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Omiya M, Morii Y, Mukai M, Mitsuhashi Y, Kato K, Isogai T. Myasthenic Crisis and Concomitant Takotsubo Syndrome Complicated by Shock. Intern Med 2024; 63:3383-3387. [PMID: 38719601 PMCID: PMC11729183 DOI: 10.2169/internalmedicine.3306-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/17/2024] [Indexed: 12/17/2024] Open
Abstract
A man in his 80s with myasthenia gravis (MG) developed dysmobility and chest discomfort. An electrocardiogram revealed ST-segment elevation, and coronary angiography revealed Takotsubo syndrome (TTS). He experienced myasthenic crisis that required ventilation and shock that was refractory to vasopressors and required intra-aortic balloon pump (IABP) insertion. He was managed conservatively without MG-specific treatment until his hemodynamics improved. On hospital day 6, he was weaned from IABP. MG is a high-risk condition for TTS, and TTS with myasthenic crisis (MC) is associated with high mortality. We successfully managed this case of TTS with MC with intubation and IABP, without MG-specific treatment.
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Affiliation(s)
- Moeko Omiya
- Department of Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yusuke Morii
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Japan
| | - Masako Mukai
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Yuya Mitsuhashi
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Japan
| | - Ken Kato
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Japan
| | - Toshiaki Isogai
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Japan
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2
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Nowak RJ, Habib AA, Klink AJ, Muppidi S, Parthan A, Sader SC, Balanean A, Gajra A, Howard JF. US Clinical Practice Experience with Eculizumab in Myasthenia Gravis: Acute Clinical Events and Healthcare Resource Utilization. Drugs Real World Outcomes 2024; 11:593-601. [PMID: 39470958 PMCID: PMC11589080 DOI: 10.1007/s40801-024-00457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2024] [Indexed: 11/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVE The terminal complement inhibitor eculizumab is approved in the USA for the treatment of patients with acetylcholine receptor antibody-positive generalized myasthenia gravis (MG). The ELEVATE study aimed to examine clinical-practice outcome data on eculizumab effectiveness in US adults with MG (generalized or ocular). This paper reports the findings on MG exacerbations and crises and associated healthcare resource utilization, and the use of rescue therapy. METHODS A retrospective chart review was conducted of US adults with MG who initiated eculizumab. Outcomes assessed for up to 2 years before and after eculizumab initiation included percentages and rates per patient per year (PPPY) of exacerbations and crises (the latter defined as intubation/impending intubation), healthcare resource utilization, and rescue therapy administration. RESULTS A total of 119 patients diagnosed with MG were enrolled in the study; 92 patients had ≥ 3 months of data both before and during eculizumab therapy and were included in the analyses. The mean rate of MG exacerbations decreased from 0.385 PPPY before eculizumab initiation to 0.152 PPPY during eculizumab treatment (p = 0.0034); the mean rate of MG crises decreased from 0.411 to 0.056 PPPY (p = 0.0018). Rates of healthcare resource utilization and rescue therapy use also decreased significantly during eculizumab treatment. CONCLUSIONS This retrospective chart review analysis provides evidence for a beneficial impact of eculizumab treatment on the incidence of MG exacerbations and crises and associated healthcare resource utilization in clinical practice, and on rescue therapy use. These data further support the therapeutic benefits of eculizumab in patients with MG.
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Affiliation(s)
| | | | | | | | - Anju Parthan
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
- FibroGen Inc., San Francisco, CA, USA
| | | | | | - Ajeet Gajra
- Cardinal Health, Dublin, OH, USA
- Hematology-Oncology Associates of CNY, E. Syracuse, NY, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina, 170 Manning Drive, CB #7025, Chapel Hill, NC, 27599, USA.
