Takotsubo Cardiomyopathy in a Squash Player

Takotsubo cardiomyopathy is usually described following acute emotional stress. We report here the case of a 48-year-old woman admitted for acute coronary syndrome after an intensive squash match. Diagnosis of Takotsubo cardiomyopathy due to acute physical stress was suspected in presence of normal coronary arteries and transitory left ventricular dysfunction with typical apical ballooning. Cardiac magnetic resonance imaging confirmed regional wall-motion abnormalities and was helpful in excluding myocardial infarction diagnosis. During squash the body is subject to sudden and vigorous demands inducing a prolonged and severe workload on the myocardium

0272: Unfractionated heparin addition during percutaneous coronary intervention in acute coronary syndrome patients previously treated with enoxaparin: biological impact

BackgroundThe benefit of anticoagulants (AC) to prevent thrombotic complications during percutaneous coronary intervention (PCI) is well established. In acute coronary syndrome (ACS) patients previously treated with enoxaparin, an additional bolus of AC is not recommended if the last injection was realized within 8 h. In this setting, many interventional cardiologists use unfractionated heparin (UFH) at the time of sheath insertion.ObjectivesThe aim of our study was to describe local current practices for AC use during PCI in patients already treated with enoxaparin and admitted for ACS and to assess the biological impact of UFH addition at the beginning of the procedure.MethodsA standardized survey was sent to the interventional cardiologists of the southwest of France to investigate their practice in terms of periprocedural AC use. In 2 centers, ACS patients previously treated with subcutaneous injection of enoxaparin within 8 h and who received intravenous UFH at the time of sheath insertion were prospectively included and their plasma anti-Xa activity was assessed at the sheath insertion and 30 min after UFH bolus. In-hospital bleeding and ischemic events were collected. The adequate therapeutic window was defined by anti Xa activity (range 0.5 to 0.9 IU/mL). Results: Among the 41 interventional cardiologists who replied, a large majority (75,6%) considered the addition of UFH in patients who received enoxaparin within 8 h as a valid option. 47 ACS patients were enrolled. The dose of the bolus of UFH was highly variable from 20 to 90 UI / kg. Anti-Xa activities were above 0.9 IU/mL in 14,9% of patients at the sheath insertion and in 72,3% of patients 30 min after UFH injection. 2 bleeding complications occurred, both in over-coagulated patients. No ischemic events were reported.ConclusionThe use of UFH in patients who already received enoxaparin may result in over-anticoagulation and lead to bleeding complications

0015: High LDL cholesterol decreases life expectancy in primary prevention

BackgroundThe 2012 ESC guidelines recommend a LDL-cholesterol (LDL-C) lower than 3mmol/L for subjects at low or moderate risk with a class I/A and a strong grade. According to ESC, statins should be used as the drugs of first choice. The aim of this study was to assess the association between elevated LDL-C with total and cardiovascular (CV) mortality in primary prevention.MethodsOur study population consisted in patients who had been admitted from 1995 to 2011 in a preventive cardiology unit of a large French university hospital. We excluded patients whose age was less than 30 and all patients with previous ischemic heart disease. Vital status in 2011 was checked through the death national database.Results4885 patients were included (59% men; 53±10 yrs). After a mean follow-up of 8.6 years, 129 deaths, including 31 CV deaths, were recorded. The mean LDL-C was 3.98±1.18mmol/L (3.90 in men and 4.11 in women). Among these 4885 patients, 2648 (54.2%) had LDL-C lower than 4mmol/L, 1890 (38.7%) had LDL-C between 4 and 6mmol/L, 347 (7.1%) had LDL-C higher than 6mmol/L, and 1833 (37.5%) were on current lipid-lowering treatment. After adjustment for age, gender, smoking, hypertension and diabetes, an increased LDL-C > 4mmol/L was significantly associated with all cause mortality (hazard ratio (HR) 2.06; 95% confidence interval (CI) [1.42-3.00], p=0.001) and with CV mortality (HR 2.18; 95% CI [1.04-4.57], p=0.04). After adjustment for these classical risk factors and for lipid-lowering treatment, LDL-C remained significantly associated with an increasing risk of all cause mortality; with LDL-C < 4mmol/L as a reference class, LDL-C levels between 4 and 6mmol/L were associated with an increased all cause mortality (HR 1.72; 95% CI [1.17-2.54], p=0.006) as well as LDL-C > 6mmol/L (HR 2.60; 95% CI [1.49-4.85], p=0.001).ConclusionsLDL-C levels higher than 4mmol/L were significantly associated with all-cause and cardiovascular mortality in primary prevention

