Letter to the Editor
The assessment of coronary microvascular dysfunction: An integral part of risk-stratification in Takotsubo cardiomyopathy
Avaliação da disfunção coronária microvascular: uma parte integrante da estratificação de risco na miocardiopatia de Takotsubo
Kenan Yalta
, Muhammet Gurdogan, Gokay Taylan
Corresponding author
Trakya University, Cardiology Department, Edirne, Turkey
Read
2917
Timeswas read the article
1503
Total PDF
1414
Total HTML
Share statistics
array:25 [ "pii" => "S2174204920302592" "issn" => "21742049" "doi" => "10.1016/j.repce.2020.02.011" "estado" => "S300" "fechaPublicacion" => "2020-06-01" "aid" => "1546" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2020;39:357-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S0870255120302080" "issn" => "08702551" "doi" => "10.1016/j.repc.2020.02.008" "estado" => "S300" "fechaPublicacion" => "2020-06-01" "aid" => "1546" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2020;39:357-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "The assessment of coronary microvascular dysfunction: An integral part of risk-stratification in Takotsubo cardiomyopathy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "357" "paginaFinal" => "358" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação da disfunção coronária microvascular: uma parte integrante da estratificação de risco na miocardiopatia de Takotsubo" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Kenan Yalta, Muhammet Gurdogan, Gokay Taylan" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Kenan" "apellidos" => "Yalta" ] 1 => array:2 [ "nombre" => "Muhammet" "apellidos" => "Gurdogan" ] 2 => array:2 [ "nombre" => "Gokay" "apellidos" => "Taylan" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204920302798" "doi" => "10.1016/j.repce.2020.11.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920302798?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255120302080?idApp=UINPBA00004E" "url" => "/08702551/0000003900000006/v2_202007190644/S0870255120302080/v2_202007190644/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204920302798" "issn" => "21742049" "doi" => "10.1016/j.repce.2020.11.004" "estado" => "S300" "fechaPublicacion" => "2020-06-01" "aid" => "1557" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2020;39:359-60" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Assessment of coronary microvascular dysfunction: An integral part of risk-stratification in Takotsubo cardiomyopathy - A response" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "359" "paginaFinal" => "360" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação da disfunção coronária microvascular: uma parte integrante da estratificação de risco na miocardiopatia de Takotsubo. Resposta" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jeremias Bayón, Alejandro Gutierrez-Barrios, Carlos Gonzalez-Juanatey" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jeremias" "apellidos" => "Bayón" ] 1 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Gutierrez-Barrios" ] 2 => array:2 [ "nombre" => "Carlos" "apellidos" => "Gonzalez-Juanatey" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255120302407" "doi" => "10.1016/j.repc.2020.06.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255120302407?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920302798?idApp=UINPBA00004E" "url" => "/21742049/0000003900000006/v1_202012131841/S2174204920302798/v1_202012131841/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204920302580" "issn" => "21742049" "doi" => "10.1016/j.repce.2020.02.010" "estado" => "S300" "fechaPublicacion" => "2020-06-01" "aid" => "1549" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2020;39:353-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "A rare case of isolated anomalous origin of the left pulmonar artery" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "353" "paginaFinal" => "355" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Um caso raro e isolado de origem anómala do ramo esquerdo da artéria pulmonar" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1059 "Ancho" => 1667 "Tamanyo" => 117325 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Aortic angiography demonstrating anomalous origin of the left pulmonary artery from the descending thoracic aorta.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">LPA: left pulmonary artery; DAo: descending Aorta.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Lisete Lopes, Helena Andrade, António Pires" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Lisete" "apellidos" => "Lopes" ] 1 => array:2 [ "nombre" => "Helena" "apellidos" => "Andrade" ] 2 => array:2 [ "nombre" => "António" "apellidos" => "Pires" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255120302110" "doi" => "10.1016/j.repc.2020.02.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255120302110?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920302580?idApp=UINPBA00004E" "url" => "/21742049/0000003900000006/v1_202012131841/S2174204920302580/v1_202012131841/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "The assessment of coronary microvascular dysfunction: An integral part of risk-stratification in Takotsubo cardiomyopathy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "357" "paginaFinal" => "358" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Kenan Yalta, Muhammet Gurdogan, Gokay Taylan" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Kenan" "apellidos" => "Yalta" "email" => array:1 [ 0 => "kyalta@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Muhammet" "apellidos" => "Gurdogan" ] 2 => array:2 [ "nombre" => "Gokay" "apellidos" => "Taylan" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Trakya University, Cardiology Department, Edirne, Turkey" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação da disfunção coronária microvascular: uma parte integrante da estratificação de risco na miocardiopatia de Takotsubo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo cardiomyopathy (TC) is widely regarded as a reversible form of stress-induced cardiomyopathy and has a variety of suggested underlying mechanisms and prognostic factors in a clinical setting.