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3
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Khadka J, Bhattarai P, Adhikari A, Acharya R, Rayamajhi P. Myasthenic crisis-induced Takotsubo cardiomyopathy: a case report. Ann Med Surg (Lond) 2024; 86:1704-1707. [PMID: 38463080 PMCID: PMC10923365 DOI: 10.1097/ms9.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/05/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction and importance Myasthenic crisis (MC) is characterized by severe weakness in the bulbar and respiratory muscles. Takotsubo cardiomyopathy (TC) is a rare clinical entity mainly associated with postmenopausal women. We report a case of both these conditions in a premenopausal woman. Case presentation A 31-year-old woman with hypothyroidism presented with dyspnea. Bedside echocardiography in the ICU revealed an apical ballooning with an ejection fraction of 25%, and she was treated with losartan, furosemide, and spironolactone. She was intubated after 2 days as she developed respiratory distress and type II respiratory failure. Upon investigation, the patient tested positive for anti-acetylcholine receptor antibody. Treatment with five doses of IVIG (intravenous immunoglobulin) was given, and she made a remarkable recovery. Repeat echocardiography revealed her ejection fraction is normal and cardiac function is resolved. Clinical discussion The association between TC and MC is unusual and not commonly observed. MC can be a natural progression of myasthenia gravis or due to stressors, such as infection, medicine, pregnancy, and surgery. Stressful events can lead to TC. This leads to the possibility of TC, along with other cardiac complications, in patients with MC. Conclusion Patients with MC may be at potential risk of developing TC, thus careful cardiac monitoring is necessary while treating them for a better prognosis.
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Affiliation(s)
| | | | | | - Rajat Acharya
- Department of Internal Medicine, Kathmandu Medical College, Kathmandu, Nepal
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Parthan A, Royston M, Thanataveerat A, East EL, Parzynski CS, Habib AA. Burden of illness and costs in patients with myasthenia gravis currently receiving treatment in the United States. Muscle Nerve 2024; 69:157-165. [PMID: 38018505 DOI: 10.1002/mus.27992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION/AIMS If myasthenia gravis (MG) symptoms are inadequately controlled, patients may experience exacerbations or life-threatening myasthenic crises. Patients with inadequately controlled MG symptoms tend to be treated with chronic intravenous immunoglobulin (IVIg) therapy and/or multiple immunosuppressant therapies (ISTs). This study aimed to examine disease burden, healthcare resource utilization, and associated costs in these patients. METHODS This was a retrospective observational study using a claims database. Patients with MG were classified into three cohorts based on treatment over a 1-y follow-up period: (a) treated with four or more IVIg episodes (chronic IVIg cohort); (b) received two or more non-steroidal ISTs (NSISTs) sequentially (multiple NSIST cohort); (c) received neither chronic IVIg nor multiple NSISTs (reference cohort). Incidences of crises and exacerbations and annual healthcare costs in each cohort were estimated. RESULTS In total, 3516 patients with MG were included in the analysis. Compared with the reference cohort (n = 2992), the MG crisis rate was approximately twice as high in both the chronic IVIg (n = 324) and multiple NSIST (n = 291) cohorts (p < 0.001); and the MG exacerbation rate was approximately four-fold higher in the chronic IVIg cohort (p < 0.001) and three-fold higher in the multiple NSIST cohort (p < 0.001). Median annual MG-related inflation-adjusted total healthcare costs were higher in the chronic IVIg ($81,900) and multiple NSIST ($30,300) cohorts than in the reference cohort ($2540). DISCUSSION The burden of crises/exacerbations was substantially higher and healthcare costs were considerably greater in patients with MG treated with chronic IVIg or multiple NSISTs than in patients not receiving these treatments.
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Affiliation(s)
- A Parthan
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - M Royston
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | - E L East
- Genesis Research Group, Hoboken, New Jersey, USA
| | | | - A A Habib
- University of California, Irvine, California, USA
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5
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Desai R. Response to the Study by Chong et al. on the ChiTTS Registry. Int J Cardiol 2023; 389:131190. [PMID: 37454823 DOI: 10.1016/j.ijcard.2023.131190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Rupak Desai
- Independent Outcomes Researcher, Atlanta, GA, USA.
