using a student's t test, and categorical variables were compared using a Chi-square test.

RESULTS

Among 34 patients included in the study, the most common presenting symptom was dyspnea (17 patients, 50%). Subarachnoid hemorrhage (SAH) was the most common neurological inciting event (11 patients, 32.4%), but two-thirds of this cohort had other neurological triggers. The most common electrocardiogram changes were QT-interval prolongation (30 patients, 88.2%) and T-wave inversion (22 patients, 64.7%). The most common echocardiographic pattern was the apical variant (14 patients, 41.2%), and 26% of patients had right ventricular involvement (P = 0.03) which was a predictor of poor outcome along with inotropic support (P = 0.006). Functional outcome was poor (mRS > 3) in 53% of patients at discharge, but function improved over time in most survivors.

CONCLUSIONS

NSC is most common after SAH, but can result from a wide spectrum of acute brain insults. Requirement of inotropic support was the strongest indicator of prognosis at last follow-up. Patients with NSC often have poor function at discharge but many improve over time.

Epidemiology, pathogenesis, and management of takotsubo syndrome

Takotsubo syndrome is a recently recognized acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome. The typical takotsubo syndrome patient has a unique circumferential left (bi-) ventricular contraction abnormality profile that extends beyond a coronary artery supply territory and appears to follow the anatomical cardiac sympathetic innervation. The syndrome predominantly affects postmenopausal women and is often preceded by emotional or physical stress. Patients with predisposing factors such as malignancy and other chronic comorbidities are more prone to suffer from takotsubo syndrome. The pathogenesis of takotsubo syndrome is elusive. Several pathophysiological mechanisms involving myocardial ischemia (multivessel coronary artery spasm, microvascular dysfunction, aborted myocardial infarction), left ventricular outlet tract obstruction, blood-borne catecholamine myocardial toxicity, epinephrine-induced switch in signal trafficking, and autonomic nervous system dysfunction have been proposed. The syndrome is usually reversible; nevertheless, during the acute stage, a substantial number of patients develop severe complications such as arrhythmias, heart failure including pulmonary edema and cardiogenic shock, thromboembolism, cardiac arrest, and rupture. Treatment of precipitating factors, predisposing diseases, and complications is fundamental during the acute stage of the disease. The epidemiology, pathogenesis, and management of takotsubo syndrome are reviewed in this paper.

A Review of Neurogenic Stunned Myocardium

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician's awareness of NSM and its features to help tailor management according to the patient's clinical profile.

Effects of preadmission beta-blockers on neurogenic stunned myocardium after aneurysmal subarachnoid hemorrhage: A meta- analysis

OBJECTIVE

Spontaneous subarachnoid hemorrhage is mostly caused by the rupture of an aneurysm. Neurogenic stunned myocardium (NSM) is one of the most frequent complications caused by aneurysmal subarachnoid hemorrhage (aSAH). The possible pathogenesis of NSM may be that the catecholamine peak resulting from aSAH leads to subendocardial ischemia or coronary artery spasm. We designed this meta-analysis to find out whether beta-blockers (BB) can significantly reduce the incidence of NSM and improve the outcomes of aSAH.

PATIENTS AND METHODS

We systematically searched PubMed, Embase, Cochrane library, Elsevier and Medline from inception to Feb 2016. All studies related to the preadmission beta-blocker with aSAH were included.

RESULTS

Three retrospective studies and 691 patients were included. The incidence of mortality [OR=0.68, 95%CI (0.08-3.50), P=0.57], cardiac dysfunction [OR = 0.55, 95% CI (0.05-6.49), P=0.63], cerebral vasospasm (OR=0.52 95% CI(0.18-2.56), P=0.50] had no statistical difference between the preadmission BB group and no BB group.

CONCLUSION

The preadmission beta-blocker cannot decrease the incidence of mortality, cardiac dysfunction, cerebral vasospasm in patients with aSAH. A further research of the usefulness of preadmission beta-blocker in patients with aSAH will be needed.

