Fixing A Broken Heart!

1. Fixing A Broken Heart!

2. DEPARTMENT OF INTERNAL MEDICINE MEDICAL GRANDROUNDSRANIER T. TANALGO M.D.PresenterRUTH DIVINAGRACIA M.D.Moderator9TH Floor-Ledesma HallMarch 17, 2011

3. OBJECTIVES: 1. To present a case of 71yo patient who had difficulty of breathing after diving. 2. To present a case of a patient presented with NSTEMI with normal coronary angiographic findings.

4. History of Present Illness: 1 Day PTA Deep sea diving (70 feet) Panicked/ anxiety attack Difficulty of breathing (+) chest tightness, (+) nausea, (+) dizziness, (-) epigastric pain, (-) nausea, (-) vomiting ADMISSION

5. Review of Systems: • No history of headaches, dizziness • No cough, fever, chest pain • No weight loss, edema • No abdominal pains, no urinary and bowel movement changes, no joint pains, no pruritus, no numbness • No sensorial changes, behavioral changes, visual changes, seizures, focal weekness, easy fatigability, no hearing loss

6. Past Medical history: • (+) Hypothyroid and maintained on unrecalled medication • (+) Depression treated since the 1980’s • (+) Vaginal hysterectomy • (+) Shingles in 2004 • (+) Bilateral bunionectomy • (+) Sclerotherapy for varicose veins of the lower extremities • (+) Allergic to Penicillins- itchiness • (-) Hypertension • (-) Diabetes mellitus • (-) Bronchial asthma.

7. Family History: rBoth parents sides (+) Hypertension (+) Coronary Artery Disease (+) Dyslipidemia (+) Thyroid disease

8. Personal/Social history: • Non-smoker • Occasional alcoholic beverage drinker

9. Physical Examination: Conscious, coherent, oriented, not in distress: BP=106/72mmHg HR=82bpm RR=20cpm Temp=37C O2 Sat 93% at 4LPM nasal cannula Ht: 167.64 cm Wt: 68kgs BMI: 24.19 kg/M2

10. Physical Examination: • Skin: warm, good turgor, no pallor, no cyanosis, no skin color changes • HEENT: anicteric sclera, pinkish palpebral conjunctivae, no naso-aural discharges, no tonsilopharyngeal congestion, • Neck: no neck vein distention, JVP=5-6cm, no lymphadenopathy, non-palpable thyroid gland, no carotid bruit

11. Physical Examination: • Chest and Lungs: no retractions, symmetrical chest expansion, mid to base bilateral coarse rales, no wheezing • Heart: normal rate, regular rhythm, apex beat at 5th ICS LMCL, S1>S2 at apex, S2>S1 at base, no S3, no heave, no thrill, no murmur

12. Physical Examination: • Abdomen: flat, normoactive bowel sounds, soft, non-tender, no organomegaly, no masses • Extremities: no edema, left leg noted slightly bigger than right leg (reportedly fell 3 weeks ago and injured left knee)

13. Salient features Subjective Findings Objective findings • 71/Female • Difficulty of breathing after diving • Elevate d Trop I • Pulmonary edema on CXR • Bilateral crackles from mid to base • Bilateral crackles from mid to base • Normal vital signs

14. Differential Diagnosis • Chest pain described as a pressure sensation, fullness, or squeezing in the midportion of the thorax • Radiation of chest pain into the jaw or teeth, shoulder, arm, and/or back • Associated dyspnea or shortness of breath • Associated epigastric discomfort with or without nausea and vomiting • Associated diaphoresis or sweating • Syncope or near syncope without other cause • Impairment of cognitive function without other cause Patient Non ST Elevation Myocardial Infarction • 71/Female • Difficulty of breathing after diving • Difficulty of breathing after diving • Elevate d Trop I • Pulmonary edema on CXR • Bilateral crackles from mid to base

15. Differential Diagnosis Patient Decompression sickness • 71/Female • Difficulty of breathing after diving • Elevate d Trop I • Pulmonary edema on CXR • Bilateral crackles from mid to base • ECG: Non specific ST wave chenges • Extreme Fatigue, Pain in Joints, Muscle Pain, Dizziness, Paralysis, Rash on Skin, Staggering, Choking. Decreased Sensation, Collapse or Unconsciousness • P wave peaking and P-R depression compatible with right heart strain; S-T segment and T wave changes suggestive of myocardial ischemia; and ventricular arrhythmias ranging from unifocal premature ventricular contractions to ventricular tachycardia

