takotsubo cardiomyopathy (tcm)

CHEST PAIN & HYPOTENSION AFTER ELECTRIC CARDIOVERSION HANA AKSELROD, PGY-3 || MAINE MEDICAL CENTER || BAR HARBOR, SEPT 2015

PATIENT CASE ID: 71 F presenting to the hospital for elective electrical cardioversion of AFib with RVR

HPI: Presented to the hospital with AFib-RVR symptomatic for hypotension and dyspnea. Recent course notable for worsening AFib refractory to multiple meds and s/p one DCCV attempt with temporary conversion to sinus rhythm.

PMH/PSH:

ESRD due to PKD, s/p deceased donor renal transplants in 1996 (failed due to thrombosis) and 1998; baseline Cr ~1.3.

Atrial flutter s/p ablation 2009, sick sinus syndrome s/p PPM, and treatment-refractory Afib with RVR.

Iliocecal adenocarcinoma s/p resection, ileostomy; recently treated for C.difficile colitis.

Medications: Diltiazem, metoprolol, propafenone, warfarin, cyclosporine, prednisone, omeprazole, pravastatin

Allergies: Flecainide (vision changes), opioids (itching), fentanyl (hypotension)

Family Hx: Adult Polycystic Kidney Disease (father, sister, son, daughter), stroke (father)

Social Hx: Retired, former smoker, supportive family

Presenter

Presentation Notes

71 year old female with complicated past medical history that includes polycystic kidney disease with renal transplant in 1996 and again in 1998, baseline creatinine 1.3, diastolic heart failure, hypertension, h/o small bowel obstruction, adenocarcinoma 5/2014 with right colectomy and ileostomy followed by Dr. Whiting, sick sinus syndrome with Medtronic pacemaker placed 2009, atrial flutter s/p ablation 2009. She was discharged from MMC on 6/27 after being admitted for afib. She underwent a TEE on 6/26 that showed EF 60-65%, no LA thrombus and a successful cardioversion. She was discharged on propafenone 225 mg BID, metoprolol 25 mg BID, and diltiazem 120 mg daily. Her INR on discharge was 1.8, she was given 1 dose of lovenox on the day of discharge, and warfarin instructions to increase her dose for 2 days then resume her usual dose of 1 mg daily. She was also diagnosed with C-Diff colitis and completed a 10 day course of flagyl antibiotics that completed 7/7. She has a colostomy and her stools are no clinically helpful to determine status of infection. Her lasix was also discontinued her last admission due to hypovolemia. Since discharge she converted back to atrial fibrillation and has been severely symptomatic with SBP 80's, extremely dyspneic with any exertion and at rest, and very fatigued. She spoke with Dr. Corsello on the phone who arranged for her to be admitted via ACCU for TEE 7/8 to rule out thrombus as her INR's have been subtherapeutic in the last 2 weeks. Then her propafenone will be increased to 300 mg TID, followed by a cardioversion. She has been on propafenone for over a year and it was successful at suppressing afib until her surgery in May. Dr. Sesselberg's consult note from 6/25 admission notes that he was hesitant to start amiodarone given her chronic immunosuppression therapy and she was intolerant to flecainide with visual changes. She is admitted for TEE, increase in antiarrythmic thearpy, and cardioversion.

PATIENT CASE

Difficult sedation due to prior hypotension to fentanyl; admitted and observed overnight.

Presented to cardioversion in the morning with HR 160-180s and SBP 80s. TEE showed normal EF (consistent w/ prior full TTE done 1 week prior) and no clot in the LA.

DCCV performed with 200 J. After one shock converted to NSR, improving to SBP >100.

Presenter

Presentation Notes

R-heart cath revealed CO/CI 2.4/1.35, PA pressure 34/24 (29), PA sat 47%, and PCWP 25

Pre-cardioversion ECG

Presenter

Presentation Notes

Afib with RVR

PATIENT CASE

Difficult sedation due to prior hypotension to fentanyl; admitted and observed overnight.

Presented to cardioversion in the morning with HR 160-180s and SBP 80s. TEE showed normal EF (consistent w/ prior full TTE done 1 week prior) and no clot in the LA.

DCCV performed with 200 J. After one shock converted to NSR, improving to SBP >100.

Two hours post procedure, the patient developed substernal chest pain radiating to the back and arms.

ECG showed sinus tachycardia with anterior & inferior Q waves.

Echo showed extensive wall motion abnormalities and LVEF 25%.

Labs:

INR 2.4

Troponin T: 0.06

1.48 18 4.3

49 97 132 183 10.6

161

12.4

38.7

Presenter

Presentation Notes

R-heart cath revealed CO/CI 2.4/1.35, PA pressure 34/24 (29), PA sat 47%, and PCWP 25

After onset of chest pain

Presenter

Presentation Notes

SR with loss of R waves, new Q waves across the precordium

STAT TEE AFTER ONSET OF CHEST PAIN

• LVEF 20-25% • Extensive hypokinesis of

LV wall

COMPARISON: LAST TEE (T -1 WEEK)

• LVEF 60-65% • Moderate MR • LV hypertrophy • No wall motion

abnormalities

NEW-ONSET ACUTE LV DYSFUNCTION AFTER DCCV

Differential diagnosis

NEW-ONSET ACUTE LV DYSFUNCTION AFTER DCCV

NSTEMI was suspected and she was taken emergently to the cath lab, where no occlusive CAD was seen, however the coronary vasculature appeared diffusely constricted/spasming.