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6
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Antenucci P, Padroni M, De Gennaro R, Pugliatti M, Sette E. An atypical Takotsubo cardiomyopathy in a typical myasthenic crisis. Neurol Sci 2023; 44:3747-3749. [PMID: 37178213 PMCID: PMC10182345 DOI: 10.1007/s10072-023-06844-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Pietro Antenucci
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, Cona, Ferrara, Italy.
| | - Marina Padroni
- Department of Neurosciences and Rehabilitation, Ferrara University Hospital, Ferrara, Italy
| | - Riccardo De Gennaro
- Department of Neurosciences and Rehabilitation, Ferrara University Hospital, Ferrara, Italy
| | - Maura Pugliatti
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, Cona, Ferrara, Italy
| | - Elisabetta Sette
- Department of Neurosciences and Rehabilitation, Ferrara University Hospital, Ferrara, Italy
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Hughes T, Howard JF, Silvestri NJ, Anderson AEL, Sato M, Suchotliff S, Guptill JT, Phillips G. The economic burden of individuals living with generalized myasthenia gravis and facing social determinants of health challenges. Front Public Health 2023; 11:1247931. [PMID: 37766748 PMCID: PMC10520715 DOI: 10.3389/fpubh.2023.1247931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Objective Better understanding the impact of social determinants of health (SDOH) barriers from the patient perspective is crucial to improve holistic patient support in generalized myasthenia gravis (gMG), a rare autoimmune disorder with high disease and treatment burden. The objective of this study was to identify economic challenges experienced by individuals living with gMG and SDOH barriers to better address current unmet needs. Methods Adults (18-75 years) living with gMG and experiencing SDOH barriers in the United States were recruited to a mixed-methods study including qualitative interviews and a web-based quantitative survey. Quotas were implemented to include a balanced spread of baseline demographic categories including insurance type, living environment, and employment status among the study sample. Direct and indirect economic challenges were identified by degree of concern. Results The survey was completed by 38 individuals living with gMG, the majority of whom were enrolled in public insurance and not employed. The most commonly reported major economic concerns were managing funds for emergency care (66%), loss of income (61%), and non-medical expenses (58%), highlighting the diversity of economic challenges. Individuals who were using public insurance plans, living in non-urban environments, and unemployed experienced pronounced challenges around managing non-medical costs and accessing government assistance. Conclusion Both direct and indirect costs were emphasized as major concerns among individuals living with gMG and SDOH barriers. Increasing access to relevant, personalized, and holistic resources, including care management, should be prioritized to improve disease management and outcomes for individuals living with gMG.
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Affiliation(s)
- Tom Hughes
- Argenx US Inc., Boston, MA, United States
| | - James F. Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | | | | | - Mai Sato
- ZS Associates, New York, NY, United States
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8
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Myocardial Injury in Hospitalized Patients with Myasthenia Gravis. J Clin Med 2022; 11:jcm11237106. [PMID: 36498680 PMCID: PMC9741152 DOI: 10.3390/jcm11237106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: To investigate the clinical characteristics and outcome of myocardial injury in patients with myasthenia gravis (MG). Methods: We retrospectively searched medical records to screen hospitalized patients with MG at our hospital. The troponin T (TnT) levels were deemed necessary to be performed based on the patient’s clinical symptoms and were used as biomarkers of myocardial injury. The patients’ demographic and clinical information were collected. Death was the primary outcome. Results: A total of 336 patients with MG measured TnT levels and were included in the final analysis. The male MG patients with elevated TnT levels had a higher prevalence of infection (56.8% vs. 30.0%, p = 0.001) and myasthenic crisis (37.5% vs. 13.3%, p = 0.001) than those with normal TnT levels. Meanwhile, the female MG patients with elevated TnT levels were older (56.0 (16.6) vs. 49.2 (17.2)) years old, p = 0.007] and had a higher prevalence of infection (65.4% vs. 32.1%, p < 0.001), myasthenic crisis (33.6% vs. 17.9%, p = 0.015), and thymoma (38.5% vs. 16.7%, p = 0.001) than those with normal TnT levels. Older age (coef. = 0.004; p = 0.034), infection (coef. = 0.240; p = 0.001), myasthenic crisis (coef. = 0.312; p < 0.001), thymoma (coef. = 0.228; p = 0.001), and ICI therapy (coef. = 1.220; p < 0.001) were independent risk predictors for increasing log TnT levels. Thirty-seven patients died during hospitalization. High log TnT levels (OR = 8.818; p < 0.001), female sex (OR = 0.346; p = 0.023), thymoma (OR = 5.092; p = 0.002), and infection (OR = 14.597; p < 0.001) were independent risk predictors of death. Conclusions: Our study revealed that the surveillance of myocardial injury biomarkers in MG patients might be beneficial.
