Dynamics of electrocardiographic changes, brain-natriuretic peptide and cortisol levels in a patient with stress (takotsubo) cardiomyopathy: A case report

Introduction. Takotsubo cardiomyopathy is a transient acute heart failure syndrome caused by stress that provokes left ventricular mid-apical akinesis and mimics acute coronary syndrome. Case report. A 66-year-old woman had chest pain and dispnoea a few hours before hospitalization. A sudden emotional stressful event preceded the symptoms. Electrocardiographic abnormalities - precordial ST elevation and modest increase of cardiac troponin mimiced acute myocardial infarction. However, echocardiographic examination showed apical ballooning with markedly diminished left ventricle ejection fraction and the obstruction in the outflow tract of the left ventricle. Coronary angiography at admission showed no coronary stenosis and slower blood flow through the left anterior descending artery. According to anamnesis, echocardiography and coronarography finding we established the diagnosis of stress cardiomyopathy - takotsubo cardiomyopathy. We described in details the slow but dynamic electrocardiographic changes, levels of brain natriuretic peptide, cortisol and echocardiography evolution of disease during a 4-month follow-up till the full recovery. Conclusion. Stress (takotsubo) cardiomyopathy - became an important differential diagnosis of acute anterior myocardial infarction and it should be reconsidered every time when emotionally stressed patients with transient-apical akinesis or dyskinesis of the LV are present

Identification of residual ischemia in the occluded coronary artery irrigation area using myocardial perfusion scintigraphy

Background. Inspite the indisputable significance of coronarography, the implications of a revealed stenosis - and how close it is to occlusion could vary in regard to its physiological importance. Myocardial perfusion scintigraphy (MPS) possibility to prove and objectivise the presence of ischemia and myocardial viability within an occlusion found coronarographically is especially significant since it makes possible to the clinician to choose an adequate therapy. Case report. We reported a 43- year-old male patient who had been hospitalized to another institution due to acute myocardial infarction (AMI) of posterolateral localisation. Following the acute AMI stage the ergometric test per Bruce protocole was performed, negative to ischemic heart disease, while multislice computed tomography showed no significant changes on the coronary arteries. The performed one-day-protocole MPS showed a massive area of residual ischemia within myocardial infarction (MI) type culprit lesion of the posterolateral zone starting from the subapical level to the basal cross-section. According to the MPS findings coronarography was indicated due to a revascularisation assessment. The performed coronarography revealed an occlusion of the circumflex coronary artery (CCA) right after the division of obtuse branch (OB) that presented discretely in the distal parts from the homo- and heterocolaterals. The distal portion of CCA presented discretely out off the right coronary artery (RCA). Echocardiography confirmed an ejection fraction of 50% with hypokinesia of inferior and posterior walls, as well as the septum, showing a mild reduction of the general contractility. Flows through confluences were well. A month after MI a percutane coronary intervention (PCI) was performed with the implantation of a drug-releasing stent (Taxus). Early after PCI (within two weeks) a control MPS was done to evaluate the effects of the therapy giving the normal findings of myocardial perfusion. Conclusion. Determination and identificantion of vivid but ischemic myocard of culprit lesion type in the occluded artery irrigation zone enable making choice of the best therapy for a patient

Current therapy of the right ventricle myocardial infarction

Background. Acute myocardial infarction of the right ventricle (AMI-RV) is a separate subgroup within the scope of inferoposterior infarction of the left ventricle. It still represents the population of patients at high risk due to numerous, often hardly predictable complications and high mortality rate. Methods. In fifteen-year period (1987-2001) 3 765 patients with the acute myocardial infarction (AMI) of different localizations of both sexes – 2 283 males and 1 482 females of the average age 61.4 ± 4.6 years were treated in our institution. Anterior myocardial infarction was diagnosed in 2 146 (56.9%) patients, inferior in 1 619 (43.1%) patients, out of whom right ventricular infarction (RVI) was confirmed in 384 (23.7%). Thrombolytic therapy was administered in 163 (42.4%) patients with RVI, and in 53 (41.7%) of these patients balloon dilatation was performed with coronary stent implantation in 24 (45.2%). Results. Favorable clinical effect of the combined thrombolytic therapy and percutaneous transluminal coronary angioplasty (PTCA) was achieved in 51 (96.1%), and in only 2 (3.9%) of patients the expected effect wasn't achieved. Myocardial revascularization was accomplished in 6 (3.6%) and 1 patient died. In 3 (3.4%) patients primary balloon dilatation with the implantation of intracoronary stent was performed within 6 hours from the onset of anginal pain. In the other group of 221 (57.5%) patients with RVI who did not receive thrombolytic therapy, or it had no effect, 26 (11.7%) patients died, which indicated the validity and the efficacy of this treatment (p<0,01). In the whole group of patients with myocardial infarction of the right ventricle 31 (8.1%) died; in the group that received thrombolytic therapy and PTCA 5 (3.1%) died, while in the group treated in a conservative way 26 (11.7%) died. Conclusion. Combined therapy was successful in the treatment of patients with RVI and should be administered whenever possible, since it was the best prevention of life-threatening complications and the decrease in the mortality of those patients

