Takotsubo Cardiomyopathy By Dymond Unutoa

OBJECTIVES Learn various names of Takotsubo Cardiomyopathy (TTC) Understand the Presentation of TTC Understand the Etiology and Pathophysiology of TTC Understand the Diagnostic tools/measures in diagnosing TTC Understand the difference between TTC and AMI Understand some Treatment/Interventions utilized after TTC diagnosis Understand the general Prognosis of TTC Understand the Prevalence of TTC

Other names know by: Stress cardiomyopathy Transient left ventricular apical ballooning7,8 “Ampulla” cardiomyopathy4 “Broken Heart Syndrome”2,3 Neurogenic Myocardial Stunning6 Stress-Induced Cardiomyopathy Apical ballooning syndrome1

The Term “Takotsubo”[3] Japanese term meaning “octopus pot” First described in 1990 by Japanese MDs correlating the heart shape to a fisherman’s tako-tsubo

Presentation[1,2,3,4] Acute onset of chest pain Dyspnoe in addition to a transient left ventricular (LV) dysfunction Acute stage: Often mimics MI (AMI) Apical Akinesia Basal Hyperkinesia

Presentation Shortened LVEF (Left Ventricle Ejection Fraction) New ECG abnormalities (ST-segment elevation and/or T-wave inversion) Modest elevation in cardiac troponin

Etiology and Pathophysiology[1-9] The true cause of TTC is still under study but some proposed factors include… Coronary spasm Emboli with spontaneous fibrinolysis Myocarditis Stunning after/during stressful event Abnormal response (increase) in catecholamines such as epinephrine/norepinephrine

Etiology cont’d Life altering stressors such as… -Death of a loved one -Loss of employment -Divorce Narcotics withdrawal -Cocaine abuse -Opiate withdrawal -Alcohol withdrawal Extreme physical exertion

Etiology cont’d Catastrophic medical diagnosis Domestic abuse Gambling losses Confrontational arguments Natural Disasters

Diagnostic Measures Echocardiography Contrast ventriculography CMRI (Cardiac MRI) To distinguish the difference between TTC and AMI, a coronary angiography (CAG) is usually performed [8]

Mayo Clinic Criteria for Dx of TTC [3,5] 1. Transient akinesis or dyskinesis of the left ventricular apical and mid-ventricular segments w/ regional wall-motion abnormalities extending beyond a single epicardial vascular distribution 2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 3. New electrocardiographic abnormalities (either ST-segment elevation or T-wave inversion)

Mayo Clinic TTC Dx cont’d ABSENCE OF: Recent significant head trauma Intracranial bleeding Pheochromocytoma Obstructive epicardial coronary artery disease Myocarditis Hypertrophic cardiomyopathy

Exclusions made before TTC Dx Coronary Artery disease (especially proximal L main or L anterior coronary artery stenosis) Acute coronary syndrome Acute myocardial infarction Myocarditis, Pericarditis, Aortic dissections

Takotsubo vs. Acute Anterior MI[8] Can be distinguished by CAG 12 Lead ECG study performed to see if other differences can be picked up between the two. 3 main results found in TTC vs. AMI were… -1. greater ST segment elevation in leads V4-6 -2. absence of reciprocal changes in the inferior leads -3. absence of abnormal Q waves

Prognosis[1,2,310] The prognosis of patients with TTC is generally favorable; however, fatal complications have been reported with TTC such as left ventricular free wall rupture. Patients generally recover in a couple of days to a few weeks with excellent outcomes. Heart failure, with or without pulmonary edema, is the most common clinical complication. We believe that the published in-hospital mortality data are underestimated. It is important to pay attention to the hemodynamics in the acute phase, which often correspond to New York Heart Association class III heart failure. Only a handful of recurrent TTC cases have been reported. Mechanisms underlying susceptibility to recurrence are not understood. Articles are being published

Prognosis Cont’d[4] In a systematic study of multiple case reports, 14, a favorable outcome was likely. In-Hospital mortality was found in 3 of 286 patient (2 multiple organ failure, 1 ovarian cancer) In addition, only 6 of 169 evaluated patients had a recurrence (true recurrence rate limited to the 169 out of 286)

So What does it look like?

