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Clean Coronaries But a Broken Heart

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Stumper

 A 75 year old woman presents with pneumonia and chest pain  In the last 24 hours, she has experienced:  Dyspnea  Sputum production  Fever  Cough  She presents to the ER for evaluation Copyright © 2014

Stumper

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T 101.2, BP 100/65, HR 110 (sinus tachycardia)

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Diffuse rhonchi, decreased breath sounds left base

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S1, S2 normal, No murmur, S3, S4

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CXR: Infiltrate left lower lobe c/w pneumonia

ECG

Nef HM, et al. Tako-tsubo Cardiomyopathy (Apical Ballooning). Heart. 2007; 93:1309 1315

Case

a) She will need symptom limited stress test in 3-4 weeks to determine prognosis.

b) With her severe LV dysfunction she is at risk for sudden death. An AICD will improve prognosis.

c) Biventricular pacing will improve prognosis.

d) Overall prognosis is poor given the severe LV dysfunction.

e) Overall prognosis is good. She should have significant improvement in LV function within 4 weeks.

Answer

e. Overall prognosis is good. She should have significant improvement in LV function within 4 weeks.

Stress Induced Cardiomyopathy Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472–9.

   Women 95% cases Mean age 68 Not just emotional stress    Intense physical stress Acute medical illness (ICU) No stress in 10%  Probably 2% of ACS cases Etiology ???

 Wall motion abnormality doesn’t correlate to single coronary distribution   Catecholamine induced vascular spasm?

Catecholamine induced reversible myocyte injury?

 Is LV apex more sensitive to injury?

Stress Induced Cardiomyopathy Diagnostic criteria:

• • • • Transient akinesis or dyskinesis of apex-distal LV New ST elevation or T wave inversion No obstructive coronary artery disease Absence of other causes of transient myopathy  Head trauma  Intracranial bleed  Pheochromocytoma  Myocarditis Copyright © 2014

Stress Induced Cardiomyopathy

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Features

 Chest pain  ECG changes and LV dysfunction out of proportion to Tn 

Rx

Stress Induced Cardiomyopathy

Sharkey SW, Lesser JR, Zenovich AG, et al

. Acute and reversible cardiomyopathy provoked by stress in women from the United States.

Circulation 2005;111:472 –9.

 136 consecutive patients  1/3 with one, or more, atypical feature  Male  < age 50  No stressor  Died in hospital  Occurred while on beta blocker  Delayed normalization of EF  Recurrence  RV or LV thrombus Copyright © 2014

Not Just Women

While initially thought to be a disease of women provoked by emotional, physical, or medical stress, Stress Induced Cardiomyopathy (Takotsubo cardiomyopathy) may occur in men and may occur without an identifiable stress event. Copyright © 2014

Answer

Overall prognosis is good. She should have significant improvement in LV function within 4 weeks.