Diagnosis and results of treatment of heart myxoma

Background/Aim. Myxoma is the most common benign primary cardiac neoplasm, and usually originates from the left atrial septum. Early diagnosis of cardiac myxomas depends on a high index of a clinical suspicion. Surgical management must be done as soon as possible after diagnosis. The aim of this retrospective study was to present diagnostics and treatment outcome data of 61 patients with cardiac myxoma treated in the Military Medical Academy, Belgrade during a 49-years period. Methods. Intrahospital diagnosis was established in all the patients by the cardiologist. Diagnostic methods were various, in dependence on the examination period and suspected diagnosis. Results. Within a 49-years period (1961-2009) heart myxoma was diagnozed and treated in 61 patients in the Military Medical Academy, Belgrade. Most of the operated patients were females (38 or 62.3%). The operated patients were 19-68 years old. Average age of all the patients was 47.9%. The great majority of them (98.4%) had atrial, and only one operated patient had ventricular myxoma. In 13 (21.3%) of the patients heart myxoma was found out accidentally due to no previous cardiologic symptomatology. In most patients (27.44%) symptomatology was presented as thromboembolic disease. Because of the suspected ventricular myxoma in one patient, the patient was operated on, but Hodgkin's lymphoma was found out which, according to the subsequent course of the disease, could be justifiably recognized as primary heart lymphoma. This study presented brief descriptions of the course of the disease in 4 patients with myxomas in each of the cardiac cavities. Conclusion. The only diagnostic difficulty in cardiac myxoma is due to its asymptomatic and oligosymptomatic presence within the longer period of time, namely, its growth period. Echocardiography should be the standard method of cardiologic examination of these patients, which could considerably contribute to early diagnosis and treatment of heart myxoma. Surgical extirpation of myxoma is the only and very successful therapeutic method

Primary percutaneous transluminal coronary angioplasty in the acute infarction of the right ventricle

Background. Predilection site for the acute myocardial infarction of the right ventricle, (AMI-RV) is the upper third of the right coronary artery and for this reason such an infarction is followed by numerous complications, primarily by conduction disorders and very often by sudden and rapid cardiogenic shock development. Methods. Primary percutaneous transluminal coronary angioplasty (PPTCA) was performed on three patients in whom the acute infarction of the right ventricular was diagnosed and who had been hospitalized six hours after the beginning of chest pain. In all three patients intracoronary stent was implanted. On the admission patients had been in the threatening cardiogenic shock, with the prominent chest pain and with the elevation of ST-segment in V4R>2 mV. In the course of intervention patients were administered low-molecular intracoronary heparin with direct platelet glycoprotein IIb/IIIa inhibitors (abciximab), according to the established procedure applied in such cases. Results. The complete dilatation of the infarcted artery was established with the signs of reperfusion and the further clinical course was completely normal, there was no heart failure and patients had no subjective difficulties. Conclusion. Invasive approach in the treatment of AMI-RV is justifiable, and possibly the therapy of choice of these patients, providing well trained and equipped team is available

Intimomedial thickness of the vertebral arteries complex: A new useful parameter for the assessment of atheroclerotic process?

Bacground/Aim. An integral part of Doppler ultrasound examination of cervical blood vessels is determination of intimomedial thicknes (IMT) of the common carotid. The aim of the study was to estimate the relations between IMT of the common carotid and vertebral arteries in order to determine if the value of IMT obtained on the vertebral artery could be applied in clinical practice. Methods. We measured IMT in a randomized, prospective and crosssectional study, performed on 50 persons both sexes (29 men and 21 women), at the age from 18 to 79 years (mean age 52.4 ± 17.63 years). All the persons were healthy, what was confirmed with clinical examination and laboratory analyses. Measurements were perfomed from January 2006 until September 2008. Intimomedial thickness was recorded by twodimensional ultrasonography in B-mode on both common carotid arteries: one value was obtained as average of three successeful measurements (measurements were perform on different places). We measured IMT on the first segment of both vertebral arteries, 1.5 cm proximal from the connection of the first and second segments (we got results of the measurement of IMT on the vertebral arteries in the same way: mean value from the three records). Results. (IMT = 0.782 ± 0.248 mm), obtained from 50 healthy persons, was higher than that measured on the vertabral artery on the first segment (IMT = 0.585 ± 0.134 mm). The values of IMT after measurement on two different places were statistically highly different (t = 7.03, SD = 0.028, p < 0.01). Coefficient of variability of IMT values in carotid circulation (CV = 34.4%) was higher than that in vertebral circulation (22.9%). Values of IMT on vertebral arteries were in statistically significant correlation with those in carotid circulation (r = 0.24 and t- = 2.48; p < 0.02). There were no statistically significant difference between IMT measurement on the right and the left side so they were analysed as the same set Conclusion. Values of IMT on the vertebral arteries are one more undependent parameter of doplersonographic examination of cervical vessels, which significantly correlates with IMT values on common carotid artery. Variability of this parameter is lower, and absolute values lower than the same in the common carotid artery. Therefore, this parameter is probably not so sensitive. On the other hand, lower variability of IMT values on the vertebral artery might be of higher specificity for prediction of atherosclerotic progress by the increased values of this parameter than based on IMT values obtained on the common carotid arteries