TRISTAH ROMERO, BSN, RN

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What happens to broken hearts?
TAKOTSUBO CARDIOMYOPATHY

• TRISTAH ROMERO, BSN, RN
• MSN NURSING STUDENT
• ALVERNO COLLEGE

Image from Microsoft clip art
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Objectives

• By the end of the tutorial the user will be able
  to
• Identify potential signs and symptoms of
  Takotsubo Cardiomyopathy.
• Indentify factors which contribute to the
  diagnosis of Takotsubo Cardiomyopathy.
• Distinguish differences between Takotsubo
  Cardiomyopathy and other cardiac conditions.
• Identify potential treatment/ management options
  for Takotsubo Cardiomyopathy.

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Review of basic concepts
Blood Flow Chart
Sympathetic Nervous System
Cardiomyopathy
Heart Failure
Hover over any of the images for a description
and click on it. It will link you to a variety of
sites for a refresher of basic concepts IF needed.
Anatomy/ Structure Blood Flow
Cardiac Cycle
Images from Microsoft clip art Google images
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Review of basic concepts quiz

• Where does blood go to immediately after leaving
  the left ventricle?

Left atrium No, that is not correct, the blood
actually came from the left atrium to the left
ventricle.
Right ventricle No, that is not correct, try
again.
Aorta You are correct! This oxygen rich blood
goes through the aorta and then out to the body.
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Review of basic concepts quiz

• If the blood from the left ventricle is unable to
  move through the aorta and out to the body, what
  will happen?

Nothing No, that is not correct, the blood has
to go somewhere and if it is not moving forward
it will likely back up and/or pool.
Cause peripheral edema No, that is not
correct, peripheral edema would be caused by
failure of the right ventricle.
Blood will back up into the lungs Yes, you are
correct, although some blood may push out to the
body, it is likely inadequate and blood will back
up into the lungs.
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Review of basic concepts quiz

• Which one of these three are more likely to turn
  on the sympathetic nervous system?

Eating That is not correct, Remember the
sympathetic nervous system is fight or flight.
Stress That is correct! Stress is one of the
many things which could turn on the sympathetic
nervous system.
Sleeping That is not correct, please try again.
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Review of basic concepts quiz

• True or False, cardiomyopathy affects the hearts
  ability to pump blood?

True You are correct!
False That is not correct. There are many types
of cardiomyopathy but all types affect the
hearts ability to pump blood.
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Defining Cardiomyopathy

• There are many variations of cardiomyopathy. A
  general definition is
• Cardiomyopathy is a weakening of the heart
  muscle or a change in the heart muscle. It often
  occurs when the heart cannot pump as well as it
  should, or with other heart function problems.
• - University of Maryland Medical Center, 2011

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What is Takotsubo Cardiomyopathy?

• Takotsubo tah-ku-su-bu cardiomyopathy was first
  identified in Japan in the 1990s.
• In Japanese takotsubo translates into octopus
  pot. The shape of the heart (during systole)
  resembles this pot used to trap octopus.
• Takotsubo has been called many names broken
  heart syndrome, stress cardiomyopathy, transient
  apical ballooning.

Mayo Clinic (2011)
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Characteristics of Takotsubo Cardiomyopathy

• ECG abnormalities ST segment changes or T wave
  inversion.
• Temporary wall motion abnormality akinesis,
  hypokinesis or dyskinesis (many times of the left
  ventricle) contradictory to coronary composition.
• Absence of obstructive coronary disease or plaque
  rupture.
• Absence of other disease/ conditions that would
  explain the clinical presentation (specifically
  including pheochromocytoma or myocarditis).
• Often a physically or emotionally stressful event
  just prior to onset of symptoms.

Akashi, Nakazawa, Sakakibara, Miyake, Koike
Sasaka (2003) Litvinov, Kotowycz Wassmann
(2009)
This list is not all inclusive nor intended to
serve as a diagnostic tool
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Takotsubo Cardiomyopathy

• Presents similar to Acute Coronary Syndrome
  (ACS).
• There are many names for Takotsubo
  Cardiomyopathy.
• There are several diagnostic characteristics.
• BUT
• The combination of the clinical presentation,
  labs, diagnostics and the exclusion other
  potential causes is what assists in the diagnosis
  of Takotsubo Cardiomyopathy.

