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Cesare Fiorentini
Medicina di genere e
malattie cardiovascolari
18 gennaio 2014
- Pio Albergo Trivulzio -
- Milano -
Female, 44 years old with
hypertension, atypical angina,
ex-ECG positive and stress
nuclear test positive in inferior
wall of LV
ACCURACY OF MDCT: complementary role
of stress test
Circulation 2006; 113
Transient Left Ventricular Apical Ballooning Syndrome
1. Gender: 6-fold female-to-male predominance2. Mean age >60 years3. Acute substernal chest pain4. ST-segment elevation and/or T-wave inversion5. Absence of significant coronary arterial
narrowing at angiography6. Systolic dysfunction (apical ballooning)7. Profound psychological stress8. Rapid restoration to previous functional
cardiovascular status
Annals of Internal Medicine 2004; 141
Distribuzione per sesso
Distribuzione degli stressor
stress fisico
stress non
riportatonon
specificato
stress
emotivo
91%
Stress emotivo
• morte cane
• nevicata
• prima teatrale
• crollo edificio
• litigio
• aggrressione
• incidente d’auto
• rapina
• intervento marito
• Furto
• diagnosi errta
• naufragio
• problemi familiari
• controllo medico
• decesso di un
familiare
• scippo di borsetta
• Ricordo di un
decesso
Stress fisico
• caduta sugli sci
• emorragia gastrointestinale
•Trauma facciale
•Post cardioversione elettrica esterna
•Successivo ad intervento chirurgico
• post lobectomia polmonare
• caduta a terra
• shock settico
•Terapia Ca orofaringe
9%
Pathophysiology
Plasma levels of catecholamines are 2 to 3 times the values among patients Killip class III AMI and 7 to 34 times publishd normal values
Cathecholamine-mediated myocardial stunning
Pathophysiology
• Serum catecholamine levels are significantlyhigher than those found in conditions such asacute myocardial infarction or cardiac failureand up to 34 times higher than normal restingvalues
• Epinephrine plasma half-life isapproximatively 3 min, and most patientspresent to emergency departments at least30 min (>10 half-lives) after symptom onset
Catecholamine-mediated myocardial stunning
NEJM 2005; 352
Lyon AR. Nature Clinical Practice 2008
Lyon AR. Nature Clinical Practice 2008
“Broken heart”Treatment
ß-blockers – Aspirin – Nitrates - Heparin
Dobutamine - Dopamine
Mechanical & hemodynamic support (IABP)
Very Late Recurrence (seven years)
of Stress Cardiomyopathy
“Future research also needs to explore why (1) a very small
proportion of the population appears to be at risk for ABS
suggesting a role for genetic predisposition; (2) in the classic
variant, there is sparing of the basal segments of the heart with
characteristic dysfunction of the apical and mid segments; and
(3) the recurrence rate is low despite the repeated exposure to
stressful events over a lifetime”.
Amecian Heart Journal 2008; 155
(A)
(B)
(C)
October 2000Coronary Angiography
February 2008Coronary Angiography
Post-ECV
Acute Pulmonary Edema
Tako-tsubo Syndrome
EF changes
0
10
20
30
40
50
60
70
Acute 1-month
46
61
NEJM 2005; 352
American Heart Journal 2008; 155
• Acute presentation
• Chest pain
• ST-segment elevation and/or T-Wave inversion
• Transient left ventricle systolic dysfunction
• Emotional or physical stress triggering
• Absence of flow-limiting coronary stenoses
Tako-Tsubo Syndrome
Tako-Tsubo SyndromeEmergency angiography
End-diastolic and end-systolic ventriculogram in right anterior oblique (RAO) view,
left and right coronary artery angiograms.
VH-IVUS: plaque composition at the site of maximal plaque burden in proximal LAD.