Takotsubo “In Motion”

Prevalence The prevalence of the disease is still unknown and under study More cases are being found in women, especially for those 60+ (one study states 75-95% of cases) Since TCC is becoming more and more widely recognized and more specific diagnostic criteria are being established, higher prevalence rates are being reported. In 2006, a study found the U.S. presenting a 2-2.2% of TTC cases for patients admitted for STEMI or unstable angina

Treatment and Intervention Immediate treatment involves the catheterization lab to rule out coronary obstruction disease Mild Heart Failure -Beta blockers -ACE Inhibitors -Diuretics Severe Heart Failure -Positive inotropic therapy -Intra-aortic balloon pump

Tx and Intervention cont’d Stress Management -Psychiatrist, Counseling Dietary changes Physical Therapy Cardiac Rehab Supervised Exercise until cleared by MD

Role of PT in Takotsubo Patients Since Takotsubo is a cardiomyopathy, cardiac rehab should be utilized. Easy non-stressful exercises Postural exercises to open chest wall Breathing exercises to aide in oxygen uptake Relaxation exercises to ease stressors

Other Related Findings… In a study, African American (AA) women had similar presenting symptoms of TTC to Non-AA women, but may differ in the electrocardiographic findings and in-hospital course of the disease. Fewer developed hypotension or needed hemodynamic support.[5] In a case report a 37 year old woman was diagnosed with TTC after being struck by lightning. She developed an acute cardiogenic shock that put her into respiratory distress during the initial hospital assessment. Transthoracic ECG confirmed the diagnosis.[6]

Limitations in Studies The ONE main factor affecting good validity of data in all research for TTC remains with subject numbers. Although it is growing in diagnostic criteria, the numbers are still relatively low and cohort studies are hard to design due to its rarity. [8,5] Timing of follow-up assessments varied widely, ranging from 8-days to 4 years.[4]

References 1. Stensææth K, Fossum E, Hoffmann P, Mangschau A, Skretteberg P, Kløøw N. Takotsubo cardiomyopathy in acute coronary syndrome; clinical features and contribution of cardiac magnetic resonance during the acute and convalescent phase. Scandinavian Cardiovascular Journal [serial online]. April 2011;45(2):77-85. 2. Biteker M, Duran N, Özkan M, et al. Broken heart syndrome in a 17-year-old girl. European Journal Of Pediatrics [serial online]. October 2009;168(10):1273-1275. 3. Koulouris S, Pastromas S, Sakellariou D, Kratimenos T, Piperopoulos P, Manolis A.S. Takotsubo Cardiomyopathy: The “Broken Heart” Syndrome. Hellenic Journal of Cardiology [serial online]. 2010;51: 451-457 4. Gianni M, Dentali F, Grandi A.M., Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. European Heart Journal. Doi:10.1093/eurheartj/ehl032. May 2006; 27, 1523-1529 5. QaQa A, Daoki J, Jallad N, Aburomeh O, Goldfarb I, Shamoon F. Takotsubo Syndrome in African American vs. Non-African American Women. Western Journal of Emergency Medicine [serial online] May 2011;12(2): 218-223

References cont’d 6. Dundon B, Puri R, Leong D, Worthley M. Takotsubo cardiomyopathy following lightning strike. BMJ Case Rep. Doi:10.1136/bcr.03.2009.1646 7. Ibanez B, Navarro F, Farre’ J, Marcos-Alberca et al. Tako-Tsubo Transient Left Ventricular Apical Ballooning Is Associated With a Left Anterior Descending Coronary Artery With a Long Course Along the Apical diaphragmatic Surface of the Left Ventricle. Rev Esp Cardiol [serial online] 2004;57(3):209-16 8. Ogura R, Hiasa Y, Takahashi T, et al. Specific Finding of the Standard 12-Lead ECG in Patients With ‘Takotsubo’ Cardiomyopathy – Comparison With the Finding of Acute Anterior Myocardial Infarction. Circulation Journal [serial online] Aug 2003; 67:687-690 9. ALEXANDRE J, BENOUDA L, CHAMP-RIGOT L, LABOMBARDA F. Takotsubo cardiomyopathy triggered by alcohol withdrawal. Drug & Alcohol Review [serial online]. July 2011;30(4):434-437. 10. Akashi Y, Goldstein D, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy:A New Form of Acute, Reversible Heart Failure. Circulation. 2008; 118: 2754-2762 doi: 10.1161/​CIRCULATIONAHA.108.767012