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9
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Cho JH, Kim H, Yum J. Takotsubo syndrome and myasthenic crisis after radiocontrast media-induced anaphylaxis. JOURNAL OF NEUROCRITICAL CARE 2022. [DOI: 10.18700/jnc.210032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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10
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Phillips G, Abreu C, Goyal A, Li Y, Whangbo A, Gelinas D, Brauer E, Bhattacharya S. Real-World Healthcare Resource Utilization and Cost Burden Assessment for Adults With Generalized Myasthenia Gravis in the United States. Front Neurol 2022; 12:809999. [PMID: 35115997 PMCID: PMC8805609 DOI: 10.3389/fneur.2021.809999] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Limited evidence exists for healthcare resource utilization (HCRU) and costs associated with generalized myasthenia gravis (gMG), a rare autoimmune disorder, for adults in the United States. Methods Adults with ≥1 diagnostic claim for MG between 2014 and 2019 were identified using Symphony Health's Integrated Dataverse®. Using a novel algorithm, HCRU and costs over 12 months following index dates were evaluated for patients with gMG including those with exacerbation events. For patients who experienced crisis events, HCRU and costs were analyzed during the 36 months preceding, during, and 12 months following the events. Results Mean HCRU and costs were higher for newly diagnosed patients compared with previously diagnosed patients (hospitalizations: 0.46 vs. 0.34; all-cause costs: $26,419.20 vs. $24,941.47; direct costs for gMG treatments: $9,890.37 vs. $9,186.47) and further increased for patients with exacerbation events (hospitalizations: 0.72; all-cause costs: $43,734.15; direct costs for gMG treatments: $21,550.02). For patients who experienced crisis events, HCRU and costs markedly increased during the 12 months immediately before the crisis event (hospitalizations: 1.35; all-cause costs: $49,236.68) compared with the 2 preceding years and increased further during the 12 months following the crisis index date (hospitalizations: 2.78; all-cause costs: $173,956.99). Cost increases were, in large part, attributed to treatments received. Discussion New diagnosis, exacerbation, and crisis events were drivers of HCRU and cost for patients with gMG. Particularly, high costs of gMG-specific medications associated with intervention for exacerbation and crisis events contributed to increased all-cause costs.
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Affiliation(s)
- Glenn Phillips
- argenx US Inc., Boston, MA, United States
- *Correspondence: Glenn Phillips
| | | | - Amit Goyal
- ZS Associates, Princeton, NJ, United States
| | - Yuebing Li
- Neuromuscular Center, Cleveland Clinic, Cleveland, OH, United States
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Jahangir A, Rafay Khan Niazi M, Sahra S, Javed A, Krzyzak M. An Unfortunate Case of Takotsubo Cardiomyopathy During Plasmapheresis for Myasthenia Crisis. Cureus 2022; 14:e20865. [PMID: 35145772 PMCID: PMC8803300 DOI: 10.7759/cureus.20865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2022] [Indexed: 11/05/2022] Open
Abstract
A literature review shows scarce reports of myasthenic crises (MC) complicated by Takotsubo cardiomyopathy (TC). This patient cohort (0.11%) has higher all-cause mortality and prolonged in-hospital course. We present a rare case of a 72-year-old man who developed cardiogenic shock post-plasmapheresis for myasthenia crisis. He became hemodynamically unstable and developed acute respiratory failure requiring intubation 30 minutes after completion of plasma exchange. Serum troponin peaked at 3.19 ng/mL while an emergent 12-lead electrocardiogram (EKG) showed new-onset diffuse ST-segment elevation. Hypokinesis of the entire apex, anterior septum, mid-and apical inferior septum, and mid-and apical inferior wall consistent with Takotsubo cardiomyopathy was seen on bedside echocardiogram. The patient received a continuous infusion of norepinephrine and vasopressin. The hospital course was complicated by multiorgan failure and eventual demise. This case highlights MC and the potential of plasma exchange therapy to induce TC.
