Transcript Acute Heart Failure in Apical Ballooning Syndrome (Takotsubo/Stress Cardiomyopathy) Clinical Correlates and Mayo Clinic Risk Score Malini Madhavan, MBBS; Charanjit S.

Acute Heart Failure in Apical
Ballooning Syndrome
(Takotsubo/Stress Cardiomyopathy)
Clinical Correlates and Mayo Clinic Risk
Score
Malini Madhavan, MBBS; Charanjit S. Rihal, MD, FACC; Amir
Lerman MD, FACC; Abhiram Prasad, MD, FRCP, FACC
Division of Cardiovascular Diseases
Mayo Clinic, Rochester
No relevant author disclosures
J. Am. Coll. Cardiol. 2011;57;1400-1401
Background
• Apical ballooning syndrome (ABS) is
characterized by transient regional
systolic dysfunction of the left ventricle in
the absence of obstructive coronary artery
disease
• Acute heart failure (HF) is the most
common complication
• Acute HF can cause significant morbidity
in ABS
Aims
• To examine the frequency and
prognosis of patients with acute HF
complicating ABS
• To identify the risk factors for acute
HF in ABS
Methods
Study Population
• Study cohort
• 118 consecutive ABS patients
identified between January 2002
and January 2008
• Validation cohort
• 52 consecutive ABS patients
identified between Feb 2008 and
December 2009
Methods
Mayo diagnostic criteria for ABS
• Transient akinesis, hypokinesis or dyskinesis of
the left ventricular mid segments with or without
apical involvement. The regional wall motion
abnormalities extend beyond a single epicardial
vascular distribution
• Absence of obstructive coronary disease or
angiographic evidence of acute plaque rupture,
• New ECG abnormalities (either ST-segment
elevation and/or T wave inversion) or elevated
cardiac troponin,
• The absence of pheochromocytoma or
myocarditis
Prasad et al. Am Heart J 155(3):408-17
Methods: Definitions
Acute heart failure
• New onset symptoms such as dyspnea, and
• At least 2 of the following physical signs -
pulmonary rales, elevated central venous
pressure, and the presence of a third heart sound
Cardiogenic shock
• Systolic blood pressure of <90 mm Hg for greater
than 1 hour secondary to cardiac dysfunction
associated with signs of hypoperfusion
• Patients with systolic blood pressure increase to
>90 mm Hg within 1 hour after administration of
inotropic agents, who met other criteria for
cardiogenic shock
Clinical Characteristics
No Acute HF
(N=65)
Acute HF
(N=53)
p-value
67 (12)
73 (12)
0.02
Female gender
63 (97%)
52 (98%)
0.7
Presenting symptom
Chest Pain
Dyspnea
51 (78%)
26 (40%)
23 (43%)
35 (66%)
<0.0001
0.005
Variable
Age (years)
Precipitating factor
Emotional stress
Physical stress
19 (30%)
23 (35%)
11 (21%)
37 (70%)
Electrocardiogram
ST-segment elevation
Deep T wave inversion
23 (36%)
39 (60%)
31 (58%)
26 (49%)
0.0003
0.01
0.2
Clinical Characteristics
Variable
Biomarkers
Admission Troponin T (ng/ml)
Peak Troponin T (ng/ml)
BNP (pg/ml) (N=48)
Angiography
Ejection fraction (%)
LVEDP (mm Hg)
Grade 3 or 4 MR
Admission Echocardiogram
Ejection fraction (%)
Wall motion score index
No Acute HF
(N=65)
Acute HF
(N=53)
pvalue
0.37 (0.42)
0.55 (0.56)
783 (753)
0.71 (0.85)
0.93 (0.90)
1161 (1010)
0.009
0.01
0.1
46 (11)
23 (7)
5 (10%)
35 (13)
28 (7)
8 (21%)
0.0001
0.001
0.08
44 (13)
1.74 (0.41)
36 (13)
2.05 (0.47)
0.004
0.0006
Independent Predictors of Acute HF
Multivariate Analysis
Predictor
Odds
Ratio*
95%
P value
confidence
interval
Age (years)
1.06
1.02 - 1.11
0.001
Physical stress trigger
4.01
1.64 – 10.36
0.002
Admission Troponin T
2.43
1.05 – 6.59
0.04
LV Ejection fraction
0.96
0.92 - 0.99
0.01
ST-segment elevation
1.34
0.5 – 3.52
0.7
*Per unit change in variable
Troponin T Stratified by Severity of HF
Mayo Clinic Risk Score for Acute
HF in ABS
• One point was assigned to each of the
following independent risk factors:
• Age > 70 years
• Presence of physical stressor
• Ejection fraction < 40%
• Troponin T was not included due to
heterogeneity in assay and cut-off value used
at different institutions
Mayo Clinic Risk Score for Acute
HF in ABS
• Significant positive correlation between
the frequency of acute HF and the risk
score in the:
• Development cohort – C statistic 0.77,
p<0.001
• Validation cohort – C statistic 0.77,
p=0.002
Acute HF Stratified by Mayo Risk Score
Development cohort
Validation cohort
Outcome in ABS
Cardiogenic shock
No acute HF
(N=65)
Acute HF
(N=53)
P value
N/A
25 (47%)
N/A
Cardio respiratory support
Inotrope use
Intra-aortic balloon pump use
Mechanical ventilation
<0.001
0
0
3 (5%)
20 (38%)
9 (17%)
15 (28%)
Duration of hospitalization (days)
5.4 (8.7)
11.2 (5.4)
0.0004
Outcome at discharge
Residual HF
Death in hospital
N/A
0 (0%)
6 (11%)
3 (6%)
N/A
0.09
Discharge medications
Beta blocking agent
ACE inhibitor/ ARB
Furosemide
49 (77%)
39 (61%)
6 (9%)
41 (82%)
37 (74%)
20 (40%)
0.5
0.1
0.0001
Follow-up echocardiogram
Time from presentation (days)
Ejection fraction (%)
Wall motion score index
74 (148)
62 (6)
1.08 (0.21)
78 (120)
60 (10)
1.13 (0.29)
0.9
0.3
0.4
Conclusions
• Heart Failure is a common complication of ABS
• Approximately 50% developed HF
• One in five developed cardiogenic shock
• Patients who developed acute HF had,
• Greater myocardial injury and stunning
• Greater morbidity and longer hospitalization
• Prognosis is good with resolution of HF with
supportive management in the majority of
patients
• Mortality secondary to cardiogenic shock
occurred in 3 patients
Conclusions
• The Mayo Clinic risk score is predictive of acute HF
in patients with ABS
• Risk stratification using the Mayo Clinic risk score
may:
• Assist in triaging high risk patients to an
intensive care unit for management
• Allow physicians to identify patients in whom
early initiation of beta-adrenergic blockers may
be harmful