Tako-Tsubo SyndromeBackground
Although non-significant coronary stenoses are
found in 10% of patients with Tako-Tsubo
Syndrome, no data is available regarding
atherosclerotic burden and plaque composition
of coronary artery wall
“Virtual Histology-IVUS” coronarica
nella Sindrome di Tako-tsubo
Tako-Tsubo Syndrome VH-IVUS Aim of the study
To evaluate with intravascular ultrasound
virtual histology (VH-IVUS) atherosclerotic
burden and plaque composition of coronary
arteries in Tako-Tsubo patients
Intravascular ultrasound virtual histology
(VH-IVUS)
• Autoregressive spectral analysis of radiofrequencyultrasound backscatter signals to assess plaquecomposition (fibrotic, fibrolipidic, necrotic core anddense calcium)
• Provides two-dimensional colour-coded maps: green(fibrous); light-green (fibro-fatty); red (necrotic core)and white (dense calcium).
• Good correlation between the maps obtained andhistological findings.
Intravascular ultrasound virtual histology
(VH-IVUS)
Tako-Tsubo Syndrome VH-IVUS Methods
We assessed plaque characteristics in 8 consecutive patients without flow-
limiting coronary stenoses in the acute phase of Tako-Tsubo Syndrome.
VH-IVUS was performed in mid and proximal LAD with a 20-MHz catheter (Eagle
Eye, Volcano Corporation, Rancho Cordova, CA, USA), with motorized pullback
at 0.5 mm/s.
Tako-Tsubo Syndrome VH-IVUSMethods
Off-line volumetric reconstruction of the four VH-IVUS plaque
components
fibrous (FI)
fibro-fatty (FF)
necrotic core (NC)
dense calcium (DC)
and the
NC/DC ratio
measured in every recorded frame and expressed as
percentage of total plaque volume and percentage of cross-
sectional area at the level of the most relevant plaque
Tako-Tsubo Syndrome VH-IVUS Patient demographics
• Age 62 ± 2
• F/M 7 / 1 (87.5%)
• Hypertension 3 (37.5%)
• Diabetes 0
• Smoke habitus 0
• Dyslipidemia 2 (25%)
• Family history of CAD 1 (12.5%)
Tako-Tsubo Syndrome VH-IVUS
Results
• The mean analyzed length
was 46 ± 18,67 mm (range
30.2 – 67.8)
• The plaque volume (%) was:
63
310
24FI
FF
NC
DC
NC/DC 3.3
Tako-Tsubo Syndrome VH-IVUS
Results
• Mean analisys cross-
sectional area (%) at the
level of the most relevant
plaque was:
57
9
19
15
FI
FF
NC
DC
NC/DC 2.1
Tako-Tsubo Syndrome VH-IVUS
Normal vessel
NC/DC 1,4
Patient AC; 51 yrs; female
Tako-Tsubo Syndrome VH-IVUS
Stable plaque
Patient GM; 57 yrs; male
NC/DC 4,7
MLA 11 mm²
Tako-Tsubo Syndrome VH-IVUS
Unstable plaque (TCFA)
Patient RL; 59 yrs; female
NC/DC 7,8
MLA 5,4
mm²
ACS VH-IVUS
Unstable plaque (TCFA)
Patient AL; 69 yrs; male
NC/DC 3,9
Tako-Tsubo Syndrome VH-IVUSConclusions
In Tako-Tsubo patients:
• VH-IVUS shows atherosclerotic plaques
• Fibrous tissue is the largely predominantcomponent
• Likewise unstable angina, focal, lipid-rich andpotentially vulnerable lesions are detected
Tako-Tsubo Syndrome VH-IVUSConclusions (2)
• Aggressive medical treatment (ASA, clopidogrel,
statins) is mandatory to stabilize vulnerable plaque
• As well as in ACS, stent passivation of unstable
plaque, in order to prevent new events, must be
investigated
PCI anno 2012:Caratteristiche popolazione per genere
Maschi Femmine
Numero 1535 444
ACS 24.8% 35.6% p < 0.0001
Età > 80 anni 9.7% 21.8% p < 0.0001
Età media (anni) 65.9 71.4
Diabete 20.6% 19.1% p = ns
Malattia multivaso 30.2% 24.1% p = 0.01
PCI anno 2012Outcome intra-ospedaliero per genere:
p =ns
p = 0.0019
p = nsp = 0.026
§MACCE = cumulativo di morte, Q-MI non fatale, stroke, rivascolarizzazione urgente
§
PCI anno 2012:Outcome intra-ospedaliero per genere
in base alla presentazione clinica
p = 0.019
Grazie a:
Franco Fabbiocchi
Daniele Andreini
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