clean coronaries but a broken heart copyright © 2014, all rights reserved from the publishers of
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Clean Coronaries But a Broken Heart
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A 75 year old woman presents with pneumonia and chest pain
Stumper
In the last 24 hours, she has experienced: Dyspnea Sputum production Fever Cough
She presents to the ER
for evaluation
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Stumper
T 101.2, BP 100/65, HR 110 (sinus tachycardia)
Diffuse rhonchi, decreased breath sounds left base
S1, S2 normal, No murmur, S3, S4CXR: Infiltrate left lower lobe c/w
pneumonia
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ECG
Nef HM, et al. Tako-tsubo Cardiomyopathy (Apical Ballooning). Heart. 2007; 93:1309-1315.
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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.
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Answer
e. Overall prognosis is good. She should have significant improvement in LV function within 4 weeks.
She has stress induced cardiomyopathy. Takotsubo Cardiomyopathy, Apical ballooning syndrome
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Stress Induced CardiomyopathySharkey 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 casesEtiology ???
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?
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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
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Stress Induced Cardiomyopathy
Features Chest pain ECG changes and LV dysfunction out of proportion to Tn
Rx ACE Beta Blocker Aspirin
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Stress Induced CardiomyopathySharkey 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
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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.
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Answer
Overall prognosis is good. She should have significant improvement in LV function within 4 weeks.
*Most with return to normal LV function in 1-4 weeks
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