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Takotsubo Ryan Sanford 2/15/09 The Name A Japanese term, named after the jar used for trapping octopus In Popular Culture • A mechanism of being scared to death? o o Ananias and Sapphira Legal Larry Whitfield – on trial for 1st degree murder while holding 79F at gunpoint – “fear induced heart attack” Willie Ingram – convicted of murder for “emotional upset” causing heart attack, a 64M Mark Fisher – convicted of murder of 89F for “fear induced heart attack” AKA • Broken Heart Syndrome • Transient Left Ventricular Apical Ballooning • Stress Cardiomyopathy Definition • An acute completely reversible systolic heart failure • Typical: apical akinesia [ballooning] and hypercontractile base • Atypical: midventricular akinesia and hypercontractile base • No relevant CAD • Mimics symptoms of ACS Causes/Epidemiology • Triggered by extreme emotional or physical stress o Deaths, accidents, surprise party, procedure, arguments, legal, public speaking, armed robbery • Strong predominance in postmenopausal women • Under-recognized, ~2% of all ACS Pathophysiology 1.Coronary Spasm • Stunned myocardium 1.not favored 2.Wall involvement extends beyond single vascular territory 3.Few patients demonstrate spasm with provocation during catheterization 4.CEs only slightly elevated, not high enough 2.Microvascular Impairment 1.Certainly present 2.Correlative, but causation doubted Pathophysiology 1.Catecholamine Cardiotoxicity 1.Plasma levels of Epi/NE increased, even higher than in pt’s w/ similar HF. 2.Not uniformly present, but close 3.Pheochromocytoma can cause similar cardiac event 4.Histological findings simliar to in other forms of catecholamine cardiotoxicity Pathophysiology Signs / Symptoms • Think ACS o CP, dyspnea, syncope • Complications o o o o o Pulmonary edema and respiratory failure Cardiogenic shock Ventricular tachyarrhythmias Ventricular wall rupture Mural thrombus Labs • CEs: normal or slightly elevated • Elevated BNP • High serum catecholamines EKG ST Elevation, TWI, Prolonged QT Imaging Figure 1 Selective coronary angiography. Left (A) and right (B) coronary arteries in a patient presenting with tako-tsubo cardiomyopathy, excluding coronary artery disease. Left ventriculography during diastole (C) and systole (D) demonstrate the typical left ventricular apical ballooning and a hypercontractile base. Nef, H. M et al. Heart 2007;93:1309-1315 Copyright ©2007 BMJ Publishing Group Ltd. Typical Atypical Figure 4 Transthoracic echocardiogram showing four-chamber views during diastole (A) and systole (B) in a patient presenting with tako-tsubo cardiomyopathy. Real time three-dimensional echocardiography shows the typical contractile pattern of tako-tsubo cardiomyopathy with akinesia of apical segments and hypercontractility of the basal segments (diastole, C; systole, D). Nef, H. M et al. Heart 2007;93:1309-1315 Copyright ©2007 BMJ Publishing Group Ltd. Treatment Supportive care according to complications • Arrhythmias • Cardiogenic shock • Pulmonary edema Careful use of pressors Prognosis • ~1% hospital mortality • ~10% recur ?? • Return of LVEF within 2-4 weeks References • Nef HM et al. Tako-Tsubo Cardiomyopathy (Apical Ballooning). Heart 2007;93:1309-1315 • Akashi YJ et al. Takotsubo Cardiomyopathy – A New Form of Acute, Reversible Heart Failure. Circulation 2008;118:2754-2762 • Wittstein IS et al. Neurohumora Features of Myocardial Stunning Due to Sudden Emotional Stress. NEJM 2005;352:539-548 • Kurowski V et al. Apical and Midventricular Transient Left Ventricular Dysfunction Syndreom (Tako-Tsubo Cardiomyopathy) – Frequency, Mechanisms, Prognosis. Chest 2007; 132:509-816 • Hassan T et al. A Case of Tako-tsubo Cardiomyopathy. Heart 2008;94:177 • UpToDate. Stress-induced (takotsubo) Cardiomyopathy. 2009.