Faculty Bibliography

The clinical management of takotsubo cardiomyopathy is challenging. Its diagnosis must be made on clinical grounds and differentiated from alternative diagnoses with echocardiography, serum biomarkers, cardiac catheterization, and cardiac magnetic resonance imaging. Acute therapy includes supportive care, targeting the precipitating trigger if known, b-blockade, inhibitors of the renin-angiotensin system, and consideration of systemic anticoagulation in all patients. Recovery of left ventricular function to normal is expected regardless of early therapy. Although the prognosis is generally favorable, monitoring for early dangerous complications is essential. There is no evidence to support use of long-term medical therapy to reduce the risk of recurrence.

OBJECTIVE: We sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis. BACKGROUND: Heart failure patients are frequently admitted for both heart failure and other causes. METHODS: Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and gender-standardized hospitalization rates were determined by dividing the number of hospitalizations by the United States population in a given year and using direct standardization. RESULTS: The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, while secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and gender-adjusted rates of primary heart failure hospitalizations decreased steadily over 2001-2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased, from 1370 to 1476 per 100,000 from 2001-2006, then decreased to 1359 per 100,000 in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections. CONCLUSIONS: Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and non-cardiac conditions.

Background: Vasculature involvement of AL amyloid or amyloid fibrils has been commonly reported in tissue biopsy. However, the prognostic role of vasculature involvement has not been studied. Methods: Tissue biopsies of patients with biopsy-proven AL amyloidosis were reviewed between 2006 to 2011. Tissue and vasculature involvement were recorded from Congo red staining and/or electronic microscopic detection of amyloid fibrils in tissue and/or capillaries. Amyloid deposition in vasculature was defined as Congo red staining of small vessels and fibrils deposition in capillaries under electronic microscope. EKG and echocardiography at the time of diagnosis were reviewed. NCCN Guidelines Version 1.2012 was used for reassessing cardiac involvement for all patients. Death was censored till November 30, 2011. Results: 28 patients with biopsy data available were included for the analysis. Mean age was 64.8 +/- 9.9 years. All patients had at least one organ biopsy with tissue Congo Red staining positive. 18 patients with positive amyloid deposition in vasculature (V positive), 14 (77.8%) had cardiac involvement based on NCCN criteria; 10 patients with negative amyloid deposition (V negative), 4 (40%) had cardiac involvement (P<0.01). LV wall thickness and LV filling pressure (E/e') were significantly increased in V positive group comparing with V negative group (15 mm +/- 0.07 vs 1.1 mm +/- 0.07; 21.6 +/-1.7 vs 11 +/-1.7 respectively, both P = 0.002). 7 cases in V positive group had pericardial effusion comparing 0 case in V negative group (P = 0.03). 12 cases with low voltage from ECG in V positive group comparing with 3 cases in V negative group (P = 0.03). LV ejection fraction, left atrium size, pulmonary pressure, troponin I and NT-ProBNP levels were not significantly different between two groups. Mortality rate in V positive group (10/18, 55.6%) was significantly higher comparing with V negative group (2/10, 20%) (P = 0.04) Conclusions: The patients with positive amyloid deposition in vasculature !

Background: Obese adolescent with T2DM and /or pre diabetes demonstrate endothelial dysfunction (ED), a key early event in atherogenesis. Flow mediated dilatation (FMD) of the brachial artery is a well validated surrogate for ED. Traditional cardiovascular risk factors (BMI, LDL-cholesterol, systolic blood pressure and smoking) have a deleterious effect on the vasculature in adolescents. Objective and hypotheses: We proposed to delineate the relationship between glucose tolerance categories and ED in obese adolescents. Methods: 25 adolescents with a mean age of 15.7 +/- 1.5 years, BMI 35+/- 6 (60% female and Hispanic) underwent a 75 gram oral glucose tolerance test (OGTT). Duplex ultrasound (11MHz transducer) measured endothelium dependent vasodilatation. Reference range in our vascular lab for FMD is 5.89+/- 2.88% (95% CI: 4.53- 7.23). Results: Based on OGTT results: 16 subjects had normal glucose tolerance (NGT: fasting glucose <= 99 mg/dl and/ or 2 hour post challenge glucose <= 139 mg/dl) and 6 subjects were diagnosed with pre diabetes(fasting glucose>= 100 and/ or 2 hour post challenge glucose >= 140 mg/dl). Adolescents with T2DM (n= 3) had lower FMD (3.2+/- 2.8%) compared to adolescents with NGT (6.5+/- 5.08%) and of those with NGT; five had an impaired FMD (<= 5.8%). Adolescents with pre diabetes had FMD values (9.8+/- 3.08%) higher than NGT group, though differences between the glucose tolerance categories did not reach statistical significance (NGT vs. pre diabetes vs. T2DM, p= 0.26). FMD did not correlate with CVS risk factors in these adolescents. In adolescents with NGT, FMD was negatively correlated with 2 hour glucose (r= -0.6, p= 0.03). Conclusions: Adolescents with prediabetes compared to those with T2DM appear to have preserved endothelium dependent vasodilatation. In adolescents with NGT, lower FMD predicts impaired glucose tolerance and accelerated vascular dysfunction. CVS risk factors did not appear to affect FMD in these obese adolescents

BACKGROUND: The incidence and predictors of heart failure (HF) after myocardial infarction (MI) with modern post-MI treatment have not been well characterized. METHODS AND RESULTS: A total of 2,201 stable patients with persistent infarct-related artery occlusion >24 hours after MI with left ventricular ejection fraction <50% and/or proximal coronary artery occlusion were randomized to percutaneous intervention plus optimal medical therapy (PCI) or optimal medical therapy (MED) alone. Centrally adjudicated HF hospitalizations for New York Heart Association (NYHA) III/IV HF and mortality were determined in patients with and without baseline HF, defined as a history of HF, Killip Class >I at index MI, rales, S3 gallop, NYHA II at randomization, or NYHA >I before index MI. Long-term follow-up data were used to determine 7-year life-table estimated event rates and hazard ratios. There were 150 adjudicated HF hospitalizations during a mean follow-up of 6 years with no difference between the randomized groups (7.4% PCI vs. 7.5% MED, P = .97). Adjudicated HF hospitalization was associated with subsequent death (44.0% vs. 13.1%, HR 3.31, 99% CI 2.21-4.92, P < .001). Baseline HF (present in 32% of patients) increased the risk of adjudicated HF hospitalization (13.6% vs. 4.7%, HR 3.43, 99% CI 2.23-5.26, P < .001) and death (24.7% vs. 10.8%, HR 2.31, 99% CI 1.71-3.10, P < .001). CONCLUSIONS: In the overall Occluded Artery Trial (OAT) population, adjudicated HF hospitalizations occurred in 7.5% of subjects and were associated with increased risk of subsequent death. Baseline or prior HF was common in the OAT population and was associated with increased risk of hospitalization and death.