Importance of temporal changes in myocardial strain in Takotsubo cardiomyopathy

A review of biomarker and imaging monitoring to predict heart failure recovery

Heart failure is a clinical syndrome caused by structural cardiac abnormalities that lead to increased intracardiac pressures and decreased cardiac output. Following cardiovascular insult or direct myocardial injury, neurohormonal activation triggers hemodynamic changes and cardiac remodeling to preserve cardiac output. While initially adaptive, cardiac remodeling eventually causes pathologic changes in cardiac structure that often compromise cardiac function. Reverse remodeling is the regression of abnormal cardiac chamber geometry and function after myocardial injury. In recent years, several classes of therapeutics have been associated with greater likelihood of reverse remodeling. Heart failure recovery and heart failure remission, terms encompassing the clinical correlates of reverse remodeling, have been associated with improved survival in patients with heart failure with reduced ejection. As such, identifying predictors of heart failure recovery can have important implications for guiding clinical practice and therapeutic innovation. This review addresses the role of biomarkers and imaging monitoring in predicting structural, functional, and clinical recovery in patients with acute and chronic heart failure.

Takotsubo cardiomyopathy in a child with single-ventricle disease

Takotsubo cardiomyopathy, a disease that causes transient contractile abnormalities mainly in the left ventricular apex, is rarely reported in children, especially in those with single-ventricle disease. A 4-year-old boy with a single right ventricle was transferred to our hospital following a severe seizure and was diagnosed with takotsubo cardiomyopathy by echocardiography. His cardiac function improved; however, he developed hypoxic-ischemic encephalopathy.

Early Differentiation of Stress Cardiomyopathy from Acute Anterior Wall Myocardial Using Changing Cardiac Enzyme Patterns

BACKGROUND

Most patients with acute anterior wall ST elevation myocardial infarction (STEMI) or stress cardiomyopathy (SCMP) show elevations in cardiac enzymes that peak within 24 hours. The changing pattern of cardiac enzymes can be an early clue to the differentiation of anterior STEMI and SCMP.

METHODS

This study was a retrospective analysis (matching cases and respective control subjects) performed at a single center. We compared 27 patients with SCMP and 30 patients with anterior STEMI. We used laboratory data included cardiac marker, such as the initial creatine kinase MB (CK-MB) fraction and troponin T (Tn-T), at admission and peak CK-MB and Tn-T at follow up.

RESULTS

The mean age was 69.3 ± 14.1 years, and 38.6% of patients were female. The SCMP patients were older, more often female, and had lower left ventricular ejection fractions than the anterior STEMI patients. The initial CK-MB was higher in the anterior STEMI group than in the SCMP group. In contrast, the initial Tn-T level was not significantly different between the 2 groups. Peak CK-MB and Tn-T levels and change from initial levels were significantly greater in the anterior STEMI group than they were in the SCMP group. SCMP could be differentiated from anterior STEMI based on peak CK-MB > 46.65 ng/mL or Tn-T > 1.56 ng/mL.

CONCLUSIONS

Follow-up changes in cardiac enzymes can be an effective early tool for differentiating SCMP from anterior STEMI.

Left ventricular global longitudinal strain assessment in patients with takotsubo cardiomyopathy: a call for an echocardiography-based classification

BACKGROUND

Takotsubo cardiomyopathy (TTC) is classified into 4 types depending on the anatomical area affected identified on gross visual assessment. We have sought to understand if it is feasible and advantageous to use left ventricular global longitudinal strain (LVGLS), LV segmental longitudinal strain and right ventricle free wall strain (RVFWS) to classify TTC.

METHODS

We conducted a retrospective observational study on twenty-five patients who meet the Modified Mayo Clinic Criteria for TTC [1]. Two independent reviewers performed strain analysis, they were both blinded to patient's diagnosed classification and outcomes.

RESULTS

Based on classification by traditional assessment the 92% (N.=23) were diagnosed with typical TTC, indicating apical involvement. The entire LV was affected, 67% (N.=16) had abnormal strain (STE>-18) in all three LV regions (base, mid-ventricle and apex). Seventy-one percent of patients (N.=17) had abnormal LVGLS (>-18). Abnormal strain across all three LV regions was associated with higher prevalence (70%, N.=8 Vs 30%, N.=4, respectively) of composite cardiovascular events and longer length of hospital stay. There was a statistically significant difference in average length of hospital stay in those patients who had abnormal strain in all three regions compared to those that did not have abnormal strain across all three regions (8 days compared to 3.44 days, P=0.02).

CONCLUSIONS

A new classification of TCC based on strain analysis should be developed. The traditional model is arbitrary; it fails to recognize that in most patients the entire LV is affect, it does not have prognostic significance and the most prevalent typical variant indicates apical involvement. Our study suggests that the entire LV is affected, and strain analysis has prognostic significance.