16. Differential Diagnosis Most common symptom is unexplained shortness of breath and/or chest pain with difficulty breathing Chest pain, often worse when taking a breath A feeling of apprehension Sudden collapse Coughing Sweating Non-specific ST changes Tachycardia Patient Acute Pulmonary Embolism • 71/Female • Difficulty of breathing after diving • Elevate d Trop I • Pulmonary edema on CXR • Bilateral crackles from mid to base

17. Admitting Impression: Acute pulmonary edema probably secondary to Acute Coronary Syndrome-Non ST elevation Myocardial Infarction Rule out Decompression Sickness Rule out Acute Pulmonary Embolism

18. At the ER • Patient started on MI protocol (Enoxaparin, ASA, Clopidogrel, Bromazepam and Lactulose, Furosemide,and Rosuvastatin • ECG showed non-specific ST-T wave changes, poor R wave progression • Electrolytes

19. At the ER • CXR: There are no active parenchymal infiltrates seen. Pulmonary vessels are within normal limits. Heart is normal in size and configuration. Mediastinum, diaphragm, and bony thorax are unremarkable. • ABG: Respiratory alkalosis

20. At the ER • Cardiac enzymes were elevated (Trop I 10.62 ng/ml, CPK 732 U/L and CPK MB isoenzyme 40.40 ng/ml). • Pro BNP and D dimer were elevated • Protime was normal • CBC showed leukocytosis (WBC 13.25) with predominance of segmenters(80) and monocytes(10)

21. At the ER • 2 D echo revealed dilated left ventricular dimensions with left ventricular global hypokinesia; LVEF of 36% by Teicholz and 35% by Simpson’s. MR, mild. TR, mild.

22. Medical Intensive Care Unit Second Hopsital Day • Repet ECG: Sinus tachycardia with occasional premature ventricular contraction • Patient had hypotension • Inotropes started with Dopamine and Dobutamine • Patient was scheduled for stat left heart catheterization with coronary angiography on double set up for possible angioplasty and CABG

23. Medical Intensive Care Unit Second Hopsital Day • Repeat cardiac enzymes: Trop I 4.42, CPK 374, CPK MB isoenzyme 15.90 • Electrolytes

24. Medical Intensive Care Unit Second Hopsital Day Left heart catheterization with coronary angiography: • Conclusion: Minimal, nonobstructive, atherosclerotic coronary artery disease. • Markedly elevated LVEDP at rest. • The etiology of the LV systolic dysfunction noted on 2 D echocardiography and elevation of cardiac markers is uncertain.

25. Medical Intensive Care Unit Fourth Hopsital Day Repeat 2 D echo:NLVD with hypokinesia of the anterior interventricular septum and anterior and lateral LV wall from base to apex. LVEF 54% by Teicholz and 54% by Simpson’s. Normal left and right atria. Normal right ventricle. Normal main pulmonary artery and aortic root dimensions. Calcification on aortic walls. Mitral and aortic annular calcification.

26. Medical Intensive Care Unit Fourth Hopsital Day Repeat 2 D echo: • Color flow and Doppler study: MR, trivial. TR, trivial. Calculated pulmonary artery pressure by TR jet 40 mmHg. Pulmonary hypertension, mild. • Compared with previous study done Jan. 15, 2011-03-10 • Left ventricular end diastolic diameter decrease from 5.4cm to 4.7cm. • Ejection fraction has increase from 36% to 54%.

27. Medical Intensive Care Unit Fourth Hopsital Day • Venous dupplez scan of lower extremities: Normal • Carotid doppler: Normal

28. Medical Intensive Care Unit Fifth Hopsital Day • Patient was stable • Transferred out to regular room • Referred to cardiac rehab • Discaharged on the 8th hospital day • CXR

29. Follow up done at Mayo Clinic Follow after 1 month Trans esophangeal echocardiogram performed LV: normal LV chamber size. NLVSF. ELVEF, 65%. No regional wall motion abnormalities. NRVSF. No shunt at atria level by color flow imaging and agitated contrast injection

30. In Summary • 71/F • Sudden dyspnea after diving • Non-specific ST changes • Elevated cardiac enzymes • 2 D echo with segmental wall hypokinesia with improvement after 4 days • Normal Coronary angiogram

31. Final diagnosis • Acute Cornary Syndrome- Non ST Elevation Myocardial Infarction complicated by pulmonary edema • Tako-Tsubo cardiomyopathy