Beta Blockade and Clinical Outcomes in Aneurysmal Subarachnoid Hemorrhage

Background:

Aneurysmal subarachnoid hemorrhages are frequently complicated by hypertension and neurogenic myocardial stunning. Beta blockers may be used for management of these complications. We sought to investigate sympathetic nervous system modulation by beta blockers and their effect on radiographic vasospasm, delayed cerebral infarction, discharge destination and death.

Methods:

Retrospective chart review of 218 adults admitted to the ICU between 8/2004 and 9/2010 was performed. Groups were identified relevant to beta blockade: 77 were never beta blocked (No/No), 123 received post-admission beta blockers (No/Yes), and 18 were continued on their home beta blockers (Yes/Yes). Records were analyzed for baseline characteristics and the development of vasospasm, delayed cerebral infarction, discharge destination and death, expressed as adjusted odds ratio.

Results:

Of the 218 patients 145 patients developed vasospasm, 47 consequently infarcted, and 53 died or required care in a long-term facility. When compared to No/No patients, No/Yes patients had significantly increased vasospasm (OR 2.11 (1.06-4.16)). However, these patients also had significantly fewer deaths or need for long term care (OR 0.17 (0.05-0.64)), with decreased tendency for infarcts (OR 0.70 (0.32-1.55)). When compared to No/No patients, Yes/Yes patients demonstrated a trend toward increased vasospasm (OR 1.61 (0.50-5.29)) that led to infarction (OR 1.51 (0.44-5.13)), but with decreased mortality or need for long term care in a facility (OR 0.13 (0.01-1.30)).

Conclusion:

Post-admission beta blockade in aneurysmal subarachnoid hemorrhage patients was associated with increased incidence of vasospasm. However, despite the increased occurrence of vasospasm, beta blockers were associated with improved discharge characteristics and fewer deaths.

Contemporary review on the pathogenesis of takotsubo syndrome: The heart shedding tears: Norepinephrine churn and foam at the cardiac sympathetic nerve terminals

Takotsubo syndrome (TS), an increasingly recognized acute cardiac disease entity, is characterized by a unique pattern of circumferential and typically regional left ventricular wall motion abnormality resulting in a conspicuous transient ballooning of the left ventricle during systole. The mechanism of the disease remains elusive. However, the sudden onset of acute myocardial stunning in a systematic pattern extending beyond a coronary artery territory; the history of a preceding emotional or physical stress factor in two thirds of cases; the signs of sympathetic denervation at the regions of left ventricular dysfunction on sympathetic scintigraphy; the finding of myocardial edema and other signs consistent with (catecholamine-induced) myocarditis shown by cardiac magnetic resonance imaging; and the contraction band necrosis on histopathological examination all argue strongly for the involvement of the cardiac sympathetic nervous system in the pathogenesis of TS. In this narrative review, extensive evidence in support of local cardiac sympathetic nerve hyperactivation, disruption and norepinephrine spillover causing TS in predisposed patients is provided.

Neurogenic stunned myocardium in subarachnoid hemorrhage

"Stunned myocardium," characterized by reversible left ventricular dysfunction, was first described via animal models using transient coronary artery occlusion. However, this phenomenon has also been noted with neurologic pathologies and collectively been labeled "neurogenic stunned myocardium" (NSM). Neurogenic stunned myocardium resulting from subarachnoid hemorrhage (SAH) is a challenging pathology due to its diagnostic uncertainty. Traditional diagnostic criteria for NSM after SAH focus on electrocardiographic and echocardiographic abnormalities and troponemia. However, tremendous heterogeneity still exists. Traditional pathophysiological mechanisms for NSM encompassed hypothalamic and myocardial perivascular lesions. More recently, research on pathophysiology has centered on myocardial microvascular dysfunction and genetic polymorphisms. Catecholamine surging as a mechanism has also gained attention with particular focus placed on the role of adrenergic blockade in both the prehospital and acute settings. Management remains largely supportive with case reports acknowledging the utility of inotropes such as dobutamine and milrinone and intra-aortic balloon pump when NSM is accompanied by cardiogenic shock. Neurogenic stunned myocardium that follows SAH can result in many complications such as arrhythmias, pulmonary edema, and prolonged intubation, which can negatively impact long-term recovery from SAH and increase morbidity and mortality. This necessitates the need to accurately diagnose and treat NSM.

