Case Presentation. ESIM 8 th 12 th June Doriella Galea Malta

Transcription

1 Case Presentation ESIM 8 th 12 th June 2015 Doriella Galea Malta

2 3am: Ward Call Asked to review Ms J.D. a 45 year old lady previously healthy in view of chest pain She described central chest pain radiating to the left arm lasting for about 20 minutes. There were no associated symptoms or history of exertional symptoms.

3 History She had been admitted for observation in view of an anaphylactic reaction to an unknown trigger. Initial investigations had been unremarkable except for mildly raised white cell count. No family history of note. Non smoker. No alcohol. No history of illicit drug use.

4 Examination Ms J.D. looked comfortable at rest. Could complete sentences. Denied pain at present Vital parameters Temperature: 36.5 o C Pulse: 60 bpm Blood pressure: 110/80 mmhg SpO 2 on air: 96 % RR: 16 br/min CVS: S1 + S2 + 0 (pain was not reproducible) Chest: good air entry, R=L, no wheezing Abdomen: soft, non tender Lower limbs: no oedema, no signs of DVT No rashes

5 Investigations Blood investigations Complete Blood Count: White cell count Renal function: Normal Troponin 0.9 (normal limit 0.04)

6 Investigations [cont.] T wave inversion in the anterior leads Prolonged QTc of 680 ms

7 12 hours later Second troponin 1.45 (previously 0.9) Deepening anterior T wave inversions with QTc of 700ms

8 Provisional Diagnosis ACS (NSTEMI) Aspirin 300mg po stat Clopidogrel 300mg po stat Enoxaparin 1mg/kg/bd sc

9 Cardiology review Echocardiography: basal hypercontractility and mid and apical hypokinesia 3 rd Troponin 1.01 (18 hours after onset of chest pain) Urgent cardiac catheterisation and ventriculography was performed

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11 Day 2 after event Day 5 after event 1. NSR 2. Normal QTc

12 Provisional Diagnosis Takotsubo cardiomyopathy following anaphylaxis ACS treatment was stopped

13 Takotsubo Cardiomyopathy It is a form of an acute reversible heart failure syndrome secondary to a stressful trigger. The trigger may be physical or psychological stress. At times no trigger is identified. Pathophysiology of disease is poorly understood. There is a form of acute catecholaminergic myocardial stunning in the absence of culprit occlusive disease to explain the pattern of temporary LV dysfunction.

14 Various Triggers Medical Conditions Acute asthma and COPD Thyrotoxicosis Addisonian crisis Septic shock Myasthenic crisis Acute Guillain-Barre Syndrome Acute systemic lupus erythematosus crisis Anaphylaxis Others Exercise stress testing Dobutamine stress echocardiography Electroconvulsive therapy Induction of anaesthesia Pregnancy Restraint in custody Near drowning Iatrogenic Acute cholecystitis Head injury

15 Takotsubo Cardiomyopathy It was first diagnosed in 1990s. 1-2% of patients treated for ACS are eventually diagnosed with takotsubo cardiomyopathy. Commoner in elderly females (above age of 60). Different severity. Commoner in summer. Previously underdiagnosed.

16 Modified Mayo Clinic Criteria (all 4 required) A B Transient hypokinesia, akinesis, or dyskinesia in the left ventricular midsegments with or without apical involvement; regional wall motion abnormalities that extend beyond a single epicardial vascular distribution; and frequently but not always, a stressful trigger. The absence of obstructive coronary disease or angiographic evidence of acute plaque rupture. C New ECG abnormalities (ST-segment elevation and/or T wave inversion) or modest elevation in cardiac troponin. D The absence of phaeochromocytoma and myocarditis.

17 Gothenburg Criteria (all 3 required) 1 Transient hypokinesia, akinesia, or dyskinesia in the left ventricular segments and frequently, but not always, a stressful trigger (psychological or physical) 2 The absence of other pathological conditions that may explain the regional dysfunction 3 No elevation or modest elevation in cardiac troponin (i.e. disparity between the troponin level and the amount of the dysfunctional myocardium present)

18 Management and Prognosis Management: Supportive measure Heart failure treatment Prognosis The more co-morbidities the worse the prognosis. Depends on the severity at presentation. Serious complications such as cardiac tamponade may occur. Some resolve with hours, other may take weeks to months. Recurrence is generally more serious than first presentation.

19 Take Home Messages Think of common diseases first BUT rare diseases do occur Multi-disciplinary approach in disease management There maybe co-existing diseases Takotsubo is a rare disease Supportive measures. Good overall prognosis.

20 Grazzi (thank you)azzi