Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review.

Clinical spectrum of hypertrophic cardiomyopathy (HC) has been expanded to include patients with mild or no thickening of the left ventricle (LV), who nevertheless have outflow tract obstruction at rest or after exercise, due to systolic anterior motion (SAM) and ventricular septal contact, with mitral valve elongation and papillary muscles anomalies. Apical ballooning mimicking a takotsubo syndrome (TS) wall motion pattern can occur in HC with mild septal thickening when latent obstruction becomes unrelenting. To define the prevalence of anatomic abnormalities characteristic of HC in patients diagnosed with TS, we analyzed echocardiograms of 44 unselected TS patients, age 67±12 years, 95% women including studies performed before the event (n = 11, median 515 days) and after recovery of left ventricular function (n = 33, median 92 days, interquartile range = 29 to 327) and compared the findings to 60 age and sexed matched controls. Analysis of echocardiograms was blinded to event timing, and patient vs. control status. During the ballooning event, 13 patients (30%) had SAM including 9 with LV outflow obstruction, peak gradients 71±40 mmHg, as well as: ventricular septal thickening (16 ± 4 mm), elongated anterior leaflets (30 ± 3mm), and increased mitral coaptation to posterior wall distance (17 ± 5 mm), consistent with diagnosis of the HC phenotype. Compared to 31 TS patients without SAM, study patients with SAM had longer anterior leaflets (30 ± 3 vs 26 ± 4 mm, p = 0.006), thicker septum (16 ± 4 vs 12 ± 3 mm), increased coaptation to posterior wall distance (17 ± 5 vs 14 ± 4 mm, p

Distinctive Hypertrophic Cardiomyopathy Anatomy and Obstructive Physiology in Patients Admitted With Takotsubo Syndrome.

A 70-year-old woman with known history of hypertension presented because of a syncopal episode during dinner at a wedding party, followed by chest pain. On physical examination a systolic murmur was noted, and her electrocardiogram showed ST segment elevation in anterior leads. She had elevated troponin levels while echocardiography showed a hypertrophic interventricular septum with dyskinetic apex and left ventricular outflow (LVOT) obstruction. Emergency coronary angiography excluded obstructive coronary artery disease and confirmed the presence of LVOT obstruction with a gradient of 90 mm Hg. A left ventriculography showed hypercontractility of the basal and mid segments with apical wall dyskinesia indicating Takotsubo cardiomyopathy. Patient was discharged after 6 days of hospitalization with normalization of left ventricular function and regression of the LVOT obstruction. This is an interesting case of Takotsubo cardiomyopathy complicated with severe LVOT obstruction in a patient with hypertensive heart disease and a sigmoid septum hypertrophy.

Syncope in a hypertrophic heart at a wedding party: can happiness break a thick heart? Takotsubo cardiomyopathy complicated with left ventricular outflow tract obstruction in a hypertrophic heart

https://scholarlycommons.henryford.com/cgi/viewcontent.cgi?article=1329&context=internalmedicine_articles

Concurring hypertrophic cardiomyopathy and takotsubo cardiomyopathy: Assessment and management.

Background: Drug-eluting stents (DES) have higher marked efficacy and lower revascularization requirements compared to bare metal stents (BMS).We aimed to determine the mid-term outcomes of patients implanted with a first-generation DES "paclitaxel-eluting stents" (PES). Methods: Patients with at least 1 PES implanted in our cardiology clinic were received in the nonrandomized group. Inclusion criteria were all patients undergoing percutaneous coronary intervention and PES implantation. The mean follow-up time was 35.14 + 13.4 months. Results: A total of 302 patients (401 lesions and 337 PES) were enrolled in the study. The mean age was 61.86 + 10.27 years. Major adverse cardiac and cerebrovascular events (MACE) occurred at 17.9%, and the stent thrombosis rate was 4%. Independent predictors of stent thrombosis were serum creatinine levels [OR 1.59; 95% CI, 1.03-2.46, p=0.03] and mean platelet volume [OR 1.59; 95% CI, 1.03-2.46, p= 0.03]. Also, poor functional capacity [OR 2.46: 95% CI, 1.42-4.26, p<0.001] and positive ischemia test [OR 3.43: 95% CI, (1.73-6.82), p<0.001] were predictors of MACE's. Conclusions: We have demonstrated that PES is safe and effective in the mid-term for use in coronary artery disease.

