Takotsubo’s; An Apical Eclipse of the Heart

1. Takotsubo’s;An Apical Eclipse of the Heart LT Tyler House, DO LCDR Justin Lafreniere, MD LCDR Gregory Fuhrer, MD Naval Medical Center Portsmouth

2. Disclaimer • I have nothing to disclose • The views and opinions expressed herein do not necessarily state or reflect those of the Naval Medical Center Portsmouth, DoD, or the United States Government

3. Case • 65 year old Filipina female with Stage IV NSCLC presented with 3 weeks of progressive dysphagia • Associated Symptoms - Dysphagia is with both liquids/solids without odynophagia - Vomiting - Cough - Palpitations • Patient briefly admitted for 2 days, 3 weeks prior for food impaction s/p EGD with stricture noted

4. Case • Past Medical History - Stage IV NSCLC on maintenance Avastin Q 3 wks - Completed chemo/radiation March 2011 - Bradycardia with Pacemaker October 2012 - Atrial fibrillation s/p ablation 2010 - Anxiety • Past Surgical History - L VATS with wedge resection July 2012 - RUL resection June 2011

5. Case • Vitals and physical exam on presentation unremarkable • EGD -> severe stricture noted, biopsy taken • EGD discussed -> patient informed that stricture was suspected to be malignant -> noted by husband to become very anxious afterwards • Following hours patient developed chest pain, dyspnea, tachycardia and hypotension • Heparin initiated due to high pre-test probability for PE

6. Case • EKG unchanged, Troponin 0.906ng/ml, CXR pulmonary edema pattern • POC U/S -> depressed LV function, apical ballooning Systole Diastole

7. Case • LHC -> normal coronary arteries with apical ballooning

8. Case Systole Diastole

9. Case • BP continued to decline and perfusion indices worsened • Cardiogenic shock due to Takotsubo’s Cardiomyopathy diagnosed as cause of hypotension and hypoxia • Given the fulminant cardiogenic shock and stage IV lung cancer, the patient was placed on comfort care and died soon thereafter

10. Takotsubo’s Discussion • Reversible cardiomyopathy • 90% women, 90% post-menopausal • Triggers • “Catecholamine Theory” • “stimulus trafficking” • Mimics Acute Coronary Syndrome Akashi Y, Goldstein D, et al. Takotsubo Cardiomyopathy: A New Form of Acute Reversible Heart Failure. Circulation., 2008; 118:2754-2762

11. Takotsubo’s Discussion • New EKG findings and/or modest troponin elevation • Transient hypokinesia of middle and apical regions of LV with hyperkinetic basal region (LV gram or echo) • Normal coronary arteries by arteriography • Absence of other etiology Akashi Y, Goldstein D, et al. Takotsubo Cardiomyopathy: A New Form of Acute Reversible Heart Failure. Circulation., 2008; 118:2754-2762

12. Point of Care Ultrasonography • Rapid evaluation of heart, lungs and IVC • Early and appropriate management is critical • POC U/S facilitates early diagnosis, early treatment Volpicelli G, Lamorte A, et al. Point-of-care multiorganultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013; 39:1290-1298. Hypokinetic LV Dilated RA/RV

13. Takotsubo’s Treatment and Prognosis • Supportive • May require hemodynamic support • 96% recovery rate • Rarely cardiogenic shock and death • Could this have been prevented??

14. Breaking Bad News (BBN) • ASCO “Breaking Bad News Symposium” • Residents and Medical Students untrained • Research suggests BBN is teachable • “SPIKES” Baile WF, Buckman R et al. SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000; 5:302-311.

15. Key Points • TCM is precipitated by an acute stressor, and may rarely lead to cardiogenic shock and death • POC Ultrasound is invaluable tool in rapid diagnosis and management of cardiopulmonary failure • Residency programs should invest time in the teachable skill of “breaking bad news”

16. Questions? “The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician” American Medical Association, first code of medical ethics, 1847