Abstract-Data are sparse regarding the actual predictive utility of pulse pressure and other blood pressure measures for cardiovascular events. We included all of the participants from the Chicago Heart Association Detection Project in Industry who were free of cardiovascular disease and not receiving antihypertensive treatment at baseline (1967)(1968)(1969)(1970)(1971)(1972)(1973). Baseline blood pressure measures were assessed for predictive utility for fatal and nonfatal events over 33 years. Among 36 314 participants (mean age: 39Ϯ13 years; 43.4% women), there were 11 452 deaths: 745 were attributed to stroke, 2812 to coronary disease, and 599 to heart failure. Of the 16 393 participants who attained Medicare eligibility, 3050, 1367, and 2207 had Ն1 hospitalization for stroke, myocardial infarction, or heart failure, respectively. In univariate analyses, hazards ratios for stroke death per SD of pulse, systolic, and diastolic pressure, respectively, were 1.49, 1.75, and 1.71. Likelihood ratio 2 (134.3, 302.0, and 232.6, respectively), Bayes information criteria values (15 142, 14 974, and 15 044, respectively), and areas under receiver-operating characteristic curves (0.59, 0.64, and 0.63, respectively) all indicated better predictive utility for systolic and diastolic compared with pulse pressure. Results for coronary or heart failure death and stroke, myocardial infarction, or heart failure hospitalization were similar. Pulse pressure had weaker predictive utility at all ages but particularly for those Ͻ50 years. In this large cohort study, pulse pressure had predictive utility for cardiovascular events that was inferior to systolic or diastolic pressure. These findings support the approach of current guidelines in the use of systolic and diastolic blood pressure to assess risk and the need for treatment. Key Words: hypertension Ⅲ pulse pressure Ⅲ stroke Ⅲ coronary heart disease Ⅲ heart failure Ⅲ prediction H ypertension, currently defined by systolic (SBP) and diastolic (DBP) blood pressure (BP) levels according to Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, is a major causal risk factor for stroke, coronary heart disease (CHD), and heart failure, 1-3 3 of the leading causes of morbidity and mortality in the United States. 1 In the last decade there has been controversy regarding the value of pulse pressure (PP), defined as SBP minus DBP, compared with traditional measures of SBP and DBP, for prediction of stroke, CHD, and heart failure outcomes. 4 -13 However, most studies have merely compared relative risks for single outcomes associated with PP, SBP, and DBP without assessing measures of true predictive utility, such as model fit, informativeness, and areas under receiver-operating characteristic curves.Thus, although PP has been shown to be associated with stroke, CHD, and heart failure, 4 -13 it remains controversial whether PP has greater predictive utility than SBP or DBP. Evidence of clear improvements in prediction with use of P...

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Takotsubo cardiomyopathy mimics acute myocardial infarction but is a separate clinical entity characterized by distinct wall motion abnormalities in the absence of obstructive coronary lesions. The prevalence of this condition is relatively uncommon yet has gained increasing recognition in recent years. It has rarely been associated with the use of dobutamine infusion during cardiac stress testing. We present in detail two cases of dobutamine-induced Takotsubo cardiomyopathy from our case series, one from 2002 and the other from 2008. While both cases display the typical features of Takotsubo cardiomyopathy, the former was initially diagnosed as dobutamine-induced vasospasm. These cases may provide insight into the pathophysiological mechanism of the condition and suggest that the increasing recognition of Takotsubo cardiomyopathy results from increasing familiarity of the condition.

Patient: Female, 53Final Diagnosis: Apical hypertrophic cardiomyopathySymptoms: Chest pain • dizziness • palpitationsMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Rare diseaseBackground:Apical hypertrophic cardiomyopathy (ApHCM) is a relatively rare form of hypertrophic cardiomyopathy that predominantly affects the apex of the left ventricle and typically has a nonobstructive physiology. Its variable presentation and clinical course render ApHCM a commonly delayed or missed diagnosis.Case Report:A 53-year-old Caucasian woman presented with chronic progressive chest pain. She was initially started on treatment for acute coronary syndrome. Diagnosis of ApHCM was initially missed on echocardiography, but made on subsequent cardiac catheterization and cardiac MRI. She improved clinically with metoprolol, had a work-up for implantable cardioverter-defibrillator placement, and was referred for genetic testing.Conclusions:Despite earlier studies suggesting a more benign clinical course of ApHCM, recent studies report increased morbidity and mortality, which is comparable to the prognosis of other variants of hypertrophic cardiomyopathy such as hypertrophic obstructive cardiomyopathy. Thus, when formulating a differential diagnosis for chest pain, it is important to include structural heart disease including apical and other variants of hypertrophic cardiomyopathy as part of that differential, as appropriate management can prevent these devastating sequelae. Furthermore, when screening tests such as echocardiography cannot adequately establish the diagnosis of ApHCM, then cardiac MRI or invasive hemodynamic testing is necessary to establish or refute the diagnosis.

Left atrial appendage (LAA) occlusion or ligation is a novel approach to stroke prevention in atrial fibrillation that may obviate the need for long-term anticoagulation. The Lariat device has received Food and Drug Administration 510K clearance for the approximation of soft tissue and has been applied to transcatheter LAA ligation using a combined trans-pericardial and transseptal approach. The occurrence of late leak after transcatheter LAA ligation and its percutaneous management has not been previously reported. Herein, we report three cases of late leak with reconstitution of the LAA after initially successful Lariat closure, and present a simple percutaneous technique for leak closure.