Absence Of Obstructive Coronary Disease Research Articles

Takotsubo cardiomyopathy as a consequence of a fall in an asymptomatic geriatric patient

1. Clinical caseAn 80-year-old woman with a past of hypertension, dyslipi-demia, active smoking, alcohol dependence and depression wasadmitted to Emergency after an accidental fall. She had remainedlying on the floor for two days, unable to get up. There was nocomplaint of faintness or chest pain.An ECG performed during procedural checkup at admissionshowed deep inverted T waves (Fig. 1A).The Initial troponin level was 0.9 ng/mL decreasing to 0.7 ng/mL six hours later (normal value < 0.090 ng/mL). The patient wasasymptomatic.An echocardiography performed immediately upon admissionshowed the characteristic apical ballooning with akinesis of theapical left ventricle (Fig. 2A).At the beginning the patient received an acute myocardialinfarction treatment: beta blockers, antiplatelet therapy andanticoagulation.Considering that the patient was otherwise in good health, acoronary angiography was performed revealing the absence ofobstructive coronary artery disease.The four criteria, suggested in the Mayo clinic criteria forTakotsubo, wereall present: transientleft ventricularhypokinesis,absence of obstructive coronary disease, new electrographicabnormalities and absence of pheochromocytoma or myocarditis.We, therefore, retained the diagnosis of Takotsubo cardiomyopa-thy for this patient.A week later, the cardiac ultrasound showed a completerecuperation of systolic ventricular function (Fig. 2B).Nevertheless any change in the electrocardiographic abnor-malitieswasobservedatthistime.Weobservedthedisappearanceof the electrocardiographic abnormalities two months later(Fig. 1B).2. CommentaryTakotsubo cardiomyopathy was first reported in Japan in the1990s by Sato et al. [1].It is also known as ‘‘Stress-induced cardiomyopathy’’, ‘‘Apicalballooning syndrome’’ or ‘‘broken heart syndrome’’. It consists ofbetween 2% of all acute myocardial infarction (AMI) and 7.5% ofAMI in women [2].The name Takotsubo is taken from the Japanese word for anoctopus trap, which has a shape that is similar to the apicalconfiguration of the left ventricle in systole, in its typical form.The diagnosis of Takotsubo should be suspected in post-menopausal women admitted with an acute coronary syndromeand is often triggered by intense psychological or physical stress[3,4], as in our case, where the patient fell and remained on thefloorfortwodays,unabletogetup.Thepatientinformedusthatatthat moment she was very stressful.Results of ECG tests show a series of abnormalities that wouldnormally indicate a high reading of troponin, but in Takotsubocardiomyopathy the level is disproportionately low, ranging inmost cases from 0.01 to 5.2 ng/mL [5].The pathogenesis of this disorder is not fully understood. Someobservations support the hypothesis of catecholamine-inducedmyocardial effects:catecholamine cardio-toxicity and a stunned heart [6];partitionof thebeta–adrenergicreceptors[7,8],asillustrated inFig. 3.There is no consensus for the treatment. Despite the severity oftheacuteillness, Takotsuboisa transientdisorder.Itiscommontotreat these patients with standard medication of left ventricularsystole dysfunction including beta blockers given the pathogene-sis.Thereisaverygoodprognosis.Wenoticedadelaybetweenthemechanical and the electrical recovery: a complete recovery of

Coronary Artery Anatomy and Apical Sparing in Apical Ballooning Syndrome: Implications for Diagnosis and Aetiology