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–3</span></a> Studies to date have yielded conflicting results on the pathogenetic implications of microvascular dysfunction in TC.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> In their recently published case report,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Bayon et al. documented coronary microvascular dysfunction, assessed using parameters such as hyperemic microvascular resistance (HMR) and coronary flow reserve (CFR), in a characteristic case of TC with apical ballooning. We would like to comment on this case and obtain further information from the authors.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Firstly, coronary slow flow (CSF) pattern, assessed using the TIMI frame count (TFC) method, have been viewed as a sign of increased coronary microvascular resistance, and are generally indicative of a severe adrenergic storm and the presence of substantial levels of associated vasoconstrictor mediators, such as neuropeptide-Y (co-released with noradrenaline) in the setting of TC.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,4-10</span></a> As expected, an existing CSF in this setting might also suggest high HMR values, and vice versa. What, therefore, were the baseline TFC values in the patient's major epicardial coronary arteries? Did these values also change significantly after adenosine infusion in correlation with the HMR values? This information might shed light on whether CSF patterns and increased HMR could be used interchangeably or in a complementary fashion to determine enhanced microvascular resistance in patients with TC.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Secondly, CSF pattern in TC may not be a uniform finding, yet; a prognostic sign that might only emerge in a portion of TC cases, and might predict adverse events, including arrhythmogenesis, heart failure, etc., and in these cases,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,8-10</span></a> possibly in correlation with its extent and severity. This may also hold true for increased HMR values in this setting. Did the patient with apparently very high HMR values in two of her major coronary arteries present with an arrhythmic event or decompensated heart failure in a hospital setting? Additionally, an extreme adrenergic storm during an index TC might be a predictor of recurrent episodes<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,9,10</span></a> and might be evidenced by very high TFC<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">9</span></a> and/or HMR values in this setting. This would require close supervision of the patient<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> combined with potential preventive strategies against TC recurrence in the long-term.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,9,10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Thirdly, a significant drop in baseline HMR values in response to adenosine infusion (observed in the patient's left anterior descending artery)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> might help to identify TC cases that are most likely to benefit from coronary vasodilator strategies, thus improving overall prognosis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,9</span></a> This leads us to question whether the patient received any vasodilator therapy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">And lastly, the patient<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> was also reported to have low CFR, which has been an underrated vascular index in patients with TC. It is Important to note that acutely impaired CFR might also have adjunctive prognostic value in these patients. However, given the high predilection of syndrome-X, characterized by blunted coronary vasodilation during exercise as part of generalized endothelial dysfunction in postmenopausal women,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> impaired CFR might be present as a coincidental finding in certain TC cases (which might have occurred in the present case) long before index TC progression, potentially diminishing its value as an acute prognostic marker in this setting.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary, the authors<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> should be congratulated for their enlightening case report that documents coronary function as assessed by vascular indices in a patient with classical TC. Routine assessment of these parameters during coronary angiogram might enable initial risk-stratification of TC cases at disease onset, and help tailor patient-specific management strategies (vasodilators, antiarrhythmics, etc.) to improve overall prognosis in these patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "<span class="elsevierStyleBold">References</span>" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "<span class="elsevierStyleBold">References</span>" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment with intracoronary pressure and flow guidewire, at baseline and after intracoronary adenosine infusion, in a patient with Takotsubo syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Bayon" 1 => "M. Santás-Älvarez" 2 => "R. Ocaranza-Sánchez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2017.08.014" "Revista" => array:3 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2020" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2631811" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary slow flow in the setting of Tako-tsubo cardiomyopathy: a causative factor? An innocent bystander? Or a prognostic sign?