Cesare Fiorentini
Medicina di genere e
malattie cardiovascolari
18 gennaio 2014
- Pio Albergo Trivulzio - Milano -
ACCURACY OF MDCT: complementary role
of stress test
Female, 44 years old with
hypertension, atypical angina,
ex-ECG positive and stress
nuclear test positive in inferior
wall of LV
Circulation 2006; 113
Transient Left Ventricular Apical
Ballooning Syndrome
1.
2.
3.
4.
5.
Gender: 6-fold female-to-male predominance
Mean age >60 years
Acute substernal chest pain
ST-segment elevation and/or T-wave inversion
Absence of significant coronary arterial
narrowing at angiography
6. Systolic dysfunction (apical ballooning)
7. Profound psychological stress
8. Rapid restoration to previous functional
cardiovascular status
Annals of Internal Medicine 2004; 141
Distribuzione per sesso
Stress emotivo
• morte cane
9%
91%
Distribuzione degli stressor
• 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
non
specificato
• caduta sugli sci
stress non
riportato
stress fisico
stress
emotivo
• emorragia gastrointestinale
•Trauma facciale
•Post cardioversione elettrica esterna
•Successivo ad intervento chirurgico
• post lobectomia polmonare
• caduta a terra
• shock settico
•Terapia Ca orofaringe
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
Catecholamine-mediated myocardial stunning
• Serum catecholamine levels are significantly
higher than those found in conditions such as
acute myocardial infarction or cardiac failure
and up to 34 times higher than normal resting
values
• Epinephrine
plasma
half-life
is
approximatively 3 min, and most patients
present to emergency departments at least
30 min (>10 half-lives) after symptom onset
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 2000
Coronary Angiography
February 2008
Coronary Angiography
Post-ECV
Acute Pulmonary Edema
Tako-tsubo Syndrome
EF changes
70
60
61
50
40
46
30
20
10
0
Acute
1-month
NEJM 2005; 352
American Heart Journal 2008; 155
Tako-Tsubo Syndrome
•
•
•
•
•
•
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
Emergency 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 Syndrome
Background
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 radiofrequency
ultrasound backscatter signals to assess plaque
composition (fibrotic, fibrolipidic, necrotic core and
dense 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 and
histological findings.
Intravascular ultrasound virtual histology
(VH-IVUS)
Tako-Tsubo Syndrome VH-IVUS
Methods
We assessed plaque characteristics in 8 consecutive patients without flowlimiting 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-IVUS
Methods
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 crosssectional area at the level of the most relevant plaque
Tako-Tsubo Syndrome VH-IVUS
Patient demographics
•
•
•
•
•
•
•
Age
F/M
Hypertension
Diabetes
Smoke habitus
Dyslipidemia
Family history of CAD
62 ± 2
7 / 1 (87.5%)
3 (37.5%)
0
0
2 (25%)
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:
10
3
24
63
NC/DC 3.3
FI
FF
NC
DC
Tako-Tsubo Syndrome VH-IVUS
Results
• Mean
analisys
crosssectional area (%) at the
level of the most relevant
plaque was:
9
19
57
15
NC/DC 2.1
FI
FF
NC
DC
Tako-Tsubo Syndrome VH-IVUS
Normal vessel
NC/DC 1,4
Patient AC; 51 yrs; female
Tako-Tsubo Syndrome VH-IVUS
Stable plaque
NC/DC 4,7
MLA 11 mm²
Patient GM; 57 yrs; male
Tako-Tsubo Syndrome VH-IVUS
Unstable plaque (TCFA)
NC/DC 7,8
MLA 5,4
mm²
Patient RL; 59 yrs; female
ACS VH-IVUS
Unstable plaque (TCFA)
NC/DC 3,9
Patient AL; 69 yrs; male
Tako-Tsubo Syndrome VH-IVUS
Conclusions
In Tako-Tsubo patients:
• VH-IVUS shows atherosclerotic plaques
• Fibrous tissue is the largely predominant
component
• Likewise unstable angina, focal, lipid-rich and
potentially vulnerable lesions are detected
Tako-Tsubo Syndrome VH-IVUS
Conclusions (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 2012
Outcome intra-ospedaliero per genere:
p = ns
p = 0.026
p = 0.0019
p =ns
§
§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