Beta-blocker therapy and impact on outcome after aneurysmal subarachnoid hemorrhage: a cohort study

OBJECTIVE

Cerebral vasospasm (cVSP) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on outcome. Beta blockers (BBs) may blunt the sympathetic effect and catecholamine surge associated with ruptured cerebral aneurysms and prevent cardiac dysfunction. The purpose of this study was to investigate the association between preadmission BB therapy and cVSP, cardiac dysfunction, and in-hospital mortality following aSAH.

METHODS

This was a retrospective cohort study of patients with aSAH who were treated at a tertiary high-volume neurovascular referral center. The exposure was defined as any preadmission BB therapy. The primary outcome was cVSP assessed by serial transcranial Doppler with any mean flow velocity ≥ 120 cm/sec and/or need for endovascular intervention for medically refractory cVSP. Secondary outcomes were cardiac dysfunction (defined as cardiac troponin-I elevation > 0.05 μg/L, low left ventricular ejection fraction [LVEF] < 40%, or LV wall motion abnormalities [LVWMA]) and in-hospital mortality.

RESULTS

The cohort consisted of 210 patients treated between February 2009 and September 2010 (55% were women), with a mean age of 53.4 ± 13 years and median Hunt and Hess Grade III (interquartile range III–IV). Only 13% (27/210) of patients were exposed to preadmission BB therapy. Compared with these patients, a higher percentage of patients not exposed to preadmission BBs had transcranial Doppler-mean flow velocity ≥ 120 cm/sec (59% vs 22%; p = 0.003). In multivariate analyses, lower Hunt and Hess grade (OR 3.9; p < 0.001) and preadmission BBs (OR 4.5; p = 0.002) were negatively associated with cVSP. In multivariate analysis, LVWMA (OR 2.7; p = 0.002) and low LVEF (OR 1.1; p = 0.05) were independent predictors of in-hospital mortality. Low LVEF (OR 3.9; p = 0.05) independently predicted medically refractory cVSP. The in-hospital mortality rate was higher in patients with LVWMA (47.4% vs 14.8%; p < 0.001).

CONCLUSIONS

The study data suggest that preadmission therapy with BBs is associated with lower incidence of cVSP after aSAH. LV dysfunction was associated with higher medically refractory cVSP and in-hospital mortality. BB therapy may be considered after aSAH as a cardioprotective and cVSP preventive therapy.

Variant Neurogenic Stunned Myocardium in a Young Female After Subarachnoid Hemorrhage

Neurogenic stunned myocardium is a significant complication of subarachnoid hemorrhage. Diagnosis of neurogenic stunned myocardium is complicated by variable presentation. We present a case of a 23-year-old woman admitted with a subarachnoid hemorrhage from an arteriovenous malformation and associated aneurysm. Postoperatively, she developed pulmonary edema and mildly elevated cardiac biomarkers. Echocardiography showed hypokinesis of the basal left ventricular segments and normal contraction of the apical left ventricular segments consistent with a variant form of neurogenic stunned myocardium. We describe characteristics and outcomes of neurogenic stunned myocardium in this young patient with arteriovenous malformation-associated aneurysmal subarachnoid hemorrhage.

Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: Institutional experience and literature review

OBJECTIVES

To review the current practice in the diagnosis, monitoring and management of TCM in SAH patients at our tertiary referral institution and the relevant literature, and to evaluate the effect of certain treatment modalities on the outcome of those patients.

PATIENTS AND METHODS

A retrospective institutional chart review of 800 patients with aneurysmal SAH from 2007 to 2014. Eighteen patients were identified to have both aneurysmal SAH and TCM based on echocardiogram. Demographic data, clinical parameters, radiographic findings, treatment modalities, and laboratory results were analyzed.

