ramipril and Takotsubo-Cardiomyopathy

Takotsubo Syndrome(TTS), contrary to historical reports, is now increasingly recognised to be associated with substantial mortality and morbidity, both in the short- and long-term. Although TTS is often precipitated by a catecholamine "pulse", in-hospital hypotension is a common occurrence, increasing the risk of mortality. Furthermore, despite the transient catecholamine stimulus, there is increasing evidence that there are significant long term sequelae, including persistently impaired left ventricular(LV) systolic dysfunction, myocardial oedema with fibrosis, as well as persistent impairment of quality of life. A definitive therapeutic option to limit the extent of initial myocardial injury, and to accelerate recovery in TTS is therefore justified. However to date, there has been a lack of prospective studies in this area.. NACRAM is a multi-centre, randomised, placebo-controlled trial, sequentially testing early use of intravenous N-acetylcysteine(NAC), followed by/or oral ramipril for 12 weeks. The rationale for utilising these agents is related to their effects on limiting nitrosative stress and expression of the inflammasome activator thioredoxin interacting protein(TXNIP); both processes fundamental to the pathogenesis of TTS.. NACRAM is assessing resolution of myocardial oedema on cardiac magnetic resonance imaging(CMR), improvements in LV systolic function as measured by global longitudinal strain(GLS) on echocardiography, quality of life, and inflammatory markers.. To the best of our knowledge, NACRAM will be the first prospective study to help definitively evaluate a therapeutic option in acute attacks of TTS.

Topics: Acetylcysteine; Angiotensin-Converting Enzyme Inhibitors; Carrier Proteins; Double-Blind Method; Free Radical Scavengers; Humans; Inflammasomes; Prospective Studies; Quality of Life; Ramipril; Takotsubo Cardiomyopathy

Topics: Acetylcysteine; Electrocardiography; Humans; Ramipril; Takotsubo Cardiomyopathy

Guillain-Barré syndrome is an autoimmune disorder in which autoantibodies mainly affect the peripheral nervous system. Autonomic dysfunction is a common and severe complication of Guillain-Barré syndrome. Cardiomyopathy, though, is a rare complication in Guillain-Barré syndrome, with only a few cases reported in the literature.. We present a case of a 65-year-old Greek woman with Guillain-Barré syndrome who developed cardiomyopathy shortly after admission to the intensive care unit due to respiratory deterioration. Her estimated left ventricular ejection fraction upon admission was 20%. The result of coronary angiography was negative for coronary artery disease, and cardiac magnetic resonance imaging excluded myocarditis. Her clinical condition improved with supportive therapy, and her estimated left ventricular ejection fraction at discharge was normal.. Clinicians should be aware of this potentially lethal complication of Guillain-Barré syndrome and the therapeutic options, because early diagnosis can improve prognosis. Routine electrocardiographic and echocardiographic assessments should be performed in patients with Guillain-Barré syndrome presenting with hemodynamic instability.

Topics: Aged; Antihypertensive Agents; Cardiotonic Agents; Dobutamine; Echocardiography; Female; Furosemide; Guillain-Barre Syndrome; Humans; Ramipril; Respiratory Insufficiency; Takotsubo Cardiomyopathy; Treatment Outcome

Reversible left ventricular dysfunction, also termed Takotsubo cardiomyopathy, is rarely reported in Addison's disease after initiation of hormone replacement therapy. The pathogenesis of this cardiomyopathy is unknown.. Although we could not exclude coronary artery disease by coronary angiography, her clinical course and instrumental findings suggest Takotsubo cardiomyopathy of the apical type. Fludrocortisone overdosage and increased myocardial vulnerability due to cortisol deficiency might be pathogenetic factors, whereas myocarditis is unlikely. When hormone replacement in patients with Addison's disease is initiated, cardiac function should be monitored by electrocardiogram and echocardiography.

Topics: Addison Disease; Adult; Anti-Inflammatory Agents; Antihypertensive Agents; Biomarkers; Bisoprolol; Dose-Response Relationship, Drug; Drug Overdose; Female; Fludrocortisone; Heart Failure; Humans; Ramipril; Takotsubo Cardiomyopathy; Treatment Outcome

Rituximab is used for treatment of multiple haematological cancers. Caution for use is advised in patients with significant cardiorespiratory disease due to known cases of exacerbations of angina and arrhythmias. However, its cardiotoxicity profile is not as well recognised as other monoclonal antibodies such as transtuzumab. We report a case of a 66-year-old man who developed Takotsubo's cardiomyopathy (TC) after an elective infusion of rituximab. This case is exceptional in that rituximab has not been linked to TC, and the vast majority of chemotherapy-linked and immunotherapy-linked TC reactions have occurred during initial infusions. We also discuss the different mechanisms which link TC to immunotherapy and chemotherapy, and propose that there may be a potential for risk-stratifying recipients of this frequently used immunotherapy prior to administering treatment.

Topics: Aged; Antihypertensive Agents; Antineoplastic Agents; Bisoprolol; Electrocardiography; Humans; Leukemia, Lymphocytic, Chronic, B-Cell; Male; Ramipril; Rituximab; Takotsubo Cardiomyopathy; Treatment Outcome

Topics: Antihypertensive Agents; Aspirin; Carbazoles; Carvedilol; Diuretics; Echocardiography; Family Conflict; Female; Furosemide; Humans; Middle Aged; Platelet Aggregation Inhibitors; Propanolamines; Ramipril; Takotsubo Cardiomyopathy; Ventricular Dysfunction, Left

A 55-years-old woman, with a history of hypertension and ischemic stroke with residual left hemiparesis, was admitted to our hospital because of dyspnoea with clinical evidence of acute pulmonary edema. She was found to have a sinus tachycardia with ST-elevation in leads D1, aVL and V1-V4 in the electrocardiogram, and akinesis of the left ventricular apex with overall left ventricular systolic function being severely impaired and an ejection fraction of 28% on echocardiography. Orotracheal intubation was performed and mechanical ventilation was immediately started. Emergency cardiac catheterization was performed 2 h after the symptom onset. Coronary angiography showed no significant coronary artery disease. Blood analysis revealed an increase in the creatine kinase MB fraction, a significant positive detection in troponin T, a white blood cell count of 35000 per microliter, C-reactive protein of 59,9 mg/dl, and transient elevation in the concentration of free triiodothyronine, free thyroxine, thyroid globulin antibody, and thyroid peroxidase antibody. The symptoms improved during the next days, and follow-up echocardiography 18 days later showed complete resolution of the left ventricular dysfunction. These data suggest that tako-tsubo cardiomyopathy may be induced in patients with sepsis and transient hyperthyroidism.

Topics: Amlodipine; Anti-Bacterial Agents; Antihypertensive Agents; Antithyroid Agents; Aspirin; Echocardiography; Electrocardiography; Female; Glucocorticoids; Humans; Hyperthyroidism; Methimazole; Middle Aged; Ofloxacin; Platelet Aggregation Inhibitors; Prednisone; Propranolol; Ramipril; Sepsis; Takotsubo Cardiomyopathy