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Takotsubo Cardiomyopathy versus ST-segment elevation MI —A case series

Takotsubo Cardiomyopathy versus ST-segment elevation MI —A case series. Ashwini Davison Justin Dunn Jason Mock Deepa Rangachari May 13, 2009. Types of Trials. Controlled Study

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Takotsubo Cardiomyopathy versus ST-segment elevation MI —A case series

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  1. TakotsuboCardiomyopathy versus ST-segment elevation MI—A case series Ashwini Davison Justin Dunn Jason Mock Deepa Rangachari May 13, 2009

  2. Types of Trials • Controlled Study • - Randomize Control Trial (RCT) – type of scientific experiment most commonly used in testing the efficacy or effectiveness of healthcare services or technologies. • With sufficient numbers, this ensures that both known and unknown confounding factors are evenly distributed between treatment groups. • Considered the most reliable form because they eliminate spurious causality and bias. • Observational Study • Cohort study - group of people who share a common characteristic or experience within a defined period. • Case Control - Studies used to identify factors that may contribute to a medical condition by comparing subjects who have that condition with patients who do not have the condition but are otherwise similar • Case Series

  3. Definition of Case Series • Descriptive research study that tracks patients with a known exposure given similar treatment or examines their medical records for exposure and outcome. • Also known as clinical series • Can be retrospective or prospective • Smaller number of patients than more powerful case-control or RCTs

  4. Case Series • Provide information when other types cannot or should not be undertaken • Case series may be confounded by selection bias, which limits statements on the causality of correlations observed • Results of case series can generate hypotheses that could be useful in designing further studies • In this article the authors use a case series to ask the question what clinically (in the ED) can be used to differentiate Takotsubo cardiomyopathy versus ST-segment elevation myocardial infarction

  5. Introduction to ArticleElectrocardiographic ST-segment elevation: Takotsubocardiomyopathy versus STEMIAMERICAN JOURNAL OF EMERGENCY MEDICINE, 2009

  6. What is Takotsubo cardiomyopathy? • Also known as left ventricular apical ballooning syndrome, ampulla CM, stress CM • Develop anginal symptoms and CHF in times of stress • Extreme: acute pulmonary edema, cardiogenic shock

  7. EKG & Labs • ST segment and/or T wave abnormalities • Similar to what’s seen in STEMI • Serum markers may be elevated

  8. Cath & ventriculogram • Catheterization: abnormal LV function, but NORMAL coronary arteries Diastole Systole

  9. Diagnostic criteria (Mayo) • 1) transient LV apical akinesis or dyskinesis • 2) absence of obstructive CAD • 3) new EKG abnormalities in absence of concurrent conditions

  10. Discussion of this Case Series

  11. How Patients Were Selected • Reviewed 12 consecutive cases of Takotsubo CM that presented to UVA • 3 case excluded because of incomplete data • Then took 9 consecutive cases of STEMI for comparison • 18 cases total (9 TCM, 9 STEMI)—same time period • Comparisons made between 2 groups

  12. Demographic Results

  13. EKG Comparisons

  14. Other comparisons • CXR findings were similar in both groups • Initial troponin elevation similar • STEMI peak troponin 7.34 vs TCM with 4.91 • EF on echo—32.7% in Takotsubo, vs 25.2% in STEMI

  15. Discussion of Article

  16. Design • Not really a case series by definition—used control group (STEMI patients) • A number of case series were published prior (all with 9 or more pts), and a systematic review published in 2006. • Appears to be a case series of Takotsubo compared with a case series of STEMIs.

  17. Strengths • Used consecutive patients to help reduce selection bias in both groups (though did exclude 3 from case group) • All patients were (we assume) at the same institution

  18. Weaknesses • Time frame? Unclear how long to select patients; also unclear how STEMI pts selected. • Too few patients—9 in each group. • No distribution of values given, no hard data—only means/percentages, no medians. • No p values or confidence intervals

  19. Weaknesses • 3 people eliminated in case group for “incomplete data”—contribute to selection bias? • No risk factors noted in either group • Unclear if any question was answered.

  20. Conclusions • Takotsubo CM often mimics ACS • Anginal chest pain with acute heart failure • This retrospective case series shows its difficult to distinguish the 2 in the ER

  21. Take Home Message • Physicians need to be aware of this alternative diagnosis to a STEMI • Still need to watch for dysrhythmias & cardiogenic shock with • Ideally, if Takotsubo CM suspectedcardiac catheterization should be chosen over fibrinolytics

  22. Further Discussion • Dr. Hunter Young, former Barker ACS

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