RESULTS

The incidence of typical TCM in our patients was 2.2%. Mortality rate of TCM in SAH was 22% compared to the total mortality rate of all non-traumatic SAH patients of 15% in our institution over the same time period. Use of beta blockers prior to or after the diagnosis of TCM did not seem to affect their outcome. Majority of patients (61%) were on vasopressors prior to the diagnosis of TCM. Of those, 73% had good outcomes. Even after the diagnosis of TCM, good outcomes were observed in 6 of 7 patients who remained on vasopressors.

CONCLUSION

Despite the general agreement on the importance of the avoidance of vasopressors in TCM, our experience showed that the use of vasopressors is safe in these patients. The use of beta blockers in our patients was not associated with significantly better outcomes despite multiple previous reports on beta blocker usage in TCM.

Neurogenic stress cardiomyopathy associated with subarachnoid hemorrhage

Cardiac manifestations are recognized complications of subarachnoid hemorrhage. Neurogenic stress cardiomyopathy is one complication that is seen in acute subarachnoid hemorrhage. It can present as transient diffuse left ventricular dysfunction or as transient regional wall motion abnormalities. It occurs more frequently with neurologically severe-grade subarachnoid hemorrhage and is associated with increased morbidity and poor clinical outcomes. Managing this subset of patients is challenging. Early identification followed by a multidisciplinary team approach can potentially improve outcomes.

Plasma Catecholamine Profile of Subarachnoid Hemorrhage Patients with Neurogenic Cardiomyopathy

Purpose

To investigate the connection between sympathetic function and neurogenic cardiomyopathy (NC), and to determine whether NC is mediated primarily by circulating adrenal epinephrine (EPI) or neuronally transmitted norepinephrine (NE), following subarachnoid hemorrhage (SAH).

Methods

This is a prospective observational investigation of consecutive severe-grade SAH patients. All participants had transthoracic echocardiography and serological assays for catecholamine levels – dopamine (DA), NE and EPI – within 48 h of hemorrhage onset. Clinical and serological independent predictors of NC were determined using multivariate logistic regression analyses, and the accuracy of predictors was assessed by receiver operating characteristic (ROC) curves. Multivariate linear regression analyses were used to evaluate correlations among the catecholamines.

Results

The investigation included a total of 94 subjects: the mean age was 55 years, 81% were female and 57% were Caucasian. NC was identified in approximately 10% (9/94) of cases. Univariate analyses revealed associations between NC and worse clinical severity (p = 0.019), plasma DA (p = 0.018) and NE levels (p = 0.024). Plasma NE correlated with DA levels (ρ = 0.206, p = 0.046) and EPI levels (ρ = 0.392, p < 0.001), but was predicted only by plasma EPI in bivariate [parameter estimate (PE) = 1.95, p < 0.001] and multivariate (PE = 1.89, p < 0.001) linear regression models. Multivariate logistic regression analyses consistently demonstrated the predictive value of clinical grade for NC (p < 0.05 for all analyses) except in models incorporating plasma NE, where NC was independently predicted by NE level (OR 1.25, 95% CI 1.01-1.55) over clinical grade (OR 4.19, 95% CI 0.874-20.1). ROC curves similarly revealed the greater accuracy of plasma NE [area under the curve (AUC) 0.727, 95% CI 0.56-0.90, p = 0.02] over clinical grade (AUC 0.704, 95% CI 0.55-0.86, p = 0.05) for identifying the presence or absence of NC.

Conclusions

Following SAH, the development of NC is primarily related to elevated plasma NE levels. Findings implicate a predominantly neurogenic process mediated by neuronal NE (and not adrenal EPI), but cannot exclude synergy between the catecholamines.

The pathogenesis of reversible T-wave inversions or large upright peaked T-waves: Sympathetic T-waves

Reversible electrocardiographic (ECG) repolarization changes including T-wave inversions (TWI), large upright peaked T-waves (LUPTW) and prolongation of the corrected QT interval (P-QTc) have been reported in association with myriads of acute cardiac and non-cardiac diseases. Through the last 70 years, the TWIs have been described under different terms as; cerebral, giant, global, canyon, Wellens or coronary and cardiac memory T waves. During the last 15 years, the reversible TWI and LUPTW in association with P-QTc have been described as characteristic ECG features in takotsubo syndrome (TS), which also may be triggered by the same aforementioned acute cardiac and non-cardiac disease entities. The pathogenesis of these reversible T-wave changes is not clear-cut. In this manuscript, substantial evidences for a causal link between the local cardiac sympathetic disruption and the development of the reversible TWI and LUPTW are presented. As a result, a pathogenetic term for the reversible TWI or LUPTW, which is sympathetic T waves (sympathetic TWI or sympathetic LUPTW), would be the most appropriate term.

