Apical Ballooning Syndrome a'k'a' TakoTsubo Cardiomyopathy a'k'a' Stressinduced Cardiomyopathy a'k'a - PowerPoint PPT Presentation

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Apical Ballooning Syndrome a'k'a' TakoTsubo Cardiomyopathy a'k'a' Stressinduced Cardiomyopathy a'k'a

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Mean age is 58-75 and rarely has been reported in patients less ... 66% have a preceding physical or emotional stressor (reports ... Troponin and CK-MB ... – PowerPoint PPT presentation

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Title: Apical Ballooning Syndrome a'k'a' TakoTsubo Cardiomyopathy a'k'a' Stressinduced Cardiomyopathy a'k'a


1
Apical Ballooning Syndrome a.k.a.Tako-Tsubo
Cardiomyopathy a.k.a.Stress-induced
Cardiomyopathy a.k.a.Broken Heart Syndrome
2
Epidemiology
  • Incidence is unknown although some have estimated
    1-2 of all patients presenting with ACS
  • Mean age is 58-75 and rarely has been reported in
    patients less than 50 years of age
  • Ninety percent of the cases have occurred in women

3
Clinical Presentation
  • Essentially present as ACS patients
  • 50 with angina-like chest pain at rest
  • Dyspnea
  • 66 have a preceding physical or emotional
    stressor (reports have described various
    stressful events such as a surprise party, public
    speaking, and the death of loved one)
  • Rarely present with syncope or cardiac arrest

4
Pathophysiology
  • Catecholamine induced?
  • Very high levels of circulating catecholamines
  • Contraction band necrosis on endomyocardial
    biopsy
  • Coronary spasm
  • Myocarditis

5
Findings on workup
  • EKG Typically STE in precordial leads although
    reports have been described where no STE were
    observed.
  • Rarer findings include nonspecific T wave
    abnormalities or a bundle branch block
  • Biomarkers Elevated Troponin and CK-MB
  • Levels are not as high as expected given degree
    of cardiac dysfunction.
  • Cardiac catheterization Normal or insignificant
    disease

6
Left ventriculogram
Prasad, A. et al. American Heart Journal. 2008
155 408-417
7
Echocardiogram
  • Hypokinesis or akinesis of mid and apical
    segments of the LV
  • Motion abnormality involves more than one
    coronary artery distribution
  • Function at the base is normal
  • RV may show similar findings in 30 of patients
    (seen in sicker patients)

8
Cardiac MRI
  • Documents degree of wall motion abnormalities
  • No delayed hyperenhancement
  • MI and myocarditis show hyperenhancement

9
Proposed Mayo Clinic criteria for Diagnosis
  • Transient hypokinesis, akinesis, 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 a stressful
    trigger is often, but not always present. ?
  • Absence of obstructive coronary disease or
    angiographic evidence of acute plaque rupture.
  • New electrocardiographic abnormalities (either
    ST- segment elevation and/or T-wave inversion) or
    modest elevation in cardiac troponin.
  • Absence of Pheochromocytoma or Myocarditis

Prasad, A. et al. American Heart Journal. 2008
155 408-417
10
Treatment
  • In short, nobody really knows optimal therapy.
  • Patients will initially be treated as ACS
    (anticoagulation, asa, b-blocker, tele, etc.)
  • Beta-blockers and ACEI are reasonable at
    discharge (no asa necessary if cath revealed no
    CAD)
  • Some argue for several weeks of warfarin therapy
    if LV dysfunction is severe
  • CHF can be seen in 20 of patients which
    responds well to diuretics

11
Outcomes
  • In hospital mortality is exceedingly low
  • Typically complete recovery is seen within 4-8
    weeks.
  • ACEI can be discontinued at that time
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