Statin therapy and outcome in Takotsubo syndrome patients: Results from the multicenter international GEIST registry

BACKGROUND AND AIMS

Several studies have shown that endothelial dysfunction plays a role in the pathogenesis of Takotsubo syndrome (TTS). Given the potential benefit of statin therapy on endothelial dysfunction, we hypothesized that such treatment could improve outcome. Aim of our study was to evaluate clinical characteristics and outcome of TTS patients treated with statin therapy.

METHODS

Patients were enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry. Demographic data, clinical features and drug therapy at discharge were recorded. Primary study outcome was the occurrence of all-cause death at follow-up.

RESULTS

Study population included 2429 consecutive TTS patients: 1293 (53.2%) discharged on statin and 1136 (46.8%) without statin. Patients with statin were older (age 72 ± 11 vs 69 ± 13 years, p < 0.001), with higher prevalence of hypertension (74.3% vs 60.3%, p < 0.001), diabetes (21.1% vs 14.7%, p < 0.001), dyslipidemia (56.1% vs 23.3%, p < 0.001), history of coronary artery disease (13.3% vs 6.3%, p < 0.001) and lower rates of in-hospital complications (14.7% vs 19.3%, p = 0.003). Survival analysis showed similar mortality rates between groups (log rank p = 0.803). At univariable analysis, statin therapy at discharge was not associated with lower mortality (HR: 0.97, 95% CI 0.74-1.26, p = 0.803). At multivariable analysis age (HR: 1.06 95% CI 1.04-1.08, p < 0.001), male sex (HR: 1.83, 95% CI 1.20-2.80, p = 0.005), diabetes (HR: 2.55, 95% CI 1.83-3.54 p < 0.001), malignancies (HR: 2.41, 95% CI 1.68-3.44, p < 0.001) and physical trigger (HR: 2.24, 95% CI 1.62-3.10, p < 0.001) were associated with increased mortality.

CONCLUSIONS

Statin therapy after a TTS event was not associated with better prognosis at follow-up.

Screening and Management of Coronary Artery Disease in Kidney Transplant Candidates

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially in end-stage renal disease (ESRD) patients and during the first year after transplantation. For these reasons, and due to the shortage of organs available for transplant, it is of utmost importance to identify patients with a good life expectancy after transplant and minimize the transplant peri-operative risk. Various conditions, such as severe pulmonary diseases, recent myocardial infarction or stroke, and severe aorto-iliac atherosclerosis, need to be ruled out before adding a patient to the transplant waiting list. The effectiveness of systematic coronary artery disease (CAD) treatment before kidney transplant is still debated, and there is no universal screening protocol, not to mention that a nontailored screening could lead to unnecessary invasive procedures and delay or exclude some patients from transplantation. Despite the different clinical guidelines on CAD screening in kidney transplant candidates that exist, up to today, there is no worldwide universal protocol. This review summarizes the key points of cardiovascular risk assessment in renal transplant candidates and faces the role of noninvasive cardiovascular imaging tools and the impact of coronary revascularization versus best medical therapy before kidney transplant on a patient's cardiovascular outcome.

Utility and prognostic significance of leukocyte ratios in dogs with Primary Immune-Mediated Hemolytic Anemia

Canine immune-mediated hemolytic anemia (IMHA) is a life-threatening condition that is commonly associated with neutrophilia and monocytosis. Leukocyte ratios have been found to have prognostic value in humans and animals affected by a range of inflammatory, infectious, and neoplastic disorders. We hypothesized that in primary IMHA, neutrophil to lymphocyte (NLR), neutrophil to monocyte (NMR), band neutrophil to segmented neutrophil (BNR) and monocyte to lymphocyte (MLR) ratios would be higher in dogs that did not survive to discharge. Medical records of dogs diagnosed with IMHA at two veterinary teaching hospitals were retrospectively reviewed. Twenty-three of the 72 included dogs did not survive to discharge. NLR, NMR, BNR and MLR ratios were compared between dogs that survived to discharge and dogs that died or were euthanized. None of the ratios were significantly different between survivors and non-survivors (P = 0.14-0.99). Area under the Receiver Operating Characteristic (ROC) curve for prediction of non-survival ranged from 0.5 (95% confidence interval 0.38-0.62) for MLR to 0.61 (0.49-0.72) for NMR and was not significantly different from 0.5 for any ratio (P = 0.29-0.99). After exclusion of 31 dogs that received one or both immunosuppressive medications and blood transfusion before presentation, the area under the ROC curve for prediction of survival was significantly different from 0.5 for MLR (0.78, P = 0.01) and NMR (0.78, P = 0.0002). This study suggests that lower MLR and higher NMR may predict poorer prognosis in untreated dogs with IMHA.