Akashi, Goldstein, Barbaro Ueyama (2008)
Litvinov, Kotowycz Wassmann (2009)
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Defining Acute Coronary Syndrome

• The term acute coronary syndrome (ACS) is
  applied to patients in whom there is suspicion of
  myocardial ischemia
• - Up to date, 2011
• Acute coronary syndrome is a term used for any
  condition brought on by sudden, reduced blood
  flow to the heart.
• - Mayo Clinic, 2010

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Population affected with Takotsubo Cardiomyopathy

• First discovered in the Japanese population.
• Studies also found Caucasians from Belgium,
  people in North America, and Europe.
• One case study focused on an Italian woman.
• More commonly seen in post menopausal women.
• Has been seen in a small number of men and
  premenopausal women too!
• Many times there are no risk factors or signs of
  coronary disease.

Lisi, et al. (2007) Litvinov, Kotowycz Wassmann
(2009)
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Causes

• The most consistent statement found regarding the
  cause(s) of Takotsubo Cardiomyopathy is that it
  is still unclear.
• There have been many attempts to identify the
  cause(s) of Takotsubo Cardiomyopathy.
• One of the more promising leads is the
  possibility of damage from high levels of
  catecholamines.

Akashi, Goldstein, Barbaro Ueyama (2008)
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Now wait a minute

• Does this sound familiar?
• Examples of catecholamines are norepinephrine
  (NE) and epinephrine
• They are located in the Locus Ceruleus and the
  adrenal medulla
• They can cause an increase in
• heart rate, cardiac contractility as well as
  vascular smooth muscle contraction
• Catecholamines (among many other hormones and
  neurotransmitters) are important and used to
• Alert the body that there is something wrong AND
• Help improve cardiovascular and metabolic
  function
• BUT too much of something isnt good either ex
  SNS

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Findings on catecholamines

• Some studies have found
• Left ventricular dysfunction when testing animals
  with the use of catecholamines.
• Patients with elevated catecholamine levels.
  Levels more than 5 times the normal level.
• Patients diagnosed with Takotsubo Cardiomyopathy
  had elevated levels of catecholamines which were
  2-3 times higher then that of patients with
  myocardial infarctions (who may have already had
  elevated levels of catecholamines above the
  normal level).

Akashi, Goldstein, Barbaro Ueyama (2008)
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Causes continued

• Other proposed causes include
• Microvascular spasm
• Which can cause ischemia in the absence of an
  occlusion.
• Stunned myocardium
• Due to elevated catecholamines which can decrease
  the viability of myocytes and/ or injure the
  myocytes.
• Temporary occlusion by atherosclerotic plaque
• Caused by a combination of a thrombosis and
  narrowing of the artery that is transient.

Virani, Khan, Mendoza, Ferreira, de Marchena
(2007)
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Case Study

• A 65 year old women came into the emergency room
  with complaints of chest pain and shortness of
  breath. She was pale and diaphoretic (sweating).
  Her B/P was 100/50, heart rate 120, respirations
  were 32. An ECG and initial blood work was
  obtained. Her initial ECG showed ST elevation.
  The cardiac markers from her initial blood work
  indicated a slightly elevated troponin level.
• Patients past medical history included rotator
  cuff repair and past pregnancies. There was no
  history of any cardiac conditions. The patient
  denied any tobacco or alcohol use.

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Quiz

• What symptoms are related to the activation of
  the sympathetic nervous system?

Tachycardia You are correct, is there anything
else?
Pallor You are correct, is there anything
else?
Sweating You are correct, is there anything
else?
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Case study continued

• Upon further questioning the patient reported
  recently having financial difficulties, she began
  to sob. She stated she is about to lose her
  house, she doesnt know how she will pay for
  these medical bills and her husband had died in a
  car accident just 2 weeks prior.
• Further evaluation was needed

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Case study continued

• Finally an echocardiogram was performed and found
  apical ballooning of her left ventricle. This
  65 year old women was rushed into the cardiac
  catheterization lab. The cath lab found akinesis
  of the apical, diaphragmatic and anterolateral
  portions of her left ventricle and hyperkinesis
  of the basal segment. There were no
  signs of occlusion or cardiac vessel disease.

Click on the images above to view photos
Images from Microsoft clip art
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Quiz

• Which sign(s)/ symptom(s) from this case study
  potentially could indicate Takotsubo
  Cardiomyopathy?

