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