What happens to broken hearts?

1. What happens to broken hearts? TAKOTSUBO CARDIOMYOPATHY TRISTAH ROMERO, BSN, RN MSN NURSING STUDENT ALVERNO COLLEGE Image from Microsoft clip art

2. Navigation Home Previous slide Next slide Previous slide viewed Hover over anywordswhich areBLUEand underlined for further description/definition.

3. 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.

4. Review of basic concepts Blood Flow Chart Cardiomyopathy Sympathetic Nervous System 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

5. Review of basic concepts quiz Where does blood go to immediatelyafter 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.

6. 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. 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. Cause peripheral edema No, that is not correct, peripheral edema would be caused by failure of the right ventricle.

7. 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.

8. 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 heart’s ability to pump blood.

9. 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

10. What is Takotsubo Cardiomyopathy? Takotsubo [tah-ku-su-bu] cardiomyopathy was first identified in Japan in the 1990’s. 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)

11. 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

12. 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)

13. 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

14. 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)

15. 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)

16. 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 isn’t good either … ex: SNS Porth & Matfin, 2009

17. 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)

18. 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)

19. 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. Patient’s 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.

20. 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?

21. 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 doesn’t 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

22. 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

23. 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?

24. Treatments/ Management In general, management varies and is based on the patient’s 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)

25. Do’s & 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)

26. Significance of disease • Occurs in approximately 1-3% of suspected acute coronary syndrome patients • Approximately 80-90% of patient’s 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)

27. 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)

28. 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)

29. 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)

30. 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.edu/bowneps/pathofbloodflow/pathmap.htm Bowne, P. S., (2004-2010). Heart failure/ defects. Retrieved from http://faculty.alverno.edu/bowneps/pathofbloodflow/pathproblem.htm

31. 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

32. References continued Mayo Clinic. (2011). Acute coronary syndrome. Retrieved from http://www.mayoclinic.com/health/acute-coronary-syndrome/DS01061 Mayo Clinic. (2011). Broken heart syndrome. Retrieved from http://www.mayoclinic.com/health/broken-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/article/1513631-overview#showall University of Maryland Medical Center. (2011). Cardiomyopathy- Overview. Retrieved from http://www.umm.edu/ency/article/001105.htm

33. References continued Up to date. (2011). Criteria for the diagnosis of acute myocardial infarction. Retrieved from https://ive.aurora.org/contents/,DanaInfo=www.uptodate.com+criteria-for-the-diagnosis-of-acute-myocardial-infarction?source=search_result&search=acute+coronary+syndrome&selectedTitle=11%7E150 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), 76–79. 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/wiki/Takotsubo_cardiomyopathy

34. 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

35. 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