Emotional stress You are correct, many times
there is a significant emotionally or physically
stressful event prior to the onset of symptoms
is there anything else?
Cath lab results of apical ballooning You are
correct, with Takotsubo Cardiomyopathy the apical
ballooning is a more common sign along with no
signs of coronary artery disease. Is there
anything else?
Chest pain You are correct, this is one of the
many possible characteristics, although chest
pain could represent MANY other conditions it is
the COMBINATION of symptoms that draws a clearer
diagnosis of Takotsubo Cardiomyopathy is there
anything else?
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Treatments/ Management

• In general, management varies and is based on the
  patients present symptoms.
• There is no specific treatment regimen.
• Treatment similar to that of an Acute Coronary
  Syndrome (ACS)
• Partly because presentation is similar to that of
  ACS and ACS can not be ruled out until laboratory
  and diagnostics are completed, combined with
  signs/ symptoms the patient presents with which
  then may lead to the diagnosis of Takotsubo
  Cardiomyopathy.

Derrick (2009) Litvinov, Kotowycz Wassmann
(2009) Scharkey, Lesser, Zenovich, Maron,
Lindberg, Longe Maron (2005)
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Dos Don'ts

• Some studies have used the following
  treatment(s)
• Alpha and beta adrenoreceptor blockers
• Diuretics for fluid overload and/or pulmonary
  edema
• Anticoagulants for the treatment or prevention of
  a thrombus (controversial)
• If shock occurs, to support circulation,
  intraaortic balloon pumping have been used
• Treatments that had been avoided in prior
  studies
• Vasopressors and Beta agonist
• BUT why?

Derrick (2009) Litvinov, Kotowycz Wassmann
(2009) Scharkey, Lesser, Zenovich, Maron,
Lindberg, Longe Maron (2005)
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Significance of disease

• Occurs in approximately 1-3 of suspected acute
  coronary syndrome patients
• Approximately 80-90 of patients studied with
  Takotsubo Cardiomyopathy were women
• Mortality rate approximately 1
• Recovery within an estimated 4-6 weeks
• Reoccurrence has been found to be low
• Complications seen in 19 of patients
• heart failure, pulmonary edema, cardiogenic
  shock, mitral regurgitation, thrombus,
  ventricular arrhythmias, left ventricular outflow
  tract obstruction

Akashi, Goldstein, Barbaro Ueyama
(2008) Derrick (2009)
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Outcome/Prognosis

• Prognosis is good IF the patient can overcome the
  initial episode/symptoms of Takotsubo
  Cardiomyopathy.
• Complete recovery usually occurs within several
  weeks of the initial occurrence.
• Recent studies indicate no signs of residual
  effects.

Derrick (2009) Scharkey, Lesser, Zenovich, Maron,
Lindberg, Longe Maron (2005)
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Summary

• Takotsubo Cardiomyopathy presents similarly to
  acute coronary syndrome (ACS), treatment path is
  usually similar to ACS.
• It is the combination of diagnostics, labs and
  signs and symptoms that can assist in leading to
  the diagnosis of Takotsubo Cardiomyopathy.
• It is important to recognize the signs and
  symptoms and act promptly to support and provide
  the needed care.
• The patient prognosis is good, if symptoms are
  managed appropriately.

Tomich (2011)
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Further research needed?

• Yes, of course there is.
• Clearly defined cause(s) of Takotsubo
  Cardiomyopathy
• Studies with larger number of participants
• Long term outcomes
• Prevalence among women versus men
• Related to hormones?
• Related to anatomy?
• Relationship to menopausal women
• Role of estrogen in protecting the heart
• And much more let your thoughts be endless!

Virani, Khan, Mendoza, Ferreira de Marchena
(2007)
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References

• Akashi, Y. J., Goldstein, D. S., Barbaro, G.,
  Ueyama, T. (2008). Takotsubo Cardiomyopathy A
  new form of acute, reversible heart failure.
  Circulation. doi 10/1161CIRCULATIONAHA.108767012
• Akashi, Y. J., Nakazawa, K., Sakakibara, M.,
  Miyake, F., Koike, H., Sasaka, K. (2003). The
  clinical features of takotsubo cardiomyopathy.
  QJM, 96(8), 563-573. doi 10.1093/qjmed/hcg096
• Bowne, P. S., (2004-2010). Cardiac cycle.
  Retrieved from http//faculty.alverno.edu/bowneps/
  cardiaccycle/cardiaccycle1map.htm
• Bowne, P. S., (2004). Path of Blood Flow
  Tutorial. Retrieved from http//faculty.alverno.ed
  u/bowneps/pathofbloodflow/pathmap.htm
• Bowne, P. S., (2004-2010). Heart failure/
  defects. Retrieved from http//faculty.alverno.edu
  /bowneps/pathofbloodflow/pathproblem.htm

