Acute Heart Failure in Apical Acute Heart Failure in Apical Ballooning Syndrome Ballooning Syndrome

(Takotsubo/Stress Cardiomyopathy)(Takotsubo/Stress Cardiomyopathy)Clinical Correlates and Mayo Clinic Risk Clinical Correlates and Mayo Clinic Risk

ScoreScore

Malini Madhavan, MBBS; Charanjit S. Rihal, MD, FACC; Amir Malini Madhavan, MBBS; Charanjit S. Rihal, MD, FACC; Amir Lerman MD, FACC; Abhiram Prasad, MD, FRCP, FACCLerman MD, FACC; Abhiram Prasad, MD, FRCP, FACC

Division of Cardiovascular DiseasesDivision of Cardiovascular Diseases

Mayo Clinic, RochesterMayo Clinic, Rochester

No relevant author disclosuresNo relevant author disclosures

J. Am. Coll. Cardiol. 2011;57;1400-1401

BackgroundBackground

• Apical ballooning syndrome (ABS) is Apical ballooning syndrome (ABS) is characterized by transient regional characterized by transient regional systolic dysfunction of the left ventricle in systolic dysfunction of the left ventricle in the absence of obstructive coronary artery the absence of obstructive coronary artery diseasedisease

• Acute heart failure (HF) is the most Acute heart failure (HF) is the most common complicationcommon complication

• Acute HF can cause significant morbidity Acute HF can cause significant morbidity in ABSin ABS

AimsAims

• To examine the frequency and To examine the frequency and prognosis of patients with acute HF prognosis of patients with acute HF complicating ABS complicating ABS

• To identify the risk factors for acute To identify the risk factors for acute HF in ABSHF in ABS

MethodsMethods Study PopulationStudy Population

• Study cohortStudy cohort • 118 consecutive ABS patients 118 consecutive ABS patients

identified between January 2002 identified between January 2002 and January 2008and January 2008

• Validation cohortValidation cohort• 52 consecutive ABS patients 52 consecutive ABS patients

identified between Feb 2008 and identified between Feb 2008 and December 2009December 2009

MethodsMethods Mayo diagnostic criteria for ABSMayo diagnostic criteria for ABS

• Transient akinesis, hypokinesis or dyskinesis of Transient akinesis, hypokinesis or dyskinesis of the left ventricular mid segments with or without the left ventricular mid segments with or without apical involvement. The regional wall motion apical involvement. The regional wall motion abnormalities extend beyond a single epicardial abnormalities extend beyond a single epicardial vascular distributionvascular distribution

• Absence of obstructive coronary disease or Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture,angiographic evidence of acute plaque rupture,

• New ECG abnormalities (either ST-segment New ECG abnormalities (either ST-segment elevation and/or T wave inversion) or elevated elevation and/or T wave inversion) or elevated cardiac troponin,cardiac troponin,

• The absence of pheochromocytoma or The absence of pheochromocytoma or myocarditismyocarditis

Prasad et al. Am Heart J 155(3):408-17

Methods: DefinitionsMethods: Definitions

Acute heart failureAcute heart failure• New onset symptoms such as dyspnea, andNew onset symptoms such as dyspnea, and

• At least 2 of the following physical signs - At least 2 of the following physical signs - pulmonary rales, elevated central venous pulmonary rales, elevated central venous pressure, and the presence of a third heart soundpressure, and the presence of a third heart sound

Cardiogenic shockCardiogenic shock• Systolic blood pressure of <90 mm Hg for greater Systolic blood pressure of <90 mm Hg for greater

than 1 hour secondary to cardiac dysfunction than 1 hour secondary to cardiac dysfunction associated with signs of hypoperfusionassociated with signs of hypoperfusion

• Patients with systolic blood pressure increase to Patients with systolic blood pressure increase to >90 mm Hg within 1 hour after administration of >90 mm Hg within 1 hour after administration of inotropic agents, who met other criteria for inotropic agents, who met other criteria for cardiogenic shockcardiogenic shock

Clinical CharacteristicsClinical Characteristics

VariableVariable

No Acute HFNo Acute HF(N=65)(N=65)

Acute HFAcute HF(N=53)(N=53) p-valuep-value

Age (years) Age (years) 67 (12)67 (12) 73 (12)73 (12) 0.020.02

Female gender Female gender 63 (97%)63 (97%) 52 (98%)52 (98%) 0.70.7

Presenting symptomPresenting symptom Chest PainChest Pain DyspneaDyspnea

51 (78%)51 (78%)26 (40%)26 (40%)

23 (43%)23 (43%)35 (66%)35 (66%)

<0.0001<0.00010.0050.005

Precipitating factorPrecipitating factor Emotional stressEmotional stress Physical stressPhysical stress

19 (30%)19 (30%)23 (35%)23 (35%)

11 (21%)11 (21%)37 (70%)37 (70%)

0.00030.0003

ElectrocardiogramElectrocardiogram ST-segment elevationST-segment elevation Deep T wave inversionDeep T wave inversion

23 (36%)23 (36%)39 (60%)39 (60%)

31 (58%)31 (58%)26 (49%)26 (49%)

0.010.010.20.2

Clinical CharacteristicsClinical Characteristics VariableVariable No Acute HFNo Acute HF

(N=65)(N=65)Acute HFAcute HF

(N=53)(N=53)p-p-

valuevalue

Biomarkers Biomarkers Admission Troponin T Admission Troponin T (ng/ml)(ng/ml)

