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Cardiovascular Research Jul 2023Takotsubo syndrome (TTS) accounts for between 1 and 4% of cases presenting clinically as an acute coronary syndrome. It typically presents as a transient cardiac... (Review)
Review
Takotsubo syndrome (TTS) accounts for between 1 and 4% of cases presenting clinically as an acute coronary syndrome. It typically presents as a transient cardiac phenotype of left ventricular dysfunction with spontaneous recovery. More dramatic presentations may include cardiogenic shock or cardiac arrest. Despite progress in the understanding of the condition since its first description in 1990, considerable questions remain into understanding underlying pathomechanisms. In this review article, we describe the current published data on potential underlying mechanisms associated with the onset of TTS including sympathetic nervous system over-stimulation, structural and functional alterations in the central nervous system, catecholamine secretion, alterations in the balance and distribution of adrenergic receptors, the additive impact of hormones including oestrogen, epicardial coronary or microvascular spasm, endothelial dysfunction, and genetics as potentially contributing to the cascade of events leading to the onset. These pathomechanisms provide suggestions for novel potential therapeutic strategies in patients with TTS including the role of cognitive behavioural therapy, beta-blockers, and endothelin-A antagonists. The underlying mechanism of TTS remains elusive. In reality, physical or emotional stressors likely trigger through the amygdala and hippocampus a central neurohumoral activation with the local and systemic secretion of excess catecholamine and other neurohormones, which exert its effect on the myocardium through a metabolic switch, altered cellular signalling, and endothelial dysfunction. These complex pathways exert a regional activation in the myocardium through the altered distribution of adrenoceptors and density of autonomic innervation as a protective mechanism from myocardial apoptosis. More research is needed to understand how these different complex mechanisms interact with each other to bring on the TTS phenotype.
Topics: Humans; Takotsubo Cardiomyopathy; Heart; Catecholamines; Sympathetic Nervous System; Autonomic Nervous System; Vascular Diseases
PubMed: 37183265
DOI: 10.1093/cvr/cvad053 -
The American Journal of Emergency... Oct 2023Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival.... (Review)
Review
BACKGROUND
Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions.
OBJECTIVE
This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation.
DISCUSSION
The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic).
CONCLUSIONS
Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.
Topics: Humans; Hypertension, Pulmonary; Tricuspid Valve Insufficiency; Ventricular Dysfunction, Right; Atrial Fibrillation; Echocardiography; Pulmonary Embolism
PubMed: 37499553
DOI: 10.1016/j.ajem.2023.07.011 -
Cardiology Clinics Aug 2023Right ventricular (RV) pacing-induced cardiomyopathy (PICM) is typically defined as left ventricular systolic dysfunction resulting from electrical and mechanical... (Review)
Review
Right ventricular (RV) pacing-induced cardiomyopathy (PICM) is typically defined as left ventricular systolic dysfunction resulting from electrical and mechanical dyssynchrony caused by RV pacing. RV PICM is common, occurring in 10-20% of individuals exposed to frequent RV pacing. Multiple risk factors for PICM have been identified, including male sex, wider native and paced QRS durations, and higher RV pacing percentage, but the ability to predict which individuals will develop PICM remains modest. Biventricular and conduction system pacing, which better preserve electrical and mechanical synchrony, typically prevent the development of PICM and reverse left ventricular systolic dysfunction after PICM has occurred.
Topics: Humans; Male; Cardiac Pacing, Artificial; Cardiomyopathies; Ventricular Dysfunction, Left; Heart Conduction System; Heart Ventricles; Ventricular Function, Left
PubMed: 37321694
DOI: 10.1016/j.ccl.2023.03.010 -
Journal of the American Society of... Sep 2023Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the... (Review)
Review
Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.
Topics: Humans; Pulmonary Embolism; Echocardiography; Lung; Acute Disease; Ventricular Dysfunction, Right
PubMed: 37209948
DOI: 10.1016/j.echo.2023.05.006 -
Journal of the American College of... Aug 2023Despite the availability of lifesaving guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), there remain major gaps in... (Review)
Review
Despite the availability of lifesaving guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), there remain major gaps in utilization of these therapies among eligible patients. Simultaneous with these gaps in quality of care, HFrEF continues as a leading cause of death and hospitalization with associated clinical risk far exceeding most other cardiovascular and noncardiovascular conditions. In the context of this urgent need to improve provision of appropriate therapy, multiple lines of evidence support various implementation strategies. Such strategies include in-hospital initiation of GDMT, simultaneous or rapid sequence initiation of GDMT, participation in quality improvement registries to assess site performance and provide feedback, multidisciplinary titration clinics, virtual consult teams, reduction of cost-sharing, remote algorithm-based medication optimization, electronic health record-based interventions, and direct-to-patient educational initiatives. This review describes and contextualizes the evidence surrounding each of these potential avenues for improving use of foundational GDMTs for patients with HFrEF.
