Sudden death in a case of recurrent Takotsubo syndrome

Herein we report an unusual case of sudden death occurring in a 65 year old woman during a minor oral surgery. The subject, who had a medically treated anxiety, had a history of two reversible left ventricle dysfunction episodes consistent with recurrent Takotsubo Syndrome that had occurred seven and six years before, respectively. She also suffered from moderate, well treated post-menopausal systemic hypertension. Post-mortem examination showed apical biventricular ballooning of the heart with no cardiac rupture, coronary artery lesion or other cardiac/extra-cardiac disease. Toxicological tests and forensic investigations excluded unnatural causes of death, including pharmacological or iatrogenic causes related to medical malpractice. Only non-specific contraction bands and mild hypertrophy were observed by histology in the left ventricle myocytes. Takotsubo syndrome is usually an acute and reversible heart failure syndrome with acute left ventricle apex ballooning, no coronary artery disease or other macroscopic or microscopic cardiac changes; physical or emotional stress are well known triggering factors. Nevertheless, recurrent forms, major cardiac adverse events and even sudden death may occur in a minority of cases, meaning that a diagnosis of Takotsubo syndrome must be considered in cases of sudden death and in forensic investigations.

Comparison of Reduced-Dose Prasugrel and Standard-Dose Clopidogrel in Elderly Patients With Acute Coronary Syndromes Undergoing Early Percutaneous Revascularization

Background:

Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on-clopidogrel platelet reactivity compared with younger patients. Prasugrel 5 mg provides more predictable platelet inhibition compared with clopidogrel in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding.

Methods:

In a multicenter, randomized, open-label, blinded end point trial, we compared a once-daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years of age with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was the composite of mortality, myocardial infarction, disabling stroke, and rehospitalization for cardiovascular causes or bleeding within 1 year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg.

Results:

Enrollment was interrupted, according to prespecified criteria, after a planned interim analysis, when 1443 patients (40% women; mean age, 80 years) had been enrolled with a median follow-up of 12 months, because of futility for efficacy. The primary end point occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (hazard ratio, 1.007; 95% confidence interval, 0.78–1.30; P =0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel versus 1.9% with clopidogrel (odds ratio, 0.36; 95% confidence interval, 0.13–1.00; P =0.06). Bleeding Academic Research Consortium types 2 and greater rates were 4.1% with prasugrel versus 2.7% with clopidogrel (odds ratio, 1.52; 95% confidence interval, 0.85–3.16; P =0.18).

Conclusions:

The present study in elderly patients with acute coronary syndromes showed no difference in the primary end point between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in light of the premature termination of the trial.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01777503.

[Eluting stents implantation in patient with situs viscerum inversus]

A 73 year-old man, with known situs viscerum inversus, symptomatic for effort dyspnea, was admitted to our Department for inducible myocardial ischemia. Coronary angiography showed severe narrowings of the distal right coronary artery, treated by percutaneous coronary intervention and drug eluting stents implantation. Percutaneous coronary intervention was performed using standard diagnostic and guide catheters, requiring opposite manipulation and inverted angiographic projections.

Coronary artery anomalies and their clinical relevance

Coronary artery anomalies (CAAs) represent one of the most confusing topic in cardiology and affect approximately 1% of the general population. Although some anomalies seem to be only anatomical curiosities, others may sometimes have fatal consequences. This review describes the anatomical characteristics of main CAAs and focuses on the pathophysiological mechanisms by which CAAs may cause a pathological state. The last section describes these therapeutical options of this congenital disorders.

Renal effects of cardiac angiography with different low-osmolar contrast media

The aim of this study was to evaluate the renal effects of cardiac angiography performed with three low-osmolar contrast media (CM): iopromide (IPR), ioversol (IVR) and ioxaglate (IOX). IPR and IVR are non-ionic CM, IOX is an ionic CM. Different parameters of renal function were determined before and 6, 24, 48, 72 hrs after angiography in 45 patients: 15 patients were examined with IPR, 15 with IVR and 15 with IOX. Glomerular effects--Plasma creatinine increased slightly at the 24th hour after IVR and IOX and at 48 hours after IOP. A significant increase in plasma beta2-microglobulin was observed, at the same time, only after IOX. A significant decrease in creatinine clearance was found at 6 hours after IOX. No significant variations in glomerular filtration rate (GFR) and in effective renal plasma flow were found at 48 hours after cardiac angiography; while filtration fraction was significantly reduced after IOP and IOX. Tubular effects--A marked decrease in sodium clearance and a relevant increase of urinary activities of different tubular enzymes were found after cardiac angiography with all CM, but were more evident after the ionic CM IOX, than after the two non-ionic agents. These tubular effects reached the maximum between 6 and 24 hours and returned to baseline within 72 hrs after cardiac angiography. In conclusion, slight glomerular effects were observed mainly after IOX. A reversible tubular malfunction was found with the three low-osmolar CM and was more evident after ionic CM IOX. thus suggesting that other mechanisms, besides osmolarity, play a role in tubular toxicity due to CM. In no patient did the glomerular and tubular effects of CM have a clinical relevance.

Residual myocardial perfusion in reversibly damaged myocardium by dipyridamole contrast echocardiography

In patients with previous myocardial infarction and left ventricular asynergy, dipyridamole infusion may have the capacity to unmask myocardial viability through transient recovery of contractile function in asynergic segments. The purpose of this study was to assess simultaneous changes in myocardial perfusion and LV function--elicited by dipyridamole infusion--in infarcted, asynergic segments. The echo contrast agent Albunex was injected into the left coronary artery of 19 patients (17 males, age 49-70 years) with previous myocardial infarction and baseline left ventricular asynergy, both before and after dipyridamole infusion (up to 0.56 mg.kg-1, i.v.). Analysis was not possible in three patients due to inadequate image quality and in two due to weak contrast. There were no major adverse events, or changes in vital signs or demonstrated on the electrocardiogram. After dipyridamole, 7/14 patients, showed an improvement in regional function of asynergic segments ('responders'), whereas seven patients did not ('non-responders'). Among non-responders, five had a myocardial perfusion deficit corresponding to 41% of the total left ventricular area before dipyridamole and to 38% after dipyridamole. No baseline perfusion deficits were observed in the remaining two non-responders; one of these, however, developed transient asynergy and perfusion deficit after dipyridamole. Among responders, five showed a normal perfusion pattern, both before and after dipyridamole, while the remaining two showed a perfusion deficit which markedly decreased after dipyridamole (from 32% to 13% of total left ventricular area). Thus, residual contractile reserve of asynergic, infarcted ventricular segments appears to be associated with myocardial perfusion either preserved at baseline or recruitable by a coronary dilator stimulus.

Short-term reproducibility of dipyridamole-echocardiography test

The aim of this study was to assess the short-term reproducibility of dipyridamole-echocardiography test (DET) consisting of two-dimensional echo monitoring during dipyridamole infusion (up to 0.84 mg/kg in 10 min). The diagnostic end-point of the test is the detection of new onset or worsening regional asynergy. A group of 87 patients with rest and/or effort angina performed two DETS on two consecutive days. All 60 patients with a positive DET had a positive repeat test, and the 27 negative DETs were also negative on the following day. The timing of the asynergy was also very similar between the two tests, both in patients with angina on effort (r = .93, p less than 0.01) and at rest (r = .92, p less than 0.01). In conclusion, DET has a very high short-term reproducibility regarding the presence and timing of asynergy.