Intern Case Report Jessica Garza The Imitation Game Intern Case Report Jessica Garza

This is a 66 y/o lady who presented to BSW complaining of transient chest pain, lightheadedness, and hypotension (80’s systolic at home). Lasted for 30 minutes then dissipated, described as “tightness”. Also associated with palpitations. One day prior patient’s husband called to inform her that her son had died unexpectedly. PMH: Atrial Fibrillation s/p ablation in 2004 and 2013, Bradycardia PSH: Ablation as noted Family History: Mother-Breast Cancer/Heart Disease Father- Unknown Cancer Social History: Lives with her husband. No alcohol, drugs, or tobacco products. Our Patient

Differential Diagnosis 1) Ischemic Chest Pain -Coronary Disease (ACS) -Coronary Vasospasm -Cardiac Syndrome X 2) Valvular Heart Disease (think aortic stenosis, etc…) 3) Non-ischemic Cardiac Chest Pain -Pericarditis -Myocarditis -Acute Aortic Syndromes (Aortic Dissection…) 4) Chest Wall Pain 5) Chest Pain Secondary to Hyperadrenergic State -Stress-Induced Cardiomegaly -Cocaine Intoxication/Methamphetamine Use -Pheochromocytoma 6) Gastrointestinal 7) Pulmonary 8) Psychogenic 9) Referred Pain to the Chest Gastrointestinal: GERD, Esophageal spasm/motility issues, esophagitis Pulmonary: Acute PE, Pneumonia, Pleurisy, Pneumothorax, Sarcoidosis, COPD/Asthma Differential Diagnosis

Objective Data Vitals on Admission Physical Exam Pertinent Information BP: 93/54 P: 50 Temp: 98.8 RR: 14 Oxygen Saturation: 100% Physical Exam Pertinent Information General: Receiving oxygen on a NRB while at rest Neck: No JVD, JVP wnl, No carotid bruits Heart: Bradycardic, regular rhythm, no murmurs/gallops/rubs. No thrills or pulmonary tap. Lungs: Clear bilaterally. No chest wall tenderness. Abdomen: Non-tender Extremities: No pitting edema noted, 2+ pulses Skin: Warm, well perfused Laboratory Data CMP: Elevated AST 63, Glucose 135, Bicarbonate 20 INR: 1.0 CBC: WBC 12.2 w/ neutrophilic predominance Hgb A1C: 5.8% Troponin: 2.46 on admission Imaging Chest X-Ray showed bilateral infra-hilar parenchymal opacities. Small left pleural effusion. Cardiomegaly. Objective Data

Differential Diagnosis 1) Ischemic Chest Pain -Coronary Disease (ACS) -Coronary Vasospasm -Cardiac Syndrome X 2) Valvular Heart Disease (think aortic stenosis, etc…) 3) Non-ischemic Cardiac Chest Pain -Pericarditis -Myocarditis -Acute Aortic Syndromes (Aortic Dissection…) 4) Chest Wall Pain 5) Chest Pain Secondary to Hyperadrenergic State -Stress-Induced Cardiomegaly -Cocaine Intoxication/Methamphetamine Use -Pheochromocytoma 6) Gastrointestinal 7) Pulmonary 8) Psychogenic 9) Referred Pain to the Chest Gastrointestinal: GERD, Esophageal spasm/motility issues, esophagitis Pulmonary: Acute PE, Pneumonia, Pleurisy, Pneumothorax, Sarcoidosis, COPD/Asthma Differential Diagnosis

Read as Sinus Bradycardia w/ sinus arrhythmia QTC 479 Left Atrial Enlargement Low Voltage (Consider pulmonary disease or pericardial effusion) Possible inferolateral and anterior infarct, age undetermined Unchanged from Previous EKG’s

ED Course and Initial Hospitalization Given full dose Aspirin Due to emotional stress with intermittent chest pain, continued nausea, and troponin elevation, there was concern for cardiac etiology, likely ischemic. CVICU was consulted while in the ED. Recommended loading plavix and begin Heparin drip. NPO for possible cardiac procedures in the AM. Transferred to the floor for monitoring 10/25 Troponin Trend: 2.462.371.541.18 Cardiology saw patient on 10/26 who felt that would be prudent to monitor troponin levels, get an echocardiogram. If abnormal, the plan was to get a coronary angiogram the next day. If right ventricle was abnormal, planned for CT PE protocol. Of note, the family wanted as much non-invasive work-up as possible. ED Course and Initial Hospitalization

Echocardiogram Results Mild dilation of the left ventricle with severely depressed LVEF (32%) Regional wall motion abnormalities with abnormal mid and apical wall segments demonstrating hypokinesis. Normal basal wall motion. Plan was to go to angiography the following morning. Echocardiogram Results

Dr. Blue was called by the war room as our patient went into sustained ventricular tachycardia. Patient was temporarily un- responsive. Review of telemetry showed torsades prior to event. BP 97/46, HR 48. She was placed on non-rebreather mask and cardioverted x1 with success in achieving NSR. Received magnesium, amiodarone, and calcium chloride. CVICU was consulted and took the patient down into the ICU on Heparin and Amiodarone drip. She was stabilized w/ plan for cath in the AM. All QT Prolonging Medications were discontinued. 0450 10/27/14 Dr. Blue Called

Now saying PVC’s are present. QT Interval Prolongation

Differential Diagnosis 1) Ischemic Chest Pain -Coronary Disease (ACS) -Coronary Vasospasm -Cardiac Syndrome X 2) Valvular Heart Disease (think aortic stenosis, etc…) 3) Non-ischemic Cardiac Chest Pain -Pericarditis -Myocarditis -Acute Aortic Syndromes (Aortic Dissection…) 4) Pulmonary 5) Chest Pain Secondary to Hyperadrenergic State -Stress-Induced Cardiomegaly -Pheochromocytoma Gastrointestinal: GERD, Esophageal spasm/motility issues, esophagitis Pulmonary: Acute PE, Pneumonia, Pleurisy, Pneumothorax, Sarcoidosis, COPD/Asthma Differential Diagnosis

Coronary Angiography Results Angiogram showed no significant coronary artery disease She continued to have recurrent runs of vtach during the angiogram. Temporary Transvenous Pacemaker was placed while in the cath lab w/ rate set at 80 bpm. Left Ventriculogram was performed which showed severe hypokinesis of the left ventricle with some preserved contractility of the basal segments. Not completely typical apical ballooning. Coronary Angiography Results

Differential Diagnosis 1) Ischemic Chest Pain -Coronary Disease (ACS) -Coronary Vasospasm -Cardiac Syndrome X 5) Chest Pain Secondary to Hyperadrenergic State -Stress-Induced Cardiomegaly -Pheochromocytoma Gastrointestinal: GERD, Esophageal spasm/motility issues, esophagitis Pulmonary: Acute PE, Pneumonia, Pleurisy, Pneumothorax, Sarcoidosis, COPD/Asthma Differential Diagnosis

Stress Cardiomyopathy (Takotsubo Cardiomyopathy)

Known by several names: Apical ballooning syndrome, Broken Heart Syndrome, Takotsubo cardiomyopathy, and stress-induced cardiomyopathy. Definition: Transient systolic dysfunction of the apical or mid segments of the left ventricle. Presentation mimics an MI but has no evidence of significant coronary disease. First described in Japan. “Takotsubo” refers to term for octopus trap which has a shape similar to the apical ballooning seen on contraction during the ventriculogram. Much more common in women compared to men, making up 80- 100%. Average age ranged from 61-76 years old So, what is it?

Apical and mid segment ballooning w/ hyperkinesis of the basal walls. Ventriculogram

Talk about higher norepinephrine levels in SICM compared to MI, rat models, pheochromocytoma patients (reversibility) Theory

Epinephrine is negatively inotropic because switching from beta 2 adrenoreceptor mediated Gs protein signaling (positive inotrope) to Gi protein signaling which is negative. May be reason for greater affect on apical myocardium. Studies that looked at MICU patients and found 26/92 patients (incidence), found 2 month survival of 52% compared to 71% Apical Ballooning

Imitates an acute MI-acute substernal chest pain Imitates an acute MI-acute substernal chest pain. (Most common presentation) Prototype patient: postmenopausal woman, acute psychological stress Often have EKG changes: STEMI or new T wave inversions w/ mild troponin elevation. Accounts for 2% of ACS presentations Typical Presentation

Diagnosis The Mayo Clinic Diagnostic Criteria 1) Transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid segments w/ or w/o apical ballooning . Regional wall motion abnormalities extend beyond a single coronary artery distribution. Stressful inciting event is often present (not always). Wall motion abnormalities seen on echocardiogram or ventriculogram. 2) Absence of obstructive coronary artery disease or acute plaque rupture on angiogram. 3) New EKG findings (ST elevation or T wave inversion) or modest elevation in troponin level EKG abnormalities are the most common clinical finding w/ ST elevation mostly commonly found in the anterior precordial leads. 4) Absence of pheochromocytoma or myocarditis There are exceptions to these rules! Diagnosis

Complications Heart failure, arrhythmias (Vtach, Vfib)—our patient Valvular abnormalities-mitral regurgitation Cardiogenic Shock (stunned mycardium) LVOT-develop systolic murmur similar to that heard in HOCM Apical thrombus formation Stroke Complications

Risk Score to Predict Heart Failure Based on the following being present Age > 70 years Presence of a physical stressor LVEF <40% <10% in the absence of these risk factors 1=28% 2=58% 3=85% Risk Score to Predict Heart Failure

Management and Treatment Acute management of these patients will involve ACS protocol. Suspicion for stress-induced cardiomyopathy IS NOT a reason to without acute therapy. Many patients will undergo PCI or fibrinolytic therapy. The condition is TRANSIENT. Treatment involves supportive care. Patients improve and have recovery of systolic function usually within 1-4 weeks. Currently, recommendations are to treat with regimen for systolic CHF: ace-inhibitors, beta blockers, diuretics (if evidence of volume overload). Aspirin if any coronary disease seen. No specific guidelines for duration of therapy. Typically treat until systolic function recovers. Usually continue beta blockers or alpha blockers for adrenergic blockade as condition may recur. Management and Treatment

Management of Complications Shock Thromboembolism Perform echocardiogram to determine if LVOT is present which guides therapy. With LVOT, treatment with beta blockers is indicated to improve hemodynamics. If thrombus present, treat with anticoagulation for 3 months minimum. No thrombus with severe systolic dysfunction, recommendations state anticoagulation until systolic function improves and dyskinesis resolves. Management of Complications

Our Patient’s Follow-Up Due to concerning arrhythmias, she was discharged on a life vest though her EF improved slightly prior to admission. Holding beta blocker therapy due to persistent bradycardia. In addition, she was off anti-arrhythmic therapy for atrial fibrillation due to prolonged QT. Placed on Xalreto for anticoagulation. Aspirin for mild coronary disease. Lisinopril for systolic dysfunction. Repeat echocardiogram in Nov. 2014 showed normal LV systolic function w/ EF 50%. No regional wall motion abnormalities. Her life vest was discontinued at that time. Currently doing well  Our Patient’s Follow-Up

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