/pdf/the-effects-of-clinical-laboratory-and-angiographic-factors-3mrtxcp5.pdf

The effects of clinical, laboratory, and angiographic factors on stent thrombosis and major adverse cardiac events in paclitaxel eluting stents

Stent thrombosis is one of the most feared complications of percutaneous coronary intervention. Most commonly it occurs within the first few days after the deployment of the stent. Once the stent is completely endothelialized, this complication becomes extremely rare. Few cases of very late stent thrombosis were reported in the literature with the longest interval being around 11 years after the initial intervention. We report here the case of a 78-year-old male patient who presented with acute onset chest pain found to have acute inferior ST-segment elevation myocardial infarction due to thrombotic occlusion of a prior paclitaxel drug-eluting stent placed 12 years prior. This is, to our knowledge, the first case of stent thrombosis occurring after this long duration since stent implantation.

/pdf/extremely-late-in-stent-thrombosis-12-years-after-4c9x004nk1.pdf

Extremely Late In-Stent Thrombosis 12 Years After Implantation of a Drug-Eluting Stent.

Door-to-balloon (DTB) time of primary percutaneous coronary intervention in ST-elevation myocardial infarction (STEMI) is a predictive indicator of outcomes and mortality. Traditional gender-related differences that existed in the provision of DTB in STEMI had been allegedly improving until recent controversial data showed re-emergence of longer DTB in females. The objective of our study was to compare circadian disparities in percutaneous coronary intervention for STEMI according to gender in our institution. We compared DTB and symptom-to-balloon (STB) as well as mortality outcomes in a registry of 514 patients. We studied 117 females and 397 males. Baseline characteristics and cardiovascular risk factors were similar among both populations. Men used more self-transportation (51% vs. 38%) compared with women. Both had similar DTB median times: males, 63 (47-79) min; and females, 61 (44-76) min. In addition, STB median times were also similar: males, 155 (116-264) min; and females, 165 (115-261) min. Mortality outcomes at 1 month were comparable at 3% in males versus 0.9% in females (P = 0.164). In a review of a tertiary care center in New York, we observed no gender differences in DTB and STB, endorsing the role of emergency medical service transportation in eliminating disparities.

Gender-related Disparities of Percutaneous Coronary Interventions in ST-elevation Myocardial Infarction: A Retrospective Chart Review of 500 Patients.

Takotsubo cardiomyopathy (TCM) is a condition characterized by transient left ventricular dysfunction and apical ballooning, best seen on an echocardiogram or left ventriculogram. It mimics acute myocardial infarction but without evidence of coronary artery disease on an angiogram. Hypertrophic cardiomyopathy (HCM) is an autosomal dominant heart muscle disease that is significant with hypertrophy of the left ventricle with various morphologies. We hereby report a case of TCM in a male patient with a known history of HCM. The patient’s hemodynamic findings were challenging because the TCM produced an increased left ventricular outflow tract (LVOT) gradient that was previously not seen on his prior echocardiogram or cardiac catheterizations. Assessment and continuous monitoring are warranted in such a rare case. Supportive care afterward with beta blockers, along with echocardiogram surveillance, are the mainstay of management of such a patient.

Takotsubo Cardiomyopathy in a Patient with Preexisting Hypertrophic Cardiomyopathy.

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Papers

Extremely Late In-Stent Thrombosis 12 Years After Implantation of a Drug-Eluting Stent.

Gender-related Disparities of Percutaneous Coronary Interventions in ST-elevation Myocardial Infarction: A Retrospective Chart Review of 500 Patients.

Takotsubo Cardiomyopathy in a Patient with Preexisting Hypertrophic Cardiomyopathy.