Topics: Humans; Heart Failure; Stroke Volume; Hospitalization; Ventricular Dysfunction, Left
PubMed: 37532424
DOI: 10.1016/j.jacc.2023.03.430 -
Current Opinion in Pulmonary Medicine Sep 2023The purpose of this review is to provide an overview of assessment of right ventricular function in the context of pulmonary hypertension and pulmonary arterial... (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to provide an overview of assessment of right ventricular function in the context of pulmonary hypertension and pulmonary arterial hypertension (PAH). We will review unique features of right ventricular anatomy, delineation of cause of pulmonary hypertension through careful right ventricular assessment, echocardiographic and hemodynamic evaluation, and the importance of this assessment in prognosis.
RECENT FINDINGS
The importance of performance in prognosis and risk assessment in patients with pulmonary hypertension has been continually emphasized in ongoing research. Representative parameters of right ventricular function have been shown to be predictive of prognosis in patients with pulmonary hypertension. Further, the importance of serial right ventricular assessment in risk assessment and prognosis has remained an emerging theme.
SUMMARY
Careful evaluation of right ventricular function is paramount in assessing the cause of pulmonary hypertension and severity of disease. Further, it has prognostic significance, as many representative parameters of right ventricular function have been linked with mortality. In our opinion, right ventricular function should be assessed serially throughout the course of treatment in pulmonary hypertension, and baseline parameters in addition to dynamic changes should be incorporated into risk assessment. Achieving normal or near-normal right ventricular performance may serve as a principal goal in the treatment of pulmonary hypertension.
Topics: Humans; Hypertension, Pulmonary; Pulmonary Arterial Hypertension; Prognosis; Familial Primary Pulmonary Hypertension; Echocardiography; Ventricular Dysfunction, Right
PubMed: 37410491
DOI: 10.1097/MCP.0000000000000980 -
Seminars in Respiratory and Critical... Dec 2023Pulmonary arterial hypertension is a severe life-threatening condition associated with increased pulmonary vascular resistance and resulting right heart dysfunction....
Pulmonary arterial hypertension is a severe life-threatening condition associated with increased pulmonary vascular resistance and resulting right heart dysfunction. Admission to intensive care unit with acutely decompensated right heart failure is a significant negative prognostic event with a high risk of multisystem organ dysfunction and death. Presentations are heterogenous and may combine signs of both diastolic and systolic dysfunction complicating management. Renal dysfunction is often present, but other organ systems can be involved resulting in findings such as acute hepatic dysfunction or bowel wall congestion and ischemia. The goals of therapy are to rapidly reverse ventriculo-arterial decoupling and reduce right ventricular afterload to prevent progression to refractory or irreversible right heart failure. Triggering events must be investigated for and addressed urgently if identified. Volume status management is critical and both noninvasive and invasive testing can aid in prognostication and guide management, including the use of inotropes and vasopressors. In cases of refractory right heart dysfunction, consideration of urgent lung transplantation and mechanical circulatory support is necessary. These patients should be managed at expert centers in an intensive care setting with a multidisciplinary team of practitioners experienced in the management of right heart dysfunction given the high short- and long-term mortality resulting from acute decompensated right heart failure.
Topics: Humans; Hypertension, Pulmonary; Intensive Care Units; Lung Transplantation; Critical Care; Heart Failure; Ventricular Dysfunction, Right
PubMed: 37369216
DOI: 10.1055/s-0043-1770119 -
Journal of the American Heart... Aug 2023Background Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are known to be associated with reduced left ventricular (LV)...