Postoperative ICU management of patients after subarachnoid hemorrhage

PURPOSE OF REVIEW

This article reviews recent advances in the postoperative ICU management of patients after subarachnoid hemorrhage (SAH), especially with regards to hemodynamic management, methods of improving neurological outcomes, and management of cardiac and pulmonary complications.

RECENT FINDINGS

Several hemodynamic monitors and parameters may be useful for guiding volume therapy, including cardiac output, stroke volume variation monitoring, and global end-diastolic volume index. Early goal-directed hemodynamic therapy after SAH has recently been shown to improve clinical outcomes in patients with a poor clinical grade or coexisting cardiopulmonary complications. Recent laboratory and imaging modalities are being developed to identify patients at risk for developing vasospasm after SAH. Evidence for the use of various prophylactic adjuvant therapies to prevent vasospasm, including magnesium, phosphodiesterase 3 inhibitors, and therapeutic hypothermia, is emerging. Intrathecal administration of vasodilators or fibrinolytics may have offered advantages over systemic drug administration in the treatment of vasospasm. Pulmonary and cardiac complications are common after SAH, and are associated with an increased risk of mortality.

SUMMARY

The postoperative ICU period after SAH is associated with a significant morbidity and mortality risk, and recent studies have greatly contributed to our understanding of how to optimally manage these patients.

CNS disease triggering Takotsubo stress cardiomyopathy

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS disorders are epilepsy, stroke, infectious or immunological encephalitis/meningitis, migraine, and traumatic brain injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest not only as arrhythmias, myocardial infarction, autonomic impairment, systolic dysfunction/heart failure, arterial hypertension, or pulmonary hypertension, but also as stress cardiomyopathy (Takotsubo syndrome, TTS). CNS disease triggering TTS includes subarachnoid bleeding, epilepsy, ischemic stroke, intracerebral bleeding, migraine, encephalitis, traumatic brain injury, PRES syndrome, or ALS. Usually, TTS is acutely precipitated by stress triggered by various different events. TTS is one of the cardiac abnormalities most frequently induced by CNS disorders. Appropriate management of TTS from CNS disorders is essential to improve the outcome of affected patients.

Preadmission statin use does not improve functional outcomes or prevent delayed ischemic events in patients with spontaneous subarachnoid hemorrhage

STUDY OBJECTIVE

To determine whether preadmission statin use in patients with spontaneous subarachnoid hemorrhage (SAH) is associated with improved functional outcomes and a lower incidence of delayed cerebral ischemic events compared with statin-naive patients with SAH.

DESIGN

Prospective cohort study.

SETTING

Neurosciences intensive care unit of a tertiary care hospital.

PATIENTS

A total of 295 consecutive patients with SAH admitted between March 2006 and May 2013 who had complete medication histories; of these patients, 41 reported taking a statin prior to admission, and 254 were statin naive.

INTERVENTION

All patients received clinical management for SAH according to hospital protocol for standard care that included acute statin therapy with enteral pravastatin 40 mg/day on hospital day 1 for up to 21 days.

MEASUREMENTS AND MAIN RESULTS

Functional outcomes were assessed by using the modified Rankin Scale (mRS) at 14 days, 28 days, and 3 months. Delayed cerebral ischemia was assessed by using clinical evaluation and computed tomography. Patients taking statins prior to admission were more likely to have a history of diabetes mellitus, hypertension, coronary artery disease, and stroke. No significant difference in favorable neurologic outcome (mRS score 0-3) at 3 months was observed between the preadmission statin group compared with the statin-naive group (56.3% vs 72.4%, p=0.095). In multivariate logistic regression analysis, only age, severity of rupture, and coronary artery disease were less likely to predict a favorable neurologic outcome. No significant difference in the development of delayed cerebral ischemic events was observed between groups (p=0.48).