Transcatheter heart valve selection and permanent pacemaker implantation in patients with pre-existent right bundle branch block

Background-Right bundle branch block is an established predictor for new conduction disturbances and need for a permanent pacemaker (PPM) after transcatheter aortic valve replacement. The aim of the study was to evaluate the absolute rates of transcatheter aortic valve replacement related PPM implantations in patients with pre-existent right bundle branch block and categorize for different transcatheter heart valves. Methods and Results-We pooled data on 306 transcatheter aortic valve replacement patients from 4 high-volume centers in Europe and selected those with right bundle branch block at baseline without a previously implanted PPM. Logistic regression was used to evaluate whether PPM rate differed among transcatheter heart valves after adjustment for confounders. Mean age was 83±7 years and 63% were male. Median Society of Thoracic Surgeons score was 6.3 (interquartile range, 4.1-10.2). The following transcatheter valve designs were used: Medtronic CoreValve (n=130; Medtronic, Minneapolis, MN); Edwards Sapien XT (ES-XT; n=124) and Edwards Sapien 3 (ES-3; n=32; Edwards Lifesciences, Irvine, CA); and Boston Scientific Lotus (n=20; Boston Scientific Corporation, Marlborough, MA). Overall permanent pacemaker implantation rate post-transcatheter aortic valve replacement was 41%, and per valve design: 75% with Lotus, 46% with CoreValve, 32% with ES-XT, and 34% with ES-3. The indication for PPM implantation was total atrioventricular block in 98% of the cases. Lotus was associated with a higher PPM rate than all other valves. PPM rate did not differ between ES-XT and ES-3. Ventricular paced rhythm at 30-day and 1-year follow-up was present in 81% at 89%, respectively. Conclusions-Right bundle branch block at baseline is associated with a high incidence of PPM implantation for all transcatheter heart valves. PPM rate was highest for Lotus and lowest for ES-XT and ES-3. Pacemaker dependency remained high during followup

The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials.

OBJECTIVES: This study sought to assess whether patient age modifies the comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). BACKGROUND: Increasingly, CABG and PCI are performed in older patients to treat multivessel disease, but their comparative effectiveness is uncertain. METHODS: Individual data from 7,812 patients randomized in 1 of 10 clinical trials of CABG or PCI were pooled. Age was analyzed as a continuous variable in the primary analysis and was divided into tertiles for descriptive purposes (≤56.2 years, 56.3 to 65.1 years, ≥65.2 years). The outcomes assessed were death, myocardial infarction and repeat revascularization over complete follow-up, and angina at 1 year. RESULTS: Older patients were more likely to have hypertension, diabetes, and 3-vessel disease compared with younger patients (p < 0.001 for trend). Over a median follow-up of 5.9 years, the effect of CABG versus PCI on mortality varied according to age (interaction p < 0.01), with adjusted CABG-to-PCI hazard ratios and 95% confidence intervals (CI) of 1.23 (95% CI: 0.95 to 1.59) in the youngest tertile; 0.89 (95% CI: 0.73 to 1.10) in the middle tertile; and 0.79 (95% CI: 0.67 to 0.94) in the oldest tertile. The CABG-to-PCI hazard ratio of less than 1 for patients 59 years of age and older. A similar interaction of age with treatment was present for the composite outcome of death or myocardial infarction. In contrast, patient age did not alter the comparative effectiveness of CABG and PCI on the outcomes of repeat revascularization or angina. CONCLUSIONS: Patient age modifies the comparative effectiveness of CABG and PCI on hard cardiac events, with CABG favored at older ages and PCI favored at younger ages