806 BRIDGING COLLATERALS OF CHRONICALLY OCCLUDED LEFT INTERNAL MAMMARY ARTERY BYPASS GRAFT TO LEFT ANTERIOR DESCENDING ARTERY

Methods and results

The internal mammary artery (IMA) is the conduit of choice to bypass the left anterior descending (LAD) coronary artery in patients eligible for coronary artery bypass grafting (CABG).

In case of graft occlusion, it is still not clear whether it is better to revascularize the graft or the recipient native vessel, on top of optimal medical therapy.

A 55-year-old man, with prior CABG, underwent urgent coronary angiography for an acute coronary syndrome.

LAD CTO, severe proximal circumflex artery stenosis, and mild atherosclerosis of the right coronary artery were found. Moreover, a proximal occlusion of the venous graft to the obtuse marginal branch and LIMA CTO within the body of the graft were shown as well. Surprisingly, many well-developed bridging collaterals, arising close to the proximal cap of the LIMA occlusion, supplied the bloodstream circulation distal to the occlusion within the LIMA.

At that time, a left main–proximal circumflex artery stenting was performed (3.5×24-mm Xience Sierra, Abbott) because that was judged the culprit lesion.

One month later the patient still complained of effort angina and dyspnoea despite optimized antianginal medical therapy. The patient was scheduled for elective antegrade LIMA CTO PCI, considered the most appropriate treatment strategy. Indeed, the presence of a prior stent implanted in the left main– circumflex artery would have made difficult a proximal cap negotiation and its penetration by guidewires in case of antegrade LAD CTO PCI. Thus, the LIMA CTO negotiation was initially attempted with a Fielder FC guidewire (Asahi Intecc) and a supporting Corsair Pro (Asahi Intecc) microcatheter. The polymeric soft wire prolapsed preferentially into the bridging collaterals without the chance to engage the CTO proximal cap. Finally, a moderate-weight hydrophilic GAIA second (Asahi Intecc) succeeded in cap penetration and final CTO crossing. After lesion predilatation with a 2.0×15-mm balloon (Emerge, Boston Scientific), 2 overlapped stents, respectively 2.75×44 mm and 3.0×18 mm (VIVO ISAR, Translumina) were deployed and postdilated by a 3.0×15-mm non-compliant balloon (Accuforce, Terumo). The final result was deemed very satisfactory with a TIMI 3 flow.

Conclusions

Many studies showed that IMA has active biological functions, providing a sort of protection against atherosclerosis and self-reparative properties. These biological properties might justify the IMA high long-term patency rates as CABG conduits. The development of bridging collaterals in this patient, represents a clear proof of the LIMA self-reparative properties. Whereas bridging collaterals are a common feature of coronary CTO, their development in a LIMA bypass graft represents a unique finding which requires further investigation.

273 CORONARY ARTERIES ANEURYSMS: CASE-BASED DISCUSSION

Coronary artery aneurysm (CAA) is an abnormal dilatation of a coronary artery segment; when its diameter is bigger than 20 mm or it is more than four times bigger as compared to the normal vessel size, the coronary artery aneurysm is defined as Giant. However, there are multiple definition of Giant CAA and miss a standardized classification. The reported prevalence of coronary aneurysms in the population underwent coronary angiography, ranges from 0.3% to 5% and often CAA are found in patient with aneurysms in other sites as ascending or abdominal aorta. In half of the cases an atherosclerotic etiology could be recognized; often CAA is found in the context of acute coronary syndrome. Seldom CAA is found at the autopsy of patient died for sudden cardiac death. Up today very few data exist about CAA management and their prognostic relevance; moreover, CAA treatment is not still clearly codified but rather case-based. Indeed, up today there are not published dedicated studies on which is the best medical therapy in example with antiplatelets or anticoagulant agents rather than an interventional approach, by endovascular or surgical technique. In this review, through two clinical cases, it will be described the current evidence about diagnostic tools and treatment options of CAAs.

An Italian investigation on non-tuberculous mycobacteria in an urban water supply

BACKGROUND

Atypical or non-tuberculous mycobacteria (NTM) are considered opportunistic pathogenic bacteria. They are natural inhabitants of a broad variety of environmental reservoirs, including natural and treated waters. Due to the lack of Italian studies on these microorganisms in drinking water, an investigation was carried out on their occurrence and on species present in a municipal water distribution system in Rome. The presence of the traditional indicators of faecal contaminations and free living amoebae were also verified.

METHODS

Two different methodological approaches based on cultural and molecular techniques have been applied in parallel.

RESULTS

Mean concentrations of NTM obtained with the two analytical methodologies were roughly 102 CFU/L. Among the numerous NTM species identified, M. chelonae was the most frequently isolated. No correlation of NTM with indicators of faecal contamination and amoebae was found.

CONCLUSIONS

Mycobacteria can be present even if routine tests show water to have an excellent hygienic quality.

Rotavirus gastroenteritis in Italian children: can severity of symptoms be related to the infecting virus?