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Patel U, Desai R, Faisaluddin M, Fong HK, Singh S, Patel S, Kumar G, Sachdeva R. Prevalence and impact of takotsubo syndrome in hospitalizations for acute ischemic stroke. Proc AMIA Symp 2021; 35:156-161. [DOI: 10.1080/08998280.2021.1995932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Upenkumar Patel
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York
| | - Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
| | - Mohammed Faisaluddin
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Hee Kong Fong
- Division of Cardiology, UC Davis Medical Center, Sacramento, California
| | - Sandeep Singh
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Smit Patel
- Department of Neurology, David Geffen School of Medicine, UCLA Health, Los Angeles, California
| | - Gautam Kumar
- Division of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Rajesh Sachdeva
- Division of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
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Tin S, Lim W, Humayun A, Galligan S. A Rare Case of Takotsubo Cardiomyopathy in a Patient With No Identifiable Emotional or Physical Stressors. Cureus 2021; 13:e17281. [PMID: 34540501 PMCID: PMC8448168 DOI: 10.7759/cureus.17281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/04/2022] Open
Abstract
Takotsubo cardiomyopathy (TCM) is a cardiac condition that presents with features of acute myocardial infarction and transient systolic dysfunction without angiographic findings of obstructive coronary heart disease. Common presenting symptoms include acute substernal chest pain, dyspnea and syncope. It is usually triggered by recent emotional or physical stress such as head trauma, stroke, sepsis, overproduction of catecholamines such as pheochromocytoma or following Myasthenia crisis. We are here to report a case of TCM who does not have any identifiable emotional or physical stress prior to the event. The patient was a 76-year-old Caucasian female with a past medical history of hypertension who presented to the hospital with chest pain which initially was treated as non-ST elevation myocardial infarction (NSTEMI) with aspirin, ticagrelor and heparin infusion. Cardiac catheterization later revealed non-obstructive coronary artery disease but showed akinesis of inferior, apical and anterior walls with hyperdynamic basal segments indicating TCM.
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Affiliation(s)
- Swann Tin
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - William Lim
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Anum Humayun
- Internal Medicine, Richmond University Medical Center, new york, USA
| | - Sean Galligan
- Internal Medicine/Cardiology, Richmond University Medical Center, Staten Island, USA
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Kuo Y, Ottens TH, van der Bilt I, Keunen RWM, Akin S. Myasthenic crisis-induced Takotsubo cardiomyopathy in an elderly man: A case report of an underestimated but deadly combination. World J Cardiol 2021; 13:21-27. [PMID: 33552400 PMCID: PMC7821008 DOI: 10.4330/wjc.v13.i1.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with myasthenia gravis (MG) are at a higher risk of developing Takotsubo cardiomyopathy (TTC), particularly during a myasthenic crisis. Myasthenic crisis-associated TTC occurs predominantly in women. In this case report, we present a man with metastasized prostate carcinoma who developed TTC after new-onset MG.
CASE SUMMARY An 81-year-old man with non-insulin dependent diabetes mellitus and metastasized prostate carcinoma presented with dyspnea. During primary assessment examination at the emergency department, there was evident blepharoptosis of his right eye. His electrocardiograms were suggestive of an acute anterior wall myocardial infarction, for which he underwent emergency coronary angiography. No obstructive coronary artery disease was found. During the coronary angiography, the patient developed respiratory failure and was admitted to the Intensive Care Unit for non-invasive respiratory support. The following day, diagnostic neostigmine test revealed a myasthenic crisis. Bedside echocardiography revealed left ventricular apical ballooning with a typical appearance of TTC. Despite the potentially reversible character of both MG and TTC, the patient and family requested an end of support in the Intensive Care Unit due to age and chronic malignancy with reduced quality of life in recent months after non-chemo-responding prostate carcinoma. The patient died soon after treatment withdrawal.