Apical ballooning syndrome (ABS) is characterised by transient regional systolic dysfunction involving the left ventricular apex and mid-myocardial segments. The absence of obstructive coronary disease is required in some diagnostic criteria. Some investigators have suggested that a long "wrap-around" left anterior descending (LAD) artery may explain the pattern of regional wall motion abnormalities. We reviewed the coronary angiograms and ventriculograms findings in a prospective ABS cohort of 46 patients (mean age 63+/-13, female 96%). Normal smooth coronary arteries were observed in 54%, with 30% having minor irregularities. Moderate or severe coronary artery lesions were identified in 7 (15%) patients, including 4 with moderate LAD disease. The extent of the LAD artery around the left ventricular apex to the diaphragmatic surface of the heart was scored. This score was compared to 60 consecutive gender-matched control patients without ABS and no observed difference between the two groups (p=0.62). 42% had sparing of LV apical akinesis which was independent of the LAD extent. Moderate or severe coronary artery stenosis may co-exist in a small proportion of patients with ABS. Exclusion of these patients will underestimate the true incidence of ABS. The prevalence of "wrap-around" LAD is similar in ABS and non-ABS patients. Apical sparing in ABS is more consistent with aetiological hypotheses implicating LV stunning due to acutely elevated LV wall stress, rather than single or multi-vessel coronary spasm.

Stress (Tako-Tsubo) Cardiomyopathy Following Radiofrequency Ablation of a Liver Tumor: A Case Report

Stress cardiomyopathy is characterized by transient left ventricular dysfunction occurring in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress. We present a case of stress cardiomyopathy which developed during hepatic radiofrequency ablation of hepatocellular carcinoma.

Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging

The transient left ventricular apical ballooning is characterized by wall motion abnormalities involving the apex in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress and is most often reported in post-menopausal women. We report a case of transient left ventricular “apical ballooning” without significant coronary artery disease precipitated by high dose dobutamine infusion during pharmacological stress myocardial perfusion imaging. The unique feature of our case was precipitation by chemical stress rather than emotional/physical stress.

Apical ballooning syndrome complicated by acute severe mitral regurgitation with left ventricular outflow obstruction – Case report

BackgroundApical ballooning syndrome (or Takotsubo cardiomyopathy) is a syndrome of transient left ventricular apical ballooning. Although first described in Japanese patients, it is now well reported in the Caucasian population. The syndrome mimicks an acute myocardial infarction but is characterised by the absence of obstructive coronary disease. We describe a serious and poorly understood complication of Takotsubo cardiomyopathy.Case PresentationWe present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60–70 mmHg). Coronary angiography revealed no obstructive coronary lesions.She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well.ConclusionThis case represents a serious and poorly understood association of Takotsubo cardiomyopathy with acute pulmonary oedema, severe mitral regurgitaton and systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction. The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement. We describe a variant of Takotsubo cardiomyopathy with acute mitral regurgitation, systolic anterior motion of the mitral valve leaflet and left ventricular outflow tract obstruction of a dynamic nature.

Apical Ballooning Syndrome

Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3 The majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure …

Aortic Pulse Pressure and Aortic Pulsatility in Patients with Coronary Slow Flow

Objective: Coronary slow flow (CSF) is an angiographic phenomenon characterized by delayed opacification of coronary arteries in the absence of obstructive coronary disease. Recently, increased aortic pulse pressure (PP) and aortic pulsatility were both linked to the presence of angiographic coronary artery disease. In this study aortic PP and aortic pulsatility, derived from the invasively measured ascending aortic pressure waveform, were analyzed in patients with CSF and otherwise normal epicardial coronary arteries and compared with those with completely normal coronary arteries. Methods: Fifty consecutive patients with CSF (35 men, mean age: 51.7 ± 10 years) and fifty age and gender-matched controls (34 men, 51.1 ± 9 years) were included in the study. For determination of coronary flow, the thrombosis in myocardial infarction (TIMI) frame count method was used. Blood pressure waveforms of the ascending aorta were measured during cardiac catheterization with a fluid-filled system. Aortic pulsatility was estimated as the ratio of aortic PP to mean pressure. Results: Study groups were well matched with respect to age, gender and atherosclerotic risk factors. Although systolic, diastolic and mean pressures of the ascending aorta were similar, aortic PP (60.5 ± 19 vs. 51.7 ± 14 mm Hg, p = 0.01) and aortic pulsatility (0.63 ± 0.1 vs. 0.54 ± 0.1, p = 0.006) were significantly higher in patients with CSF compared with the controls. Besides, in all subjects, corrected TIMI frame counts of all three coronary arteries correlated with both ascending aorta PP and aortic pulsatility values. No association was found between corrected TIMI frame counts of coronary arteries and aortic mean blood pressure or brachial blood pressure parameters. Conclusion: Our findings suggest that CSF is, as with obstructive coronary artery disease, associated with more diffuse vascular disease rather than being an isolated finding.

Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease. Results from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE)

Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease. Results from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE)

Clinical characteristics and Thrombolysis In Myocardial Infarction frame counts in women with transient left ventricular apical ballooning syndrome

The characteristics of 16 women with transient left ventricular (LV) apical ballooning syndrome in a United States population are presented. Additionally, Thrombolysis In Myocardial Infarction (TIMI) frame counts were evaluated during the acute period. Patients generally presented with anterior ST-elevation acute coronary syndrome in the absence of obstructive coronary disease. All patients had LV apical wall motion abnormalities. An acute emotional or physiologic stressor preceded most cases. TIMI frame counts were abnormal in all patients and often abnormal in all 3 major coronary vessels, suggesting that the diffuse impairment of coronary microcirculatory function may play a role in the pathogenesis of the syndrome.

Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease: results from the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE).

We previously reported that 20% of women with chest pain but without obstructive coronary artery disease (CAD) had stress-induced reduction in myocardial phosphocreatine-adenosine triphosphate ratio by phosphorus-31 nuclear magnetic resonance spectroscopy (abnormal MRS), consistent with myocardial ischemia. The prognostic implications of these findings are unknown. Women referred for coronary angiography for suspected myocardial ischemia underwent MRS handgrip stress testing and follow-up evaluation. These included (1) n=60 with no CAD/normal MRS, (2) n=14 with no CAD/abnormal MRS, and (3) n=352 a reference group with CAD. Cardiovascular events were death, myocardial infarction, heart failure, stroke, other vascular events, and hospitalization for unstable angina. Cumulative freedom from events at 3 years was 87%, 57%, and 52% for women with no CAD/normal MRS, no CAD/abnormal MRS, and CAD, respectively (P<0.01). After adjusting for CAD and cardiac risk factors, a phosphocreatine-adenosine triphosphate ratio decrease of 1% increased the risk of a cardiovascular event by 4% (P=0.02). The higher event rate in women with no CAD/abnormal MRS was primarily due to hospitalization for unstable angina, which is associated with repeat catheterization and higher healthcare costs. Among women without CAD, abnormal MRS consistent with myocardial ischemia predicted cardiovascular outcome, notably higher rates of anginal hospitalization, repeat catheterization, and greater treatment costs. Further evaluation into the underlying pathophysiology and possible treatment options for women with evidence of myocardial ischemia but without CAD is indicated.

El «síndrome» de obstrucción medioventricular con aneurisma apical en la miocardiopatía hipertrófica: presentación de un caso

We report an 81-year-old woman with hypertrophic cardiomyopathy, midventricular obstruction and associated apical aneurysm partially dyskinetic. At admission she showed a lateral acute myocardial infarction with sustained episodes of uniform ventricular tachycardia and subtle cardiac physical findings. Old apical infarction was suggested by resting thallium defects in the absence of obstructive coronary disease. The ECG revealed persistent ST elevation in the anteroapical leads without Q waves at discharge. This case report represents a rare example, in a previously asymptomatic elderly woman, of a distinct syndrome within the wide clinical spectrum of hypertrophic cardiomyopathy.

