Thanks to Eric for presenting the case of an “late middle-age” woman with chest pressure, found to have ST depressions, troponin elevation, TTE with apical akinesis, and clean coronaries on cardiac cath concerning for Takotsubo cardiomyopathy.

Clinical Pearls

• Think of heart failure as ischemic vs non-ischemic
• Most common causes of heart disease are ischemia (CAD), HTN, idiopathic, valvular, infectious (viral), and drugs.
• MINOCA or myocardial infarction with nonobstructive coronary arteries is MI in the absence of coronary artery disease with >50% vessel occlusion and includes the following etiologies
  • Stress induced cariodmyopathy (Takotsubo)
  • Coronary vasospasm
  • Microvascular dysfunction
• Takotsubo cardiomyopathy most commonly presents in postmenopausal women and triggered by physical or emotional stress.  The pathogenesis is not well understood and the course is self-limited.  Treatment is largely supportive.  Prognosis to recovery of cardiac function is 1-4 weeks.

Heart failure

• Ischemic
  • CAD
  • Bridge
• Non-ischemic
  • HTN
  • Valvular disease
  • Idiopathic
  • Infectious (viral is most common)
  • Infiltrative (sarcoid, amyloid, hemochromatosis)
  • Stress induced cardiomyopathy (Takotsubo)
  • Arrhythmia
  • High output (secondary to anemia, Paget’s disease, pregnancy, AV fistula, beriberi, hyperthyroidism)
  • Post-partum
  • Hypothyroidism
  • OSA
  • Connective tissue disease

MI with non-obstructive coronary arteries (MINOCA)

• Diagnosis: requires the following
  • Clinical documentation of MI
  • Exclusion of obstructive CAD
  • No overt cause for acute MI present
• Etiologies: significant overlap with non-ischemic causes of heart failure
  • Non-cardiac
    • Reduced troponin clearance (i.e. renal impairment)
    • Increased right heart pressures (ex PE)
  • Cardiac causes
    • Stress induced cardiomyopathy
    • Inflammation (myocarditis)
    • Coronary artery spasm (vasospastic angina)
    • Microvascular dysfunction (microvascular angina, microvascular spasm, coronary slow flow phenomenon)
    • Thrombophilia
• Work up
  • MINOCA is a working diagnosis
    • Exclude non-cardiac cause
    • Rule out ischemic etiology
    • TTE
    • Cardiac MRI is often indicated
    • Provocative spasm testing (with acetylcholine etc in the case of coronary vasospasm)

Takotsubo cardiomyopathy

• First described in Japan in 1990
• It is the underlying etiology in ~1-2% of patients presenting with ACS
• More common in post-menopausal women (mean age 66.4)
• Pathogenesis:
  • Not well understood
• Clinical manifestations
  • Often triggered by emotional or physical stress but ~30% of the time, no trigger is identified
  • Symptoms
    • Most commonly present with acute substernal chest pain.  Less commonly present with SOB or syncope or heart failure symptoms
  • Exam
    • May have late peaking systolic murmur similar to HOCM
  • EKG changes:
    • ST elevation in anterior leads (43.7%)
    • ST depression (7.7%)
    • QT prolongation, T wave inversion, abnormal Q waves
  • Troponin elevation in most patients (mean initial troponin is ~7-8)
  • Diagnostic criteria
    • Transient LV systolic dysfunction (hypokinesis, akinesis, or dyskinesis), wall motion abnormalities that extend beyond a single epicardial coronary distribution
    • Absence of CAD based on cath
    • New EKG abnormalities
    • Absence of pheochromocytoma or myocarditis
  • Work up
    • Rule out ACS
    • Cardiac MRI to rule out other causes of MINOCA
  • Management
    • Supportive
  • Prognosis
    • Recovery in 1 to 4 weeks

Picture above and cool video from NEJM here.