CONCLUSION

Statin use prior to admission did not improve functional outcomes or prevent delayed cerebral ischemic events in patients with SAH. Age, severity of rupture, and coronary artery disease were less likely to predict a favorable neurologic outcome at 3 months after discharge.

Cardiac abnormalities after aneurysmal subarachnoid hemorrhage: effects of β-blockers and angiotensin-converting enzyme inhibitors

BACKGROUND

Cardiac abnormalities attributed to adrenergic surge are common after aneurysmal subarachnoid hemorrhage. Prescribed medications that block adrenergic stimulation may suppress the onset of cardiopulmonary compromise in patients after aneurysmal subarachnoid hemorrhage.

OBJECTIVES

To compare the incidence of early cardiac complications between patients who reported prescribed use of β-blockers and/or angiotensin-converting enzyme inhibitors before aneurysmal subarachnoid hemorrhage and patients who did not.

METHODS

A retrospective review of 254 adult patients after acute aneurysmal subarachnoid hemorrhage who were enrolled in an existing R01 study. Demographic data and history were obtained from patients'/proxies' reports and charts. Cardiac enzyme levels, 12-lead electrocardiograms, and chest radiographs were obtained on admission. Holter monitoring and echocardiograms were completed as a part of the R01 study.

RESULTS

Patients reporting prescribed use of angiotensin-converting enzyme inhibitors or β-blockers before aneurysmal subarachnoid hemorrhage had more ventricular and supraventricular ectopy on a Holter report than did patients who did not (P < .05). When age, race, sex, and injury (Fisher grade) were controlled for, patients reporting use of β-blockers were 8 times more likely than others to have occasional to frequent ventricular ectopy (P = .02).

CONCLUSION

No concrete evidence was found that exposure to adrenergic blockade before aneurysmal subarachnoid hemorrhage provides protection from neurocardiac injury.

Acute cardiac sympathetic disruption in the pathogenesis of the takotsubo syndrome: a systematic review of the literature to date

Takotsubo syndrome (TS), also known as broken heart syndrome and neurogenic stunned myocardium, is an acute cardiac disease entity characterized by a clinical picture mimicking that of an acute coronary syndrome. The pathogenesis of TS has not been established yet. Among the most often debated pathologic mechanisms of TS are as follows: first, multi-vessel coronary spasm; second, myocardial microvascular dysfunction; third, aborted myocardial infarction caused by transient thrombotic occlusion of a long wrap-around left anterior descending artery; fourth, left ventricular outflow tract obstruction; fifth, blood-borne catecholamine cardiac toxicity; and sixth, cardiac sympathetic disruption and norepinephrine seethe and spillover. The aim of this review is to provide a thorough analysis of the literature data coming mainly from the neurological literature and dealing with the pathogenesis of TS. Substantial evidence challenging the first five hypotheses and arguing in favor of the hypothesis that acute cardiac sympathetic eruption and norepinephrine seethe and spillover is causing TS in predisposed patients is presented.

High-dose insulin therapy for neurogenic-stunned myocardium after stroke

A 44-year-old woman with a history of complicated type 2 diabetes mellitus presented with a diagnosis of right-hemispheric ischaemic stroke. She developed acute respiratory distress with radiological evidence of pulmonary oedema. The ECG showed poorly significant ST-segment changes, with a minimal increase of cardiac biomarkers. Echocardiography showed a severely depressed left ventricular function, with also low values of cardiac output at invasive monitoring. The possibility of neurogenic-stunned myocardium was discussed and a metabolic resuscitation with high-dose insulin was proposed. An intravenous bolus of 80 units of insulin (0.72 IU/kg) was followed by a continuous infusion at the rate of 160 IU/h (1.45 IU/kg/h). The treatment led to a rapid and sustained improvement of the haemodynamic condition and was well tolerated. In comparison with dobutamine, insulin had significant inotropic effects without tachycardia. The patient unfortunately died on day 35, from respiratory complications after poor neurological recovery.