”first and finest” takotsubo’s; an apical eclipse of the heart lt tyler house, do lcdr justin...
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”FIRST AND FINEST”
Takotsubo’s;An Apical Eclipse of the Heart
LT Tyler House, DO
LCDR Justin Lafreniere, MD
LCDR Gregory Fuhrer, MD
Naval Medical Center Portsmouth
”FIRST AND FINEST”
Disclaimer
• I have nothing to disclose
• The views and opinions expressed herein do not necessarily state or reflect those of the Naval Medical Center Portsmouth, DoD, or the United States Government
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Case• 65 year old Filipina female with Stage IV NSCLC presented with 3
weeks of progressive dysphagia
• Associated Symptoms
- Dysphagia is with both liquids/solids without odynophagia
- Vomiting
- Cough
- Palpitations
• Patient briefly admitted for 2 days, 3 weeks prior for food impaction s/p EGD with stricture noted
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• Past Medical History
- Stage IV NSCLC on maintenance Avastin Q 3 wks
- Completed chemo/radiation March 2011
- Bradycardia with Pacemaker October 2012
- Atrial fibrillation s/p ablation 2010
- Anxiety
• Past Surgical History
- L VATS with wedge resection July 2012
- RUL resection June 2011
Case
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– Vitals and physical exam on presentation unremarkable
– EGD -> severe stricture noted, biopsy taken
– EGD discussed -> patient informed that stricture was suspected to be malignant -> noted by husband to become very anxious afterwards
– Following hours patient developed chest pain, dyspnea, tachycardia and hypotension
– Heparin initiated due to high pre-test probability for PE
Case
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– EKG unchanged, Troponin 0.906ng/ml, CXR pulmonary edema pattern
– POC U/S -> depressed LV function, apical ballooning
Diastole Systole
Case
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• LHC -> normal coronary arteries with apical ballooning
Case
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Diastole Systole
Case
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– BP continued to decline and perfusion indices worsened
– Cardiogenic shock due to Takotsubo’s Cardiomyopathy diagnosed as cause of hypotension and hypoxia
– Given the fulminant cardiogenic shock and stage IV lung cancer, the patient was placed on comfort care and died soon thereafter
Case
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Takotsubo’s Discussion
• Reversible cardiomyopathy
• 90% women, 90% post-menopausal
• Triggers
• “Catecholamine Theory”
• “stimulus trafficking”
• Mimics Acute Coronary Syndrome
Akashi Y, Goldstein D, et al. Takotsubo Cardiomyopathy: A New Form of Acute Reversible Heart Failure. Circulation., 2008; 118:2754-2762
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Takotsubo’s Discussion
• New EKG findings and/or modest troponin elevation
• Transient hypokinesia of middle and apical regions of LV
with hyperkinetic basal region (LV gram or echo)
• Normal coronary arteries by arteriography
• Absence of other etiology
Akashi Y, Goldstein D, et al. Takotsubo Cardiomyopathy: A New Form of Acute Reversible Heart Failure. Circulation., 2008; 118:2754-2762
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Point of Care Ultrasonography
• Rapid evaluation of heart, lungs and IVC
• Early and appropriate management is critical
• POC U/S facilitates early diagnosis, early treatment
Hypokinetic LV Dilated RA/RVVolpicelli G, Lamorte A, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013; 39:1290-1298.
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Takotsubo’s Treatment and Prognosis
• Supportive
• May require hemodynamic support
• 96% recovery rate
• Rarely cardiogenic shock and death
• Could this have been prevented??
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Breaking Bad News (BBN)
• ASCO “Breaking Bad News Symposium”
• Residents and Medical Students untrained
• Research suggests BBN is teachable
• “SPIKES”
Baile WF, Buckman R et al. SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000; 5:302-311.
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Key Points
• TCM is precipitated by an acute stressor, and may rarely lead to cardiogenic shock and death
• POC Ultrasound is invaluable tool in rapid diagnosis and
management of cardiopulmonary failure
• Residency programs should invest time in the teachable skill of “breaking bad news”
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Questions?
“The life of a sick person can be shortened not only by the acts, but also by the words or the
manner of a physician”
American Medical Association, first code of medical ethics, 1847