Background Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are known to be associated with reduced left ventricular (LV) ejection fraction and adverse outcomes in patients with structural heart disease. The relationship between subclinical LV dysfunction and ventricular arrhythmias in the general population is not established. Methods and Results Participants in the SAFARIS (Subclinical Atrial Fibrillation and Risk of Ischemic Stroke) study with normal left ventricular ejection fraction (n=503; mean age 77 years, 63% women) underwent 14-day electrocardiographic monitoring and 2-dimensional echocardiography. Frequent PVCs were defined as PVCs >500 per 24 hours and NSVT as ≥4 consecutive ventricular ectopic beats. Reduced LV global longitudinal strain (GLS) was used as an indicator of subclinical LV dysfunction. Seventy-six participants (15.1%) had PVCs >500/d, 117 (23.3%) had NSVT episodes. LV GLS was significantly reduced in both frequent PVCs and NSVT groups (<0.01). In multivariable analyses, lower LV GLS was associated with frequent PVCs (adjusted odds ratio [aOR], 1.19 [95% CI, 1.09-1.30 per unit reduction]; <0.001) and NSVT (aOR, 1.09 [95% CI, 1.01-1.17]; =0.036) independently of established risk factors and other echocardiographic parameters. Abnormal LV GLS (>-15.8%) carried a 2-fold increase in risk of ventricular arrhythmias (aOR, 2.18, =0.029 for PVCs; aOR, 2.09, =0.026 for NSVT). Conclusions PVCs and NSVT episodes were frequent in this community-based elderly cohort with normal left ventricular ejection fraction and were independently associated with lower LV GLS. The association between LV dysfunction and ventricular arrhythmias is present at an early, subclinical stage, an observation that carries possible preventative implications.
Topics: Humans; Female; Aged; Male; Stroke Volume; Ventricular Function, Left; Ventricular Dysfunction, Left; Echocardiography; Ventricular Premature Complexes; Tachycardia, Ventricular
PubMed: 37577940
DOI: 10.1161/JAHA.123.030274 -
Journal of Cardiovascular Translational... Feb 2024Heart failure (HF) caused by structural or functional cardiac abnormalities is a significant cause of morbidity and mortality worldwide. While HF with reduced ejection... (Review)
Review
Heart failure (HF) caused by structural or functional cardiac abnormalities is a significant cause of morbidity and mortality worldwide. While HF with reduced ejection fraction (HErEF) is well understood, more than half of patients have HF with preserved ejection fraction (HFpEF). Currently, the treatment for HFpEF primarily focuses on symptom alleviation, lacking specific drugs. The stressed heart undergoes metabolic switches in substrate preference, which is a compensatory process involved in cardiac pathological remodeling. Although metabolic reprogramming in HF has gained attention in recent years, its role in HFpEF still requires further elucidation. In this review, we present a summary of cardiac mitochondrial dysfunction and cardiac metabolic reprogramming in HFpEF. Additionally, we emphasize potential therapeutic approaches that target metabolic reprogramming for the treatment of HFpEF.
Topics: Humans; Heart Failure; Stroke Volume; Metabolic Reprogramming; Myocardium; Ventricular Dysfunction, Left
PubMed: 37650988
DOI: 10.1007/s12265-023-10433-2 -
The International Journal of... Feb 2024At the present time, right ventricular function in patients with aortic stenosis is insufficiently taken into account in the decision-making process of aortic valve...
At the present time, right ventricular function in patients with aortic stenosis is insufficiently taken into account in the decision-making process of aortic valve replacement. The aim of our study was to evaluate significance of right ventricular dysfunction in patients with severe aortic stenosis by modern 3D echocardiographic methods. This is prospective analysis of 68 patients with severe high and low-gradient aortic stenosis. We evaluated function of left and right ventricle on the basis of 3D reconstruction. Enddiastolic, endsystolic volumes, ejection fraction and stroke volumes of both chambers were assessed. There were more patients with right ventricular dysfunction in low-gradient group (RVEF < 45%) than in the high-gradient group (63.6% vs 39%, p = 0.02). Low-gradient patients had worse right ventricular function than high-gradient patients (RVEF 36% vs 46%, p = 0.02). There wasn't any significant correlation between the right ventricular dysfunction and pulmonary hypertension (r = - 0.25, p = 0.036). There was significant correlation between left and right ejection fraction (r = 0.78, p < 0.0001). Multiple regression analysis revealed that the only predictor of right ventricular function is the left ventricular function. According to our results we can state that right ventricular dysfunction is more common in patients with low-gradient than in high-gradient aortic stenosis and the only predictor of right ventricular dysfunction is left ventricular dysfunction, probably based on ventriculo-ventricular interaction. Pulmonary hypertension in patients with severe AS does not predict right ventricular dysfunction.
Topics: Humans; Hypertension, Pulmonary; Ventricular Dysfunction, Right; Predictive Value of Tests; Aortic Valve Stenosis; Ventricular Function, Left; Stroke Volume; Aortic Valve; Severity of Illness Index; Treatment Outcome
PubMed: 37950827
DOI: 10.1007/s10554-023-02986-9