Quantitative Doppler tissue imaging for assessment of regional myocardial velocities during transient ischemia and reperfusion

Doppler tissue imaging (DTI) is a new noninvasive imaging modality that directly interrogates myocardial velocity with high temporal and spatial resolution. This study was designed to test the hypothesis that quantitative DTI provides unique information regarding regional myocardial systolic and diastolic function during acute ischemic events. Myocardial velocities were quantified during the acute ischemic and reperfusion phases of 13 elective percutaneous coronary angioplasty procedures in 12 patients. In myocardium subtended by angioplasty vessels, peak velocities decreased during occlusive balloon inflation (from 21.2 ± 9.8 to −0.6 ± 4.0 mm/sec in systole [ p < 0.001] and from 21.7 ± 9.2 to −0.6 ± 3.9 mm/sec in diastole [ p < 0.001]). During early reperfusion, velocities exceeded those observed at baseline ( p = 0.003). In regions remote from the treated artery, peak myocardial velocities increased in the absence of significant stenosis but remained unchanged or decreased in the presence of significant stenosis of the associated vessel. We conclude that (1) myocardial velocities rapidly decrease during acute ischemia and show a rebound increase after reperfusion, and (2) in regions remote from ischemia, velocities display distinct patterns on the basis of the presence or absence of obstructive coronary disease in the associated vessel. Quantitative DTI is a useful tool for the assessment of myocardial velocity and may provide new insights into myocardial systolic and diastolic function.

Hypertension and left ventricular hypertrophy are associated with impaired endothelium-mediated relaxation in human coronary resistance vessels.

Patients with hypertension and myocardial hypertrophy may have signs and symptoms of myocardial ischemia in the absence of obstructive coronary disease. Prior investigations have demonstrated impaired coronary flow reserve and have led to speculation that microvascular dysfunction might contribute to ischemia in these patients. Experimental studies have shown that the endothelium, an important regulator of microvascular tone, can be damaged by hypertension and is dysfunctional in cardiomyopathy. We hypothesized that endothelium-dependent vasodilation is impaired in the coronary microvasculature of patients with hypertension and ventricular hypertrophy. We studied coronary microvascular responses in 10 patients with left ventricular hypertrophy secondary to essential hypertension (HTN) (mean arterial pressure at catheterization, 151/94 mm Hg; mean posterior wall thickness, 1.4 +/- 0.1 cm) and nine normal control subjects with no history of hypertension (mean arterial pressure at catheterization, 128/75 mm Hg; mean posterior wall thickness, 1.0 +/- 0.02 cm) using the intracoronary Doppler catheter and quantitative angiography to assess changes in coronary blood flow (CBF). All patients had normal left ventricular systolic function. To assess microvascular endothelial function, we infused the endothelium-dependent vasodilator acetylcholine (10(-8)-10(-6) M) and the endothelium-independent vasodilator adenosine (10(-6)-10(-4) M) into the left anterior descending coronary artery. In response to acetylcholine, CBF increased only 32 +/- 25% in HTN patients, whereas CBF increased 192 +/- 39% in normal control subjects (p = 0.003). CBF increased 465 +/- 93% in HTN patients and 439 +/- 41% in normal control subjects in response to adenosine (p = NS). The proportion of coronary flow reserve attributable to endothelium-dependent dilation (obtained from peak acetylcholine/peak adenosine flow response) was 48 +/- 9% in normal control subjects but only 7 +/- 8% in HTN patients (p = 0.008). Endothelium-dependent vasodilation is markedly impaired in the coronary microvessels of patients with hypertension and ventricular hypertrophy. Loss of this vasodilator mechanism may contribute to disordered coronary flow regulation and the ischemic manifestations of hypertensive heart disease.

Prinzmetal??s variant angina pectoris with prolonged electrocardiographic changes in the absence of obstructive coronary disease

Prinzmetal??s variant angina pectoris with prolonged electrocardiographic changes in the absence of obstructive coronary disease

Familial supravalvular aortic tenosis: Comments on the mechanisms of angina pectoris

Six documented cases of isolated supravalvular aortic stenosis are described in 2 generations of 1 family. The genetic transmission of the disorder is best explained as an autosomal dominant trait with incomplete penetrance. To date, the diagnosis in 5 of the patients has been confirmed by cardiac catheterization, and 4 patients have undergone successful surgical correction. The mechanism of angina pectoris in this disorder where the coronary arteries are peculiariy related to the site of outlet obstruction is discussed and compared to that in patients with angina in the absence of obstructive coronary disease. The relationship of reserve coronary flow, oxygen consumption and lactate production to the pathophysiology of angina pectoris is suggested.