The aim of our study was to determine whether the severity of rotavirus gastroenteritis may be related to the different characteristics of infecting viral strains. The severity of clinical symptoms in 401 children with acute rotavirus gastroenteritis was assessed using a scoring system for frequency and duration of vomiting, diarrhea, and fever, as well as the patients' requirements for intravenous rehydration. Rotavirus strains were characterized by determining the electropherotype of their double-stranded RNA, the G type and subgroup by a panel of monoclonal antibodies, and the P type by reverse transcription-polymerase chain reaction. Strains with a short electropherotype, G2P[4] type, and subgroup I were associated with more-severe gastroenteritis and affected children older than those infected with strains with a long electropherotype, G1P[8] or G4P[8] type, and subgroup II. Minor differences in clinical symptoms were also detected in children infected with different long electropherotypes and with G1P[8] and G4P[8] specificities.

Presence of Epstein-Barr virus, cytomegalovirus and human papillomavirus in normal oral mucosa of HIV-infected and renal transplant patients

OBJECTIVES

To determine the prevalence of EBV-DNA, CMV-DNA and HPV-DNA in oral healthy mucosa of HIV-infected and renal transplant patients. To associate the detection of viral genomes with laboratory parameters of immunodeficiency, gender, antiretroviral and immunosuppressive therapy.

DESIGN

A cross-sectional analysis of lingual and buccal cytobrushings from HIV-infected and renal transplant patients.

SUBJECTS AND METHODS

Lingual and buccal cytobrushings were obtained from clinically normal oral mucosa of 57 HIV+, 40 renal transplant patients and 30 healthy uninfected controls, all matched for age at baseline of examination. Presence of EBV-, CMV- and HPV-DNA was assessed by polymerase chain reaction (PCR). We evaluated their association, in HIV+ subjects, with gender, CD4+ cell count, HIV-RNA load, and antiretroviral therapy; and in renal transplant patients, with gender, CD4/CD8 ratio, and immunosuppressive therapy. Data were managed and analysed by Epi-Info 6.0.

RESULTS

EBV-DNA was detected in 42.1% of HIV+ (24/57), in 65.0% of transplant patients (26/40), and in 16.6% of controls (5/30) (P = 0.03 and P = 0.0001, respectively). Furthermore, male gender in HIV+ group was found to be significantly associated with the presence of EBV-DNA (P = 0.02) vs females, after adjusting for CD4+ cell count and HIV-RNA load. CMV- and HPV-DNA were detected in 3.5% and 7.0% of HIV+, and in none and 20.0% of transplant patients, respectively. No relationship was found between the epithelial detection of these two viruses and any parameter evaluated.

CONCLUSIONS

EBV genome was significantly detected in clinically normal oral mucosa of renal transplant and HIV+ patients. A significant gender association was found among HIV+, suggesting that oral hairy leukoplakia (OHL) is more likely to occur in HIV+ men than women.

Identification of human rotavirus strains with the P[14] genotype by PCR

A seminested PCR typing assay has been extended to identify rotavirus strains with the P[14] genotype. The specificity of the method was confirmed by Southern hybridization and by restriction analysis with the enzyme AluI. One out of four human rotavirus (HRV) strains with unusual subgroup-electropherotype linkage but none out of 50 HRV strains with usual linkage was typed as P[14].

Bone marrow micrometastases in 109 breast cancer patients: correlations with clinical and pathological features and prognosis

BACKGROUND

The presence in bone marrow of cells which react with monoclonal antibodies against tumor-associated antigens has been proposed over the last few years as a new prognostic factor in breast cancer patients.

PATIENTS AND METHODS

Bone marrow aspirates were obtained from 109 stage I and II breast cancer patients during or 2-4 weeks after primary surgery. The samples were processed for leukocyte separation on a Ficoll-Hypaque gradient and then used to prepare cytospin slides for immunocytochemical analysis. The slides were stained with a pool of monoclonal antibodies (MoAbs) which recognize tumor associated antigens, using the alkaline phosphatase anti-alkaline phosphatase method. The median follow-up was 36 months (range 15-62): 22 patients relapsed and 7 died.

RESULTS

Thirty-four of the 109 patients (31.1%) had MoAb positive bone marrow cells. The bone marrow was positive in 28/74 (37.9%) patients who had the aspirate taken during surgery and in 6/35 (17.1%) who had it taken after surgery (p = 0.055). No association was found between bone marrow positivity and tumour size, nodal status, menopausal status, estrogen receptor positivity or the proliferative index. No association was found between bone marrow and prognosis: the log-rank test was 0.291 (p > 0.5) for OS and 0.023 for DFS; the hazard ratio (positive vs negative) was 1.51 for OS (95% CI: 0.33-6.86) and 0.93 for DFS (95% CI: 0.35-2.45).

CONCLUSIONS

In our series, bone marrow positivity did not correlate with prognostic parameters or prognosis. Of interest is the relative excess of positivity when the bone marrow was obtained during surgery.