CCU October 2014: Takotsubo’s Cardiomyopathy

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CCU Presentation

Steve Mcguire, MD

 

Takotsubo’s Cardiomyopathy 

takotsubo

Case

 

HPI:

 

82 y/o female arrives via EMS with husband after she lost control of the car, accidentally running him over in the driveway. Her husband was a trauma note and severely injured, including pelvic fractures with bladder rupture. While in the ED observing the resuscitation she complained of  mid-sternal chest pain. The nurses quickly placed her in Room 11 (near the trauma bay at her request) so she can be near her ‘husband of 60years’.

 

PMH – HTN, HLD, remote history of Breast CA, clean cath in 2008 (episode of cp/SOB).

FMH/SocHx – non contributory

Meds – metoprolol, simvastatin, aspirin 81 mg

 

PE:

 

Vitals: HR 80 BP 140/90 RR 18 O2 99% 2L

 

Gen app:Mild distress, clearly agitated/concerned and weeping.

Resp: clear lungs

CV: RRR, no MRG

 

 

Work up:

takotsubo ekg

 

Labs:

Troponin – 0.73 NG/mL

 

Hospital Course:

She was started on nitroglycerin, beta-blocker, heparin and admitted to the CCU. Her echocardiography showed an EF 30-40% with multiple wall motion abnormalities and apical akinesis. She underwent a cardiac catherization the following morning. Her catherization showed no significant coronary artery disease.

 

 

takotsubo echo

Example echo: image courtesy of google images bjcardio.co.uk

 

 

Discussion:

Stress (Takotsubo) cardiomyopathy, also known as “broken heart syndrome,” was described in the 1990s and often mimics an acute coronary syndrome. It is frequently found in the context of emotional, physical, or medical stress (~70%) without significant coronary atherosclerotic disease. It typically affects 80-90% women with  >80% being post-menopausal. In the ED it tends to present in about 2% of suspected ACS cases.

The most common ECG changes are:

STE(42%)/STD(2%) often in precordial leads

T wave abnormalities( 38%) including deep TWI in Takotsubos

Broad upright T waves in reverse Takotsubo

QTc prolongation

 

In general cardiac enzymes are elevated, but tend to be lower than true ACS equivalents, and usually peak at or near ED presentation. On echocardiography LVEF is reduced <50%, especially with preservation of the base (Takotsubo or apical ballooning) but can also spare the apex and affect the base (reverse Takotsubo). In about 25 % of cases the right ventricle is affected. Typically angiography shows essentially normal coronaries (>80%) or non-critical lesions <50% occlusion.

 

Currently the mechanism of the pathophysiology is not entirely clear. As of now, the stress response leading to diffuse catecholamine mediated microvascular changes in perfusion, seems to best explain the constellation of findings, including the lack of correlation to coronary artery distribution for myocardial dysfunction. The resulting ischemia can also explain the ACS mimicry of the syndrome.

 

This mimicry also makes ED management relatively straightforward. Treat as you would for the equivalent ACS with anti-platelet therapy, anticoagulation, beta blockade, activation of the cath lab and avoid sympathomimetics. Acute congestive heart failure exacerbation can be a complication (especially RV variants) and can be treated with diuretics (on the floor).

Generally, the patients do well with supportive care, with nearly complete resolution of symptoms and signs. In the above case, follow-up ECHO was performed at 3 months, which showed LVEF of 59%.

 

References:

 

Abraham J, Mudd JO, Kapur N, Klein K, Champion HC, Wittstein IS. Stress Cardiomyopathy After Intravenous Administration of Catecholamines and Beta-Receptor Agonists. J Am Coll Cardiol.2009;53(15):1320-1325. doi:10.1016/j.jacc.2009.02.020.  PMID: 19358948

Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, Francone M, Desch S, Gutberlet M, Strohm O, Schuler G, Schulz-Menger J, Thiele H, Friedrich MG. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA. 2011 Jul 20;306(3):277-86. doi: 10.1001/jama.2011.992. PMID: 21771988

Abhiram Prasad, Amir Lerman, Charanjit S. Rihal, Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction, American Heart Journal, Volume 155, Issue 3, March 2008, Pages 408-417, http://dx.doi.org/10.1016/j.ahj.2007.11.008. PMID: 18294473

 

Smith, Stephen W. “COPD exacerbation, what do the ECG and bedside echo show?Dr. Smith’s ECG Blog. HQMedEd, March 27, 2014. Web. September 28 2014. URL

Smith, Stephen W. “Diffuse ST Elevation. What do you think?” Dr. Smith’s ECG Blog. HQMedEd, September 23, 2014. Web. September 28 2014. URL

Bybee KA, Prasad A, Stress-related cardiomyopathy syndromes. Circulation. 2008 Jul 22;118(4):397-409. PMID: 18645066

2 Comments

  • Nice presentation! I’ll just add a comment re ECG changes with Takotsubo (Stress) Cardiomyopathy – namely, that a fairly large variety of ECG changes may be seen – including marked and diffuse abnormalities with new Q waves and ST elevation and/or depression or T wave inversion that often seem out out of proportion to clinical findings – and which “don’t quite fit” the perceived clinical picture. While Takotsubo most commonly involves apical ballooning – there may be “reverse” distribution and other variants – which may be part of the reason for the diverse ECG picture. I therefore try to include Stress Cardiomyopathy in the differential of patients presenting with chest pain and/or new heart failure when ECG findings “don’t quite fit” with the clinical picture. Again – NICE presentation!

    • SteveMcG

      EKGpress (Dr. Grauer?)

      thanks for your kind words. I agree the variety of ekg findings in nearly endless. At least at this point, the good news for us in the ED is that we can include Stress cardiomyopathy in the Ddx but, as a practical matter (again as of now) the treatment pathway is straightforward– treat as ACS ekg equivalent, eg. STEMI, NSTEMI, ACS.

      In the future, as we understand the entity better, we may find subsets that we can treat differently. Do you agree?

      Thanks again.

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