CONCLUSION Elderly men should be carefully evaluated for TTC when new-onset MG is diagnosed.
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Affiliation(s)
- Yvonne Kuo
- Intensive Care Unit, Hagaziekenhuis, The Hague 2545, Netherlands
| | - Thomas H Ottens
- Intensive Care Unit, Hagaziekenhuis, The Hague 2545, Netherlands
| | - Ivo van der Bilt
- Department of Cardiology, Hagaziekenhuis, The Hague 2545, Netherlands
| | - Ruud WM Keunen
- Department of Neurology, Haga Teaching Hospital, The Hague 2545, Netherlands
| | - Sakir Akin
- Intensive Care Unit, Hagaziekenhuis, The Hague 2545, Netherlands
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15
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Desai R, Desai A, Fong HK, Mahmood A, Shah K, Varakantam VR, Haque FA, Savani S, Gangani K, Kumar G, Sachdeva R. Prevalence, trends and in-hospital outcomes of takotsubo syndrome among United States cannabis users. Int J Cardiol 2020; 316:43-46. [DOI: 10.1016/j.ijcard.2020.05.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/08/2020] [Accepted: 05/27/2020] [Indexed: 11/26/2022]
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Desai R, Parekh T, Kumar G, Sachdeva R. First episodes versus first recurrent episodes of Takotsubo syndrome: Pathophysiologic findings remain significantly different with comparable clinical outcomes. Int J Cardiol 2020; 310:23-24. [DOI: 10.1016/j.ijcard.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 11/26/2022]
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Landfeldt E, Pogoryelova O, Sejersen T, Zethraeus N, Breiner A, Lochmüller H. Economic Costs of Myasthenia Gravis: A Systematic Review. PHARMACOECONOMICS 2020; 38:715-728. [PMID: 32363541 DOI: 10.1007/s40273-020-00912-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The objective of our study was to conduct a systematic literature review of economic costs (henceforth costs) associated with myasthenia gravis (MG). METHODS We searched MEDLINE (through PubMed), CINAHL, Embase, PsycINFO, and Web of Science for studies reporting costs of MG published from inception up until March 18, 2020, without language restrictions. Two reviewers independently screened records for eligibility, extracted the data, and assessed included studies for risk of bias using the Newcastle-Ottawa Scale. Costs were inflated and converted to 2018 United States dollars ($). RESULTS The search identified 16 articles for data extraction and synthesis. Estimates of costs of MG were found for samples from eight countries spanning four continents (Europe, North America, South America, and Asia). Across studies, the mean per-patient annual direct medical cost of illness was estimated at between $760 and $28,780, and cost per hospitalization between $2550 and $164,730. The indirect cost of illness was estimated at $80 and $3550. Costs varied considerably by patient characteristics, and drivers of the direct medical cost of illness included intravenous immunoglobulin and plasma exchange, myasthenic crisis, mechanical ventilatory support, and hospitalizations. CONCLUSIONS We show that the current body of literature of costs of MG is sparse, limited to a few geographical settings and resource categories, mostly dated, and subject to non-trivial variability, both within and between countries. Our synthesis will help researchers and decision-makers identify gaps in the local health economic context of MG and inform future cost studies and economic evaluations in this patient population.