Left ventriculography showed LVEF 10% with apical hypokinesis.

Right heart pressures were moderately elevated and cardiac output was < 2.

Nitroglycerin was infused, with subsequent relaxation of the coronaries but no immediate improvement in cardiac output.

An intraaortic balloon pump was placed, dobutamine and norepinephrine infusions were started, and she was transferred to the cardiac ICU on heparin.

Troponins were trended over the next 12 hours: 0.06 0.89 0.69

CATH LAB FINDINGS

Diffuse coronary vasospasm

CATH LAB FINDINGS

Post nitroglycerin infusion

CATH LAB FINDINGS

Right side circulation

PATIENT CASE: HOSPITAL COURSE Management:

Managed initially with IABP and pressor support (dobutamine, norepinephrine, dopamine, milrinone)

Choice of pressors limited by tachycardia contributing to low cardiac output

Reverted to AFib-RVR on Day 3; managed with amiodarone, DCCV x 3

IABP weaned on Day 4, continued on milrinone

AV node ablation on Day 7

Empiric antibiotics: vancomycin, piperacillin-tazobactam, metronidazole; negative cultures

Course complicated by AKI, urinary retention, UTI, DVT, and thrombocytopenia with negative HIT panel.

Transplant team involved in admission, CVVH performed on Day 6-8 to help relieve volume overload.

Outcome:

Complete resolution of heart failure on Day 10. Pressors weaned, TTE showed LVEF 55%.

Kidney function recovered (Cr returning to baseline)

Patient survived this admission. However in the following year she had multiple hospital admissions for non-cardiac problems (ileostomy reversal, infections) and eventually succumbed to kidney failure in 2015 (faced with the need for dialysis again and chose palliative care).

TTE DAY 4

• LVEF 25% • Persistent apical

ballooning

TTE DAY 11

• LVEF ≥ 55% • LV hypertrophy

TTE DAY 30+

• LVEF ≥ 55% • LV hypertrophy

PATIENT CASE: HOSPITAL COURSE Management:

Managed initially with IABP and pressor support (dobutamine, norepinephrine, dopamine, milrinone)

Choice of pressors limited by tachycardia contributing to low cardiac output

Reverted to AFib-RVR on Day 3; managed with amiodarone, DCCV x 3

IABP weaned on Day 4, continued on milrinone

AV node ablation on Day 7

Empiric antibiotics: vancomycin, piperacillin-tazobactam, metronidazole; negative cultures

Course complicated by AKI, urinary retention, UTI, DVT, and thrombocytopenia with negative HIT panel.

Transplant team involved in admission, CVVH performed on Day 6-8 to help relieve volume overload.

Outcome:

Complete resolution of heart failure on Day 10. Pressors weaned, TTE showed LVEF 55%.

Kidney function recovered (Cr returning to baseline)

Patient survived this admission. However in the following year she had multiple hospital admissions for non-cardiac problems (ileostomy reversal, infections) and eventually succumbed to kidney failure in 2015 (faced with the need for dialysis again and chose palliative care).

TAKOTSUBO CARDIOMYOPATHY EPIDEMIOLOGY, PATHOPHYSIOLOGY, AND MANAGEMENT

EPIDEMIOLOGY

Incidence: consensus opinion, ~2% of patients presenting with MI to hospital, and up to 10% in select groups of post-menopausal women

Large hospital in California: of 1,297 post-menopausal women presenting with ACS-like syndrome and positive troponins, 5.9% met criteria for Takotsubo Cardiomyopathy (TCM)

In the National Inpatient Sample study (2008-2009), 24701 patients with TCM were compared to controls with MI and Ortho presentations:

More likely to be female, Caucasian, and wealthier

Less likely to have “traditional” cardiovascular risk factors

More likely to have h/o CVA, mood disorders, drug abuse, malignancy, chronic liver disease, or sepsis

No difference in age vs. controls

EPIDEMIOLOGY

Incidence: consensus opinion, ~2% of patients presenting with MI to hospital, and up to 10% in select groups of post-menopausal women

Large hospital in California: of 1,297 post-menopausal women presenting with ACS-like syndrome and positive troponins, 5.9% met criteria for Takotsubo Cardiomyopathy (TCM)

In the National Inpatient Sample study (2008-2009), 24701 patients with TCM were compared to controls with MI and Ortho presentations:

More likely to be female, Caucasian, and wealthier

Less likely to have “traditional” cardiovascular risk factors

More likely to have h/o CVA, mood disorders, drug abuse, malignancy, chronic liver disease, or sepsis

No difference in age vs. controls [AJC 2009]

CLINICAL FEATURES

Diagnosis:

NSTEMI-like presentation (“typical” anginal chest pain, nonspecific ECG)

Elevated troponins (nearly always)

“Clean” coronary angiography

Reduced EF:

Characteristic echographic appearance

Average LVEF at diagnosis: 37% in RI TCM registry

Initial description:

First described in Japan in 1991 [Dotey et al.]