Peak Troponin T Peak Troponin T (ng/ml)(ng/ml)

BNP BNP (pg/ml) (N=48)(pg/ml) (N=48)

0.37 (0.42)0.37 (0.42)0.55 (0.56)0.55 (0.56)783 (753)783 (753)

0.71 (0.85)0.71 (0.85)0.93 (0.90)0.93 (0.90)

1161 (1010)1161 (1010)

0.0090.0090.010.010.10.1

AngiographyAngiography Ejection fraction (%)Ejection fraction (%) LVEDP (mm Hg)LVEDP (mm Hg) Grade 3 or 4 MRGrade 3 or 4 MR

46 (11)46 (11)23 (7)23 (7)

5 (10%)5 (10%)

35 (13)35 (13)28 (7)28 (7)

8 (21%)8 (21%)

0.00010.00010.0010.0010.080.08

Admission EchocardiogramAdmission Echocardiogram Ejection fraction (%)Ejection fraction (%) Wall motion score indexWall motion score index

44 (13)44 (13)1.74 (0.41)1.74 (0.41)

36 (13)36 (13)2.05 (0.47)2.05 (0.47)

0.0040.0040.00060.0006

Independent Predictors of Acute HFIndependent Predictors of Acute HF Multivariate AnalysisMultivariate Analysis

PredictorPredictor Odds Odds Ratio*Ratio*

95% 95% confidence confidence

intervalinterval

P valueP value

Age (years) 1.06 1.02 - 1.11 0.001

Physical stress trigger 4.01 1.64 – 10.36 0.002

Admission Troponin T 2.43 1.05 – 6.59 0.04

LV Ejection fraction 0.96 0.92 - 0.99 0.01

ST-segment elevation 1.34 0.5 – 3.52 0.7

*Per unit change in variable

Troponin T Stratified by Severity of HFTroponin T Stratified by Severity of HF

Mayo Clinic Risk Score for Acute Mayo Clinic Risk Score for Acute HF in ABSHF in ABS

• One point was assigned to each of the One point was assigned to each of the following independent risk factors:following independent risk factors:

• Age > 70 yearsAge > 70 years• Presence of physical stressorPresence of physical stressor• Ejection fraction < 40%Ejection fraction < 40%

• Troponin T was not included due to Troponin T was not included due to heterogeneity in assay and cut-off value used heterogeneity in assay and cut-off value used at different institutionsat different institutions

Mayo Clinic Risk Score for Acute Mayo Clinic Risk Score for Acute HF in ABSHF in ABS

• Significant positive correlation between Significant positive correlation between the frequency of acute HF and the risk the frequency of acute HF and the risk score in the:score in the:

• Development cohort – C statistic 0.77, Development cohort – C statistic 0.77, p<0.001p<0.001

• Validation cohort – C statistic 0.77, Validation cohort – C statistic 0.77, p=0.002p=0.002

Acute HF Stratified by Mayo Risk ScoreAcute HF Stratified by Mayo Risk Score

Development cohort Validation cohort

Outcome in ABSOutcome in ABS No acute HFNo acute HF(N=65)(N=65)

Acute HFAcute HF(N=53)(N=53)

P valueP value

Cardiogenic shock N/A 25 (47%) N/A

Cardio respiratory support Inotrope useIntra-aortic balloon pump useMechanical ventilation

00

3 (5%)

20 (38%)9 (17%)

15 (28%)

<0.001

Duration of hospitalization (days) 5.4 (8.7) 11.2 (5.4) 0.0004

Outcome at dischargeResidual HFDeath in hospital

N/A0 (0%)

6 (11%)3 (6%)

N/A0.09

Discharge medicationsBeta blocking agentACE inhibitor/ ARB Furosemide

49 (77%)39 (61%)

6 (9%)

41 (82%)37 (74%)20 (40%)

0.50.1

0.0001

Follow-up echocardiogramTime from presentation (days)Ejection fraction (%)Wall motion score index

74 (148)62 (6)

1.08 (0.21)

78 (120)60 (10)

1.13 (0.29)

0.90.30.4

ConclusionsConclusions

• Heart Failure is a common complication of ABSHeart Failure is a common complication of ABS• Approximately 50% developed HFApproximately 50% developed HF• One in five developed cardiogenic shockOne in five developed cardiogenic shock

• Patients who developed acute HF had,Patients who developed acute HF had,• Greater myocardial injury and stunningGreater myocardial injury and stunning• Greater morbidity and longer hospitalizationGreater morbidity and longer hospitalization

• Prognosis is good with resolution of HF with Prognosis is good with resolution of HF with supportive management in the majority of supportive management in the majority of patientspatients

• Mortality secondary to cardiogenic shock Mortality secondary to cardiogenic shock occurred in 3 patientsoccurred in 3 patients

ConclusionsConclusions

• The Mayo Clinic risk score is predictive of acute HF The Mayo Clinic risk score is predictive of acute HF in patients with ABS in patients with ABS

• Risk stratification using the Mayo Clinic risk score Risk stratification using the Mayo Clinic risk score may:may:

• Assist in triaging high risk patients to an Assist in triaging high risk patients to an intensive care unit for managementintensive care unit for management

• Allow physicians to identify patients in whom Allow physicians to identify patients in whom early initiation of beta-adrenergic blockers may early initiation of beta-adrenergic blockers may be harmfulbe harmful