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Affiliation(s)
- Erik Landfeldt
- Department of Women's and Children's Health, Karolinska Vägen 37A, 171 76, Stockholm, Sweden.
| | | | - Thomas Sejersen
- Department of Women's and Children's Health, Karolinska Vägen 37A, 171 76, Stockholm, Sweden
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ari Breiner
- Division of Neurology, Department of Medicine, The Ottawa Hospital, and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Hanns Lochmüller
- Division of Neurology, Department of Medicine, The Ottawa Hospital, and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
- Department of Neuropediatrics and Muscle Disorders, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada
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Unrevealing Takotsubo Syndrome: Appraising what has emerged from the International Journal of Cardiology contributions in 2019. Int J Cardiol 2020; 302:131-133. [DOI: 10.1016/j.ijcard.2019.11.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
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Desai R, Desai A, Abbas SA, Patel U, Bansod S, Damarlapally N, Doshi R, Savani S, Gangani K, Sachdeva R, Kumar G. National prevalence, trends and outcomes of takotsubo syndrome in hospitalizations with prior history of mediastinal/intrathoracic cancer and radiation therapy. Int J Cardiol 2020; 309:14-18. [PMID: 32087939 DOI: 10.1016/j.ijcard.2020.02.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radiation therapy (RT) for cancers in thoracic/mediastinal region has been linked with heart damage following years of radiation exposure. However, prevalence of takotsubo syndrome (TTS) in patients with prior intrathoracic/mediastinal malignancies treated with RT has never been analyzed on a large scale. METHODS We identified adult hospitalizations with prior mediastinal/intrathoracic cancer and RT and TTS using ICD-9 CM codes and the National Inpatient Sample (2007-2014) after excluding current admissions for chemotherapy. We then assessed the prevalence, odds, trends and in-hospital outcomes of TTS-related admissions in patients with vs. without prior intrathoracic cancer and RT. RESULTS We identified a total of 5,991,314 hospitalizations with prior intrathoracic/mediastinal malignancies and RT (~73 yrs., 85.2% female), of which 7663 (0.13%, 128 per 100,000) were diagnosed with TTS (~74 yrs., 95.8% females, 88.1% white). Higher odds and rising trends in TTS per 100,000 hospitalizations (from 31 to 241) were seen among patients with prior intrathoracic malignancies and RT as compared to those without (from 19 to 104) (ptrend < 0.001). All-cause in-hospital mortality (4.6% vs 2.8%; OR 1.45; 95%CI 1.29-1.63, p < 0.001), cardiogenic shock (4.3% vs 0.2%), cardiac arrest (3.1% vs 0.9%), arrhythmia (34.3% vs 24.6%), stroke (3.6% vs 2.8%), respiratory failure (14.5% vs 4.6%), and median length of stay and hospital charges were significantly higher in the TTS cohort. CONCLUSIONS This study showed higher odds and increasing trends in TTS-related admissions with worse in-hospital outcomes among patients with prior intrathoracic/mediastinal cancer and RT, irrespective of the time interval from cancer diagnosis or RT to TTS occurrence.
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Affiliation(s)
- Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, USA.
| | - Aakash Desai
- Department of Internal Medicine, University of Connecticut School of Medicine, UCONN Health, Farmington, CT, USA
| | | | - Upenkumar Patel
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Snehal Bansod
- Department of Internal Medicine, St John Episcopal Hospital, Far Rockaway, NY, USA
| | - Nanush Damarlapally
- Department of Health Sciences, Coleman College of Health Sciences, Houston, TX, USA
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada School of Medicine, Reno, NV, USA
| | - Sejal Savani
- Public Health, New York University, New York, NY, USA
| | - Kishorbhai Gangani
- Department of Internal Medicine, Texas Health Arlington Memorial Hospital, Arlington, TX, USA
| | - Rajesh Sachdeva
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, USA; Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, USA; Division of Cardiology, Medical College of Georgia, Augusta, GA, USA
| | - Gautam Kumar
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, USA; Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
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Desai R, Sachdeva R, Kumar G. Reply to: Myasthenic crises triggering Takotsubo cardiomyopathy. Int J Cardiol 2020; 300:47. [DOI: 10.1016/j.ijcard.2019.11.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022]
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Pelliccia F, Gaudio C. Takotsubo Syndrome and myasthenia gravis: When neuromuscolar disease meets cardiac dysfunction. Int J Cardiol 2020; 299:73-74. [DOI: 10.1016/j.ijcard.2019.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
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