Formally recognized by AHA in 2006

PubMed: 8 citations 2003; 246 in 2013

Japan patient characteristics: over 90% female, average age 74

PRECIPITATING FACTORS

Physical (less common) or emotional stress

Underlying psychological factors?

Role for chronic stress?

Case reports:

Drug overdose

Pulmonary illness attack

Pheochromocytoma

Cardioversion

[AJC 2009]

A 76-year-old woman presenting in acute heart failure with nonspecific ECG changes and non-occlusive findings on coronary angiography, 10 hours after elective DCCV for AFib [Heart Lung Circ 2008]

A 67-year-old woman who developed acute cardiogenic shock and findings characteristic for TCM immediately after undergoing DCCV for AFib [Tex Heart Inst J 2014]

The patients made their recovery after supportive measures; duration of treatment consistent with TCM.

TAKOTSUBO CM AFTER CARDIOVERSION

PATHOPHYSIOLOGY

Contraction patterns similar to pheochromocytoma-related cardiomyopathy

Catecholamine overload mechanism:

Initial phase: activation of β-adrenergic receptors

Subsequent: a negatively-inotropic pathway

MANAGEMENT AND PROGNOSIS

Supportive management

Predictors of mortality [AJC 2014]:

Meta-analysis of 382 studies (2,120 patients, 11 countries). Mean age was 68 years, 87% female.

The in-hospital mortality rate among patients with TCM was 4.5%. Of these, 38% were directly 2/2 TCM.

Male gender was associated with higher mortality rate (OR 2.6, p=0.0008)

Patients who died tended to be older (72±7 vs 65±7 years).

OTHER COMPLICATIONS OF DCCV

Thromboembolic events

Transient hypotension associated with sedation (fentanyl)

Induction of arrhythmias (bradycardia, AV block, asystole, VT/VF)

Electric burns to skin / soft tissues

Injuries to health care workers

No direct myotoxicity from electricity in studies

SUMMARY POINTS

Considering Takotsubo cardiomyopathy in relation to iatrogenic events

Risks and benefits of direct-current cardioversion

Medical complexity, stress, and risk of adverse events

Challenges in communication and expectations

REFERENCES

El-Sayed AM, Brinjikji W, Salka S. Demographic and co-morbid predictors of stress (takotsubo) cardiomyopathy. Am J Cardiol. 2012 Nov 1;110(9):1368-72.

Sharkey SW, Maron BJ. Epidemiology and clinical profile of Takotsubo cardiomyopathy. Circ J. 2014;78(9):2119-28.

Sy F, Basraon J, Zheng H, Singh M, Richina J, Ambrose JA. Frequency of Takotsubo cardiomyopathy in postmenopausal women presenting with an acute coronary syndrome. Am J Cardiol. 2013 Aug 15;112(4):479-82.

Sanchez-Recalde A, Costero O, Oliver JM, Iborra C, Ruiz E, Sobrino JA. Images in cardiovascular medicine. Pheochromocytoma-related cardiomyopathy: inverted Takotsubo contractile pattern. Circulation. 2006 May 2;113(17):e738-9.

Friedman PL, Montgomery S, Matas N. Sotalol and a broken heart. J Cardiovasc Electrophysiol. 2010 Feb;21(2):207-10.

Singh K, Carson K, Shah R, Sawhney G, Singh B, Parsaik A, Gilutz H, Usmani Z, Horowitz J. Meta-analysis of clinical correlates of acute mortality in takotsubo cardiomyopathy. Am J Cardiol. 2014 Apr 15;113(8):1420-8.

Wright PT, Tranter MH, Morley-Smith AC, Lyon AR. Pathophysiology of takotsubo syndrome: temporal phases of cardiovascular responses to extreme stress. Circ J. 2014;78(7):1550-8.

Regnante RA, Zuzek RW, Weinsier SB, Latif SR, Linsky RA, Ahmed HN, Sadiq I. Clinical characteristics and four-year outcomes of patients in the Rhode Island Takotsubo Cardiomyopathy Registry. Am J Cardiol. 2009 Apr 1;103(7):1015-9

Siegfried JS, Bhusri S, Guttenplan N, Coplan NL. Takotsubo cardiomyopathy as a sequela of elective direct-current cardioversion for atrial fibrillation. Tex Heart Inst J. 2014 Apr 1;41(2):184-7.

THANK YOU

Dr. John Love

Drs. Mehdi Gheshlaghi and Deirdre Mooney

Dr. Stephen Hayes

Christopher Barnaby

“Med C” team, July 2014

takotsubo cardiomyopathy (tcm)

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