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References continued

• Bowne, P. S., (2004-2010). Sympathetic nervous
  system. Retrieved from http//faculty.alverno.edu/
  bowneps/snsreview/snsintro.htm
• Cherry, E. M., Fenton, F. H. (n.d.) Heart
  structure, function and arrhythmias. Retrieved
  from http//thevirtualheart.org/3dpdf/Heart_3d.pdf
  
• Derrick, D. (2009). The broken heart syndrome
  Understanding takotsubo cardiomyopathy. American
  Association of Critical-Care Nurses, 29, 49-57.
  doi 10.4037/ccn2009451
• Lisi, M., et al. (2007). Takotsubo cardiomyopathy
  in a caucasian Italian woman Case report.
  Cardiovascular Ultrasound, 5(18). doi
  10.1186/1476-7120-5-18
• Litvinov, I. V., Kotowycz, M. A., Wassmann, S.
  (2009). Iatrogenic epinephrine-induced reverse
  Takotsubo cardiomyopathy direct evidence
  supporting the role of catecholamines in the
  pathyophysiology of the broken heart syndrome.
  Clinical Research in Cardiology, 98(7), 457-462.
  doi 10.1007/soo392-009-0028-y

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References continued

• Mayo Clinic. (2011). Acute coronary syndrome.
  Retrieved from http//www.mayoclinic.com/health/ac
  ute-coronary-syndrome/DS01061
• Mayo Clinic. (2011). Broken heart syndrome.
  Retrieved from http//www.mayoclinic.com/health/br
  oken-heart-syndrome/DS01135
• Porth, C., Matfin, G. (2009). Pathophysiology
  Concepts of Altered Health States. Philadelphia,
  PA Lippincott Williams Wilkins
• Scharkey, W. S., Lesser, J. R., Zenovich, A. G.,
  Maron, M. S., Lindberg, J., Longe, T. F.,
  Maron, B. J. (2005). Acute reversible
  cardiomyopathy provoked by stress in women from
  the united states. Circulation. doi.
  10.1161/01.CIR.0000153801.51470.EB
• Tomich, E. B. (2011). Takotsubo Cardiomyopathy.
  Retrieved from http//emedicine.medscape.com/artic
  le/1513631-overviewshowall
• University of Maryland Medical Center. (2011).
  Cardiomyopathy- Overview. Retrieved from
  http//www.umm.edu/ency/article/001105.htm

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References continued

• Up to date. (2011). Criteria for the diagnosis of
  acute myocardial infarction. Retrieved from
  https//ive.aurora.org/contents/,DanaInfowww.upto
  date.comcriteria-for-the-diagnosis-of-acute-myoca
  rdial-infarction?sourcesearch_resultsearchacute
  coronarysyndromeselectedTitle117E150
• Virani, S. S., Khan, A. N., Mendoza, C. E.,
  Ferreira, A. C., de Marchena, E. (2007).
  Takotsubo cardiomyopathy, or broken-heart
  syndrome. Texas Heart Institute Journal, 34(1),
  7679.
• Wittstein, I. S., et al. (2005). Neurohumoral
  features of myocardial stunning due to sudden
  emotional stress. The New England Journal of
  Medicine, 352(6), 539-548. doi
  10.1056/NEJMoa043046
• Wikipedia. (2008). Takotsubo cardiomyopathy
  images. Retrieved from http//en.wikipedia.org/wik
  i/Takotsubo_cardiomyopathy

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ECG of patient with Takotsubo Cardiomyopathy
ECG showing sinus tachycardia and non-specific
ST and T wave changes from a patient with
confirmed Takotsubo Cardiomyopathy Wikipedia,
2008
Image from Wikipedia- used with permission
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Left ventriculogram of a patient with
Takotsubo Cardiomyopathy__
Left ventriculogram during systole displaying
the characteristic apical ballooning with apical
motionlessness in a patient with Takotsubo
Cardiomyopathy - Wikipedia, 2008

• Schematic representation of takotsubo
  cardiomyopathy
• compared to the situation in a normal person.
• - Wikepedia, 2008

Image from Wikipedia- used with permission