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Yalta" 1 => "M. Yilmaztepe" 2 => "F. Ucar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2015.06.146" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2015" "volumen" => "198" "paginaInicial" => "229" "paginaFinal" => "231" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26201689" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular dysfunction in the setting of takotsubo cardiomyopathy: a review of clinical patterns and practical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Yalta" 1 => "M. Yilmaztepe" 2 => "C. Zorkun" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.15420/cfr.2018:24:2" "Revista" => array:6 [ "tituloSerie" => "Card Fail Rev" "fecha" => "2018" "volumen" => "4" "paginaInicial" => "14" "paginaFinal" => "20" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29892470" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Elevated serum levels of neuropeptide Y in stress cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Szardien" 1 => "H. Möllmann" 2 => "S. Voss" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2010.05.010" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2011" "volumen" => "147" "paginaInicial" => "155" "paginaFinal" => "157" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20557961" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuropeptide Y-induced coronary microvascular dysfunction: a significant contributor to the adverse outcomes in stress cardiomyopathy?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Yalta" 1 => "N. Sivri" 2 => "T. Yalta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2010.09.095" "Revista" => array:5 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2011" "volumen" => "147" "paginaInicial" => "284" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21145602" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical impact of left ventricular outflow tract obstruction in takotsubo cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Kawaji" 1 => "H. Shiomi" 2 => "T. Morimoto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1253/circj.CJ-14-1148" "Revista" => array:6 [ "tituloSerie" => "Circ J" "fecha" => "2015" "volumen" => "79" "paginaInicial" => "839" "paginaFinal" => "846" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25739572" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary slow flow or syndrome Y: dysfunction at rest, preserved reactivity ofthe peripheral endothelium" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Muxel" 1 => "M. Fineschi" 2 => "E.R. Hauser" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2010.04.043" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2011" "volumen" => "147" "paginaInicial" => "151" "paginaFinal" => "153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20488564" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0075" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Montone RA, Galiuto L, Meucci MC, et al. Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome. Heart. 2020 Jan 10. pii: heartjnl-2019-315909, https://doi.org/10.1136/heartjnl-2019-315909.[Epub ahead of print]." ] ] ] 8 => array:3 [ "identificador" => "bib0080" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Yalta K, Yalta T. Takotsubo cardiomyopathy and its implications in the setting of acute manic attack. Proc (Bayl Univ Med Cent), ht*tp://dx.doi.org/10.1080/08998280.2020.1765664 (article in press)." ] ] ] 9 => array:3 [ "identificador" => "bib0085" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Yalta K, Yetkin E, Yalta T. Recurrent takotsubo cardiomyopathy: Further insights into morphological patterns. Cardiovasc Pathol, https://doi.org/10.1016/j.carpath.2020.107225.(article in press)." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003900000006/v1_202012131841/S2174204920302592/v1_202012131841/en/main.assets" "Apartado" => array:4 [ "identificador" => "29282" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003900000006/v1_202012131841/S2174204920302592/v1_202012131841/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920302592?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 4 | 11 |
| 2024 October | 85 | 47 | 132 |
| 2024 September | 49 | 28 | 77 |
| 2024 August | 69 | 45 | 114 |
| 2024 July | 41 | 41 | 82 |
| 2024 June | 28 | 23 | 51 |
| 2024 May | 34 | 33 | 67 |
| 2024 April | 41 | 47 | 88 |
| 2024 March | 33 | 30 | 63 |
| 2024 February | 26 | 34 | 60 |
| 2024 January | 38 | 28 | 66 |
| 2023 December | 22 | 25 | 47 |
| 2023 November | 40 | 62 | 102 |
| 2023 October | 35 | 40 | 75 |
| 2023 September | 23 | 34 | 57 |
| 2023 August | 27 | 22 | 49 |
| 2023 July | 17 | 19 | 36 |
| 2023 June | 21 | 18 | 39 |
| 2023 May | 39 | 35 | 74 |
| 2023 April | 26 | 13 | 39 |
| 2023 March | 36 | 24 | 60 |
| 2023 February | 24 | 20 | 44 |
| 2023 January | 17 | 32 | 49 |
| 2022 December | 24 | 21 | 45 |
| 2022 November | 22 | 29 | 51 |
| 2022 October | 21 | 31 | 52 |
| 2022 September | 18 | 33 | 51 |
| 2022 August | 28 | 44 | 72 |
| 2022 July | 34 | 39 | 73 |
| 2022 June | 37 | 36 | 73 |
| 2022 May | 28 | 27 | 55 |
| 2022 April | 39 | 37 | 76 |
| 2022 March | 24 | 46 | 70 |
| 2022 February | 18 | 50 | 68 |
| 2022 January | 30 | 40 | 70 |
| 2021 December | 25 | 36 | 61 |
| 2021 November | 22 | 33 | 55 |
| 2021 October | 30 | 45 | 75 |
| 2021 September | 22 | 29 | 51 |
| 2021 August | 27 | 35 | 62 |
| 2021 July | 15 | 22 | 37 |
| 2021 June | 22 | 34 | 56 |
| 2021 May | 20 | 34 | 54 |
| 2021 April | 35 | 38 | 73 |
| 2021 March | 20 | 16 | 36 |
| 2021 February | 18 | 13 | 31 |
| 2021 January | 28 | 20 | 48 |
| 2020 December | 29 | 11 | 40 |
Show all
