Tako-tsubo cardiomyopathy

Transcription

1 Tako-tsubo cardiomyopathy Δημήτριος Καρατζάς Καρδιολόγος Αν. Διευθυντής ΕΡΡΙΚΟΣ ΝΤΥΝΑΝ H.C Αντιπρόεδρος Ομάδας Εργασίας Καρδιακής Ανεπάρκειας Ελληνικής Καρδιολογικής Εταιρείας

2 Tako-tsubo cardiomyopathy Αύξηση της αναγνώρισης της (πρόκληση η ΔΔ με ΟΕΜ/ μυοκαρδίτιδα) Επιδημιολογικές μελέτες και καταγραφές (registries) ΔΕΝ επιβεβαιώνουν την αρχική άποψη περί μιας απολύτως καλοήθους πάθησης

3

4 Tako-tsubo syndrome not a cardiomyopathy Not Primary muscle disorder, no common genetic basis Full recovery and low rate of major adverse cardiac events

5 Tako-tsubo syndrome Takotsubo has been generally regarded as a relatively benign disease More than half of pts had an acute, former, or chronic neurologic or psychiatric disorder!! Complications occur 52% 24h CCU (risk assess) Therapy? Tako: octopus tsubo: pot

6 Tako-tsubo syndrome Primary and secondary Takotsubo 1% to 2% of pts who present with an ACS Occur MAINLY in postmenopausal women

7 Tako-tsubo syndrome - Diagnosis 1. Transient RWMA of LV or RV frequently, not always, preceded by a stressful trigger (emotional/physical). 2. RWMA usually extend beyond a single epicardial vascular distribution 3. Absence of culprit atherosclerotic CAD or other conditions (HCM, myocarditis). 4. New and reversible ECG abnormal (ST-elevation-50%, ST, T-wave, LBBB) 5. Significantly elevated natriuretic peptide (BNP/NT-proBNP) 6. Relatively small elevation in troponin (disparity to dysfunction) 7. Recovery of ventricular systolic function at follow-up (3 6m)

8 Differences between Takotsubo syndrome and acute myocarditis

9 Electrocardiography The combination of the presence of ST-segment depression in lead avr and the absence of ST-segment elevation in lead V 1 identified TC (91% sens, 96% specif -95% pred accuracy) ST elevation 75-80% (V2-V3)

10 Electrocardiography New pathological (transient?) Q waves may be seen (6-30%) Frequent prolongation of the QTc interval (500ms TdP 4-6%)

11 Risk stratification in Takotsubo HIGH RISK pt : ONE MAJOR or two minors

12 Cardiac catheterization

13 Echocardiography Improvement during the first 7 days

14 Serial late gadolinium enhancement-cmr (A C)baseline vigorous basal systolic function with apical hypokinesia (A and B) in the absence of late gd+ (C).A repeat scan 3 months later shows complete normalization of ventricular function(d and E),with no late enhac (F).

15 Acute catecholaminergic myocardial stunning Stress/ Sympathetic activation Norepinephrine release (2-3xAMI) Microvasculature ENDOTHELIUM (Apoptosis/contrast) Transient myocardial ischemia Myocardium/ induce β2- coupling from Gs to Gi. Inflammation Ca overload/free radicals LV dysfunction Exogenously administered Myocardial injury Contraction band necrosis (sd)

16 Complications and prognosis

17 RV involvement

18 CMR (RV involvement, 33%) Older age, lower LVEF, a higher frequency of hf, pleural effusion and a longer hospital stay

19 Complications and prognosis

20 TCS LVOTO BP, MR, shock NO NTG/inotropes

21 Complications and prognosis

22 Apical thrombus in TCs 2 5 days after onset, when LV function is still depressed (14 days after) LV thrombi may resolve with 2 weeks of therapeutic anticoagulation, but a longer course (usually 3 months) should be considered

23 Complications and prognosis Death is mainly caused by refractory cardiogenic shock(inotropes?, or VF 5-year recurrence rates of 5 22% (3 months to 10 years after) Recurrence of a different anatomical variant.

24 Tako-tsubo syndrome / Conclusions Consider TC in differential diagnosis of an ACS, especially in post-menopausal women with recent history of acute stress Be alert in acute medical unit, endocrinology/neurology ward, anaesthetic room, intensive care obstetric/psychiatric ward. Many questions regarding the aetiology, pathophysiology and management of this syndrome remain unanswered Assess the RISK (complications) There are no randomized clinical trials to support specific treatment recommendations in Takotsubo syndrome (ASA, statin?) FOLLOW UP (3-6m MRI/LGE, b-blocker/no recur protection) One international registry, the InterTAK registry (NCT ), has been launched to gather 10-year follow-up data

25 Ευχαριστώ για την προσοχή σας