32. Tako-TsuboCardiomyopathy (TTC) • Tako-Tsubo – Japanese name for octopus trap fisherman uses to catch octopus. • TTC – Heart (LV) • Like the shape of an octopus trap

33. Broken Heart Syndrome Other names: • Stress induced cardiomyopathy • Transient LV apical balooning • Apical balooning syndrome • Tako-Tsubo Cardiomyopathy

34. An antique tako-tsubo.

36. Epidemiology • Early 1990’s – 1st reported in Japan by Sato et al • Early 2000 – recognized in western white population, Africans, Americans, Asians • High prevalence in Japan • Women : men ratio (7:1) • Age • 68.6 + 12.2 women • 65.9 + 9.1 men Kinji Ishikawa, M.D.

37. Epidemiology • TTC accounts for 2% of all patients presenting with CP and ST elevation. Gianni et al European Heart Journal 2006 27: 1523-1529

38. Mayo Clinic criteria for tako-tsubo cardiomyopathy • Transient, reversible akinesis or dyskinesis of the left ventricular apical and mid-ventricular segments with regional wall motion abnormalities extending beyond a single vascular territory on left ventriculography. • Absence of obstructive coronary artery stenosis > 50% of the luminal diameter or angiographic evidence of acute plaque rupture. MJA • Volume 187 Number 6 • 17 September 2007

39. Mayo Clinic criteria for tako-tsubo cardiomyopathy • New electrocardiographic abnormalities consisting of ST-segment elevation or T-wave inversion. • Absence of:recent head trauma, intracranial bleeding, phaeochromocytoma, obstructive epicardial coronary artery disease, myocarditis, hypertrophic cardiomyopathy

40. Pathophysiology • Exact mechanism unknown • Evidences point to: • Catecholamine mediated mechanism via cardiac sympathetic neurons which can be triggered by emotional or physical stress.  • Myocardial stunning form multiple site microvascular spasm

41. Pathophysiology • Wall motion localized at the distal half of the LV (apical balooning) • More dense adrenoreceptors at the apex.

42. Pathophysiology • Stressors • 65 – 80% - with identifiable stressors • 50% - emotion • 50% - physical • 20 – 35% – non identified Irfran Abdulla, MD Clinical Update MJA vol 187 No. 6 – 17 Sept 07

43. Common physical, psychological and emotional stressors precipitating tako-tsubo cardiomyopathy • Unexpected death in the family • Gambling and financial losses • Devastating medical diagnosis • Car accidents • Public speaking • Earthquakes • Acute physical trauma • Robbery • Major surgical procedures MJA • Volume 187 Number 6 • 17 September 2007

44. FIGURE 1. Different end-systolic left ventricular (LV) silhouettes published in different articles under the term “Takotsubo syndrome” (transient LV apical ballooning or broken heart syndrome). The tracing was done exactly over the shape of the angiograms from the articles (A, Abe et al8; B, San Roman Sanchez et al9; C, Wittstein et al10; D, Rivera et al3; E, Desmet et al11; and F, Reyburn and Vaglio4). As can be clearly seen, there is wide heterogeneity among the different patterns, varying from a relatively small akinetic apical area in C to a wide global akinesia in D and E. Mayo Clin Proc. • June 2006;81(6):732-735 • www.mayoclinicproceedings.com

45. Usual Presentation • Post menopausal – female • Chest pain, dyspnea, hypotension • 1-5% hemodynamically unstable • ECG – ST elevation in V3 – V6 or diffuse ST – T changes • Troponin & CK-MB – no rise or min 

46. Usual Presentation • Serum nor epinephrine – significantly  • LV wall motion – apical balooning or dyskinesia and basal hyperkinesia during systole • Coronary Angio – no significant CAD • Precipitating factors – severe emotional or physical stress

47. Treatment • Self – limiting disorder •  – Blocker • ACE I • Caution on patients • With LVOT obstruction • Avoid • Inotropes • Volume depletion • Vasodilators

48. Prognosis • Excellent despite • Hemodynamic compromise in some patients • Hospital mortality 0 – 8% • LV systolic function (N) in 1 – 4 weeks • Recurrent rate low 1 – 5% • Long term Rx – unclear

50. Conclusions 1. Is a reversible cardiomyopathy triggered by psychologically stressful events. 2. Occurs in older women and may mimic evolving acute myocardial infarction or coronary syndrome.