Takotsubo Cardiomyopathy

Transcription

1 Advances in Heart Disease 2008 Takotsubo Cardiomyopathy Mary O. Gray, MD, FAHA, FACC Associate Professor of Medicine University of California, San Francisco Staff Cardiologist and Training Faculty Divisions of Cardiology and Clinical Pharmacology San Francisco General Hospital 1

2 Case Presentation 49 year old woman with dull pain starting in back, radiating to the chest, both arms, and the jaw while driving to work on No previous episodes of chest discomfort. Chronic hypertension treated with lisinopril. No tobacco use. Two glasses of wine daily. Works as a nurse in a busy urban hospital. 2

3 Physical Examination BP 130/80 mmhg. HR 100 bpm. RR 18 breaths/min. Pulmonary: Clear lung fields. No rales or wheezing. Cardiac: JVP 12 cm. Regular tachycardia. No murmur. No gallop or rub. Normal peripheral pulses. Mild edema. Neurologic: Normal mental status. No motor deficits. 3

4 Electrocardiogram: Initial ED Presentation 4

5 Electrocardiogram: 4.5 Hours after Presentation 5

6 Electrocardiogram: 24 Hours after Presentation 6

7 Clinical Laboratory Data Normal complete blood count Normal coagulation parameters Normal metabolic panel and electrolytes Troponin I: Initial ED presentation = 0.39 ng/ml Troponin I: 4.5 Hours after presentation = ng/ml Troponin I: 24 hours after presentation = ng/ml 7

8 Left Ventriculogram: 2.5 Hours after Presentation QuickTime and a H.264 decompressor are needed to see this picture. 8

9 Parasternal Short Axis View: Day of Admission QuickTime and a Microsoft Video 1 decompressor are needed to see this picture. 9

10 Apical Four-Chamber View: Day of Admission QuickTime and a Microsoft Video 1 decompressor are needed to see this picture. 10

11 Cardiology Rounds December

12 Dote K, Sato H, Uchinda AT, Ishihara M (1991) Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J. Cardiol. 21, Tsuchihashi K, Ueshima K, Uchida T, et al. (2001) Transient apical ballooning without coronary stenosis: a novel syndrome mimicking myocardial infarction. Angina Pectoris - Myocardial Infarction Investigators in Japan. J. Am. Coll. Cardiol. 38, Kurisu S, Inoue I, Kawagoe T, et al. (2003) Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo left ventricular dysfunction. J. Am. Coll. Cardiol. 41,

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14 Annals of Internal Medicine 2004;141:

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16 New England Journal of Medicine 2005;352:

17 New England Journal of Medicine 2005;352:

18 New England Journal of Medicine 2005;352:

19 New England Journal of Medicine 2005;352:

20 New England Journal of Medicine 2005;352:

21 acute infarction 21

22 American Heart Journal 2008;155:

23 American Heart Journal 2008;155:

24 Cardiac Troponin T Release: ABS vs. AMI American Heart Journal 2008;155:

25 New England Journal of Medicine 2005;352: peak troponin I: median value 0.18 ng/ml interquartile range 0.08 to 0.69 normal value < 0.06 Circulation 2005;111: peak troponin T: range < 0.01 to 25.8 ng/ml normal value <

26 American Heart Journal 2008;155:

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28 Initial Management Supportive therapy leads to spontaneous recovery. Heart failure is the most common complication. It is important to exclude dynamic left ventricular outflow tract obstruction with echocardiography in patients with severe heart failure or hypotension. American Heart Journal 2008;155:

29 Initial Management Left ventricular outflow tract obstruction absent: Diuretics are effective in most heart failure cases. If tolerated, it is reasonable to initiate β-blockers. Cardiogenic shock may require inotrope therapy or intra-aortic balloon counterpulsation (IABP). American Heart Journal 2008;155:

30 Initial Management Left ventricular outflow tract obstruction present: Systolic anterior motion of mitral leaflet and MR. Cautious trial of intravenous fluids and β-blocker. Alternatively, phenylephrine to increase afterload. American Heart Journal 2008;155:

31 Initial Management Mechanical complications are relatively rare. Reports of free wall rupture or severe MR. Ventricular tachycardia and fibrillation are rare. Atrial arrhythmias and non-sustained VT. Left ventricular thrombus formation is infrequent. 31

32 Chronic Management β-blocker therapy to reduce likelihood of recurrence. Consider angiotensin-converting enzyme inhibitor. Annual follow-up because natural history is unclear. American Heart Journal 2008;155:

33 QuickTime and a Microsoft Video 1 decompressor are needed to see this picture. QuickTime and a Microsoft Video 1 decompressor are needed to see this picture. QuickTime and a Microsoft Video 1 decompressor are needed to see this picture. QuickTime and a Microsoft Video 1 decompressor are needed to see this picture. 33

34 J. Am. Coll. Cardiol. 2007;50:

35 J. Am. Coll. Cardiol. 2007;50:

36 Unanswered Questions Why are women susceptible to stress cardiomyopathy? What mechanisms cause this form of cardiomyopathy? How long should pharmacological therapy be continued? What is the optimal use of magnetic resonance imaging? 36

37 Recommended References Aurigemma, G.P. (2006) Acute stress cardiomyopathy and reversible left ventricular dysfunction. Cardiology Rounds Volume 10, Issue 10. Bybee, K.A., Kara, T., Prasad, A., Lerman, A., Barsness, G.W., Wright, R.S., Rihal, C.S. (2004) Systematic review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann. Int. Med. 141: Eitel, I., Behrendt, F., Schindler, K., Kivelitz, D., Gutberlet, M., Schuler, G., Thiele, H. (2008) Differential diagnosis of suspected apical ballooning syndrome using contrast-enhanced magnetic resonance imaging. Eur. Heart J. 29:

38 Recommended References Elesber, A.A., Prasad, A., Lennon, R.J., Wright, R.S., Lerman, A., Rihal, C.S. (2007) Four-year recurrence rate and prognosis of the apical ballooning syndrome. J. Am. Coll. Cardiol. 50: Prasad, A., Lerman, A., Rihal, C.S. (2008) Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am. Heart J. 155: Wittstein, I.S., Thiemann, D.R., Lima, J.A.C., Baughman, K.L., Schulman, S.P., Gerstenblith, G., Wu, K.C., Rade, J.J., Bivalacqua, T.J., Champion, H.C. (2005) Neurohumoral features of myocardial stunning due to emotional stress. N. Engl. J. Med. 353: