Apical ballooning of the left ventricle was first introduced as takotsubo-like left ventricular dysfunction in 1990 by Satoh and colleagues. The syndrome is characterised by reversible extensive akinesia of the apical and mid-portions of the left ventricle with hypercontraction of the basal segment. For the first time two sisters with this syndrome are reported, suggesting a possible genetic aetiology.A pical ballooning of the left ventricle was first introduced as takotsubo-like left ventricular dysfunction in 1990 by Satoh and colleagues.1 The syndrome is characterised by reversible extensive akinesia of the apical and mid-portions of the left ventricle with hypercontraction of the basal segment. We report for the first time two sisters with this syndrome suggesting a possible genetic aetiology. CASE PRESENTATIONSCase 1 A 44 year old woman with a history of chronic obstructive pulmonary disease and depression presented to the emergency department with acute thoracic pain and dyspnoea after an argument with her husband. The ECG showed tall T waves in the anterior leads. Troponin I, creatine kinase, and creatine kinase MB concentrations were only slightly increased. Echocardiography showed extensive apical akinesia and a severely reduced left ventricular ejection fraction (35%). Coronary angiography showed normal coronary arteries. The patient had complete functional recovery with normalisation of the left ventricular systolic function on echocardiographic evaluation three weeks later.Case 2 A 52 year old woman without any significant medical history was admitted with sudden dyspnoea and orthopnoea after physical exercise. She had no thoracic pain. The ECG showed tall T waves in the anterior leads. The troponin I concentration was only slightly elevated and echocardiography showed severely decreased left ventricular systolic function due to anteroapical akinesia. Coronary angiography showed normal coronary arteries. The systolic function gradually improved and a transthoracic echocardiography showed normalisation of the regional contractility on day 7. DISCUSSIONApical ballooning of the left ventricle is a syndrome that consists of acute onset of reversible balloon-like left ventricular wall motion abnormality of the apex, hypercontraction of the basal segment, and acute myocardial infarction on ECG without significant stenosis on coronary angiography. The diagnostic criteria of this syndrome were reported by Abe and colleagues.2 The syndrome is often associated with a physical or emotional stress factor, chest pain, and only a limited release of cardiac markers. Apical ballooning has been described in Japanese and white patients, most of whom are women.3 4 The precise aetiology is unclear. Various pathophysiological mechanisms have been hypothesised such as multiple vasospastic angina and enhanced sympathetic activity secondary to internal (emotional) and external stresses (trauma, surgical procedure, etc).We report on two sisters who where admitted to our hospital with apical ballooning of the left ventricle. ...

AimsCardiac resynchronization therapy (CRT) leads to reverse ventricular remodelling, improved functional capacity, and better clinical outcome in patients with advanced chronic heart failure, reduced ejection fraction, and evidence of ventricular conduction delay, who are under optimal medical therapy. This study investigated whether these benefits can be extrapolated to older patients, typically not included in randomized clinical trials. Methods and resultsConsecutive patients who received a CRT device between October 2008 and June 2011, including optimization afterwards in a dedicated clinic, were stratified into 3 pre-specified groups, according to age: ,70 years (n ¼ 76); 70 -79 years (n ¼ 95); and ≥80 years (n ¼ 49). Left ventricular remodelling, functional capacity, heart failure hospitalization, and mortality data were assessed during follow-up. Reverse left ventricular remodelling and improvement in New York Heart Association functional class were similar in all groups at 6 months after implantation. During mean follow-up of 20 months, 32 patients died and 66 were admitted for heart failure. Annualized mortality rates were significantly higher in elderly patients (6% vs. 8% vs. 15% in all groups, respectively; P , 0.001), but time to death or first heart failure admission was similar among age groups (P ¼ 0.531). Progressive pump failure was the major cause of death (50%), with co-morbidity-related deaths also being frequent (41%). ConclusionReverse left ventricular remodelling and functional capacity improvement after CRT are sustained at advanced age. Moreover, time to all-cause mortality or heart failure admission was similar, irrespective of age, in a context of maximized optimization including optimal medical therapy.--

Despite improvement in morbidity and mortality with cardiac resynchronization therapy (CRT), disease progression continues to affect a subset of patients and there is limited effort to identify contributing factors. Our objective was to investigate if a protocol-driven approach incorporated in a management strategy of heart failure immediately after implantation would provide incremental benefits beyond usual care after implantation. We reviewed 114 consecutive patients with CRT implanted from 2005 through 2009 who received usual care after implantation or underwent protocol-driven CRT care after implantation. Preimplantation characteristics in patients receiving usual versus protocol-driven care were similar in left ventricular (LV) dimension (LV internal diastolic diameter 6.2 ± 0.8 vs 6.4 ± 1.0 cm), LV ejection fraction (26 ± 8% vs 25% ± 8%), QRS width, and medication usage. Major adjustments during the protocol-driven approach were uptitration of neurohormonal blockers (64%), echocardiographically guided atrioventricular optimization (50%), heart failure education (42%), arrhythmia management (19%), and LV lead repositioning (7%). Although positive LV remodeling was noted in the 2 groups at 6 months, extent was significantly greater in the protocol-driven approach compared to usual care (change in LV internal diastolic diameter 0.7 ± 0.6 cm vs 0.2 ± 1.2 cm, p = 0.01; change in LV ejection fraction 11 ± 7% vs 7 ± 9%, p = 0.01), which was associated with fewer major adverse events (14% vs 53%, p <0.001). In conclusion, a protocol-driven approach for patients with CRT started immediately after implantation is associated with incremental favorable effects on reverse remodeling and fewer adverse events compared to usual care after implantation. These effects appeared to be driven not only by changes in device settings and arrhythmia management but also by concomitant medication optimization and heart failure education.

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Patients with established rheumatoid arthritis (RA) have a higher cardiovascular morbidity and mortality in comparison with the general population. It is considered to be an independent risk factor for cardiovascular disease. The purpose of this article is to describe the mechanisms responsible for accelerated atherogenesis in RA patients and to give an overview of the eff ects of diff erent RA therapies (methotrexate, TNF antagonists and other biologicals).