Stress-induced cardiomyopathy – 9/5/18

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

Picture1

Picture above and cool video from NEJM here.

 

 

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