intern morning report 9 17
DESCRIPTION
Internal medicineTRANSCRIPT
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Picture QuizPicture QuizWhat is the diagnosis?What is the diagnosis?
Sandra Susanibar - UAMS
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Picture QuizPicture QuizWhat is the diagnosis?What is the diagnosis?
Sandra Susanibar - UAMS
Pleural plaque
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Picture QuizPicture QuizWhat is the diagnosis?What is the diagnosis?
Sandra Susanibar - UAMS
Pleural plaque
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AsbestosisAsbestosis• Diagnosis:
o A reliable history of exposure to asbestos with a proper latency period (years) +
o Presence of markers of exposure (eg, pleural plaques or recovery of sufficient quantities of asbestos fibers/bodies in bronchoalveolar lavage or lung tissue) +
o Definite evidence of interstitial fibrosis +o Absence of other causes of diffuse parenchymal lung disease.
Sandra Susanibar - UAMS
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Morning ReportMorning Report CaseCase
Sept 17, 2014
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Case simulationCase simulation• ~50-60 yo woman comes in to clinic with fatigue,
mild confusion, and general malaise.• She doesn’t provide much more history, but has
been having a tough time with her family lately.• Physical exam is pretty unremarkable except her
cardiac exam reveals what sounds like sinus tachycardia ~130. You ask about chest pain, dyspnea, palpitations, n/v/d/anorexia, she denies all.
• You order an ECG…
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ECG ECG
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InterpretationInterpretation• Sinus tachycardia w q waves in II, III, aVF, ST
elevation w inverted waves in V2-6
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Glad you got the ECGGlad you got the ECG• What now?• DC to home? Go to ED? Activate cath lab?
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To the EDTo the ED• She goes to the ED, where cath lab has been
activated• Troponin is elevated, but less than 5. She
continues to deny chest discomfort/dyspnea.• (next slides are examples of left side and right
side pictures during a left heart cath example of this disease)
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End of DiastoleEnd of Diastole(ventriculogram)(ventriculogram)
End of Systole
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Diagnosis?Diagnosis?• STEMI w no evidence of acute ischemia on left
heart catheterization with left ventriculogram evidence of apical hypokinesis and mild global ejection fraction dysfunction…
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Takotsubo Takotsubo CardiomyopathyCardiomyopathy
AKA Apical Ballooning SyndromeAKA Broken Heart Syndrome
AKA Stress-Induced Cardiomyopathy
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DefinitionDefinition• Transient systolic dysfunction of the apical and/or
mid segments of the LV that mimics MI, but in the absence of obstructive coronary disease
• Decreased contractile function: apex of LV• Hyperkinesis: basal walls• Women>>>>>>Men• Prevalence 1.2% of troponin positive ACS
Uptodate.com
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PathogenesisPathogenesis• Triggers: acute illness,
intense emotional or physical stress
• Proposed mechanisms:o Catecholamine excesso Coronary artery spasmo Microvascular dysfunction
• Catecholamine excesso Mouse Model: switch from Beta-2 Gs
(positively inotropic) to beta-2 Gi (negatively inotropic); higher levels of epinephrine act on Gi
Uptodate.comMedscape.com
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Clinical PresentationClinical Presentation• Similar to Acute MI
o Acute substernal Chest Pain (most common)o Dyspnea, syncope, shocko EKG abnormalities (ST elevation anterior precordial leads)o Mild troponin elevations (<5.2)
• Acute Complicationso Heart failureo Tachy and Bradyarrhythmiaso Mitral regurgitationo Cardiogenic shocko LV outflow tract obstructiono Apical thrombus formation and stroke
Uptodate.com
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DiagnosisDiagnosis• Suspect in postmenopausal women who
experience severe stress and present with ACS and have presentation/EKG findings out or proportion to cardiac markers
Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, et al. Systematic Review: Transient Left Ventricular Apical Ballooning: A Syndrome That Mimics ST-Segment Elevation Myocardial Infarction. Ann Intern Med. 2004;141:858-865.
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TreatmentTreatment• Therapy is based upon patient’s overall clinical
condition• If they have symptoms of HF and fluid overload
o ACE-I, BB, Diureticso Treat until systolic function recovers (1-4 weeks)
• Coexisting coronary atherosclerosiso Aspirin
• Due to possibility of recurrence (up to 10%)o Continue adrenergic blockade with BB or combined AB/BB indefinitely unless
contraindicated
• Hypotension and Shock: Get urgent ECHO to determine if LVOT obstruction is present (13-18%)o No LVOT: can cautiously use inotropes (dobutamine, dopamine) or IABPo LVOT: BB, fluid replacement
• Thrombus: Get an ECHO to checko 3 months of anticoagulation if LV thrombus detectedo No thrombus but severe LV dysfunction: 3 months or until function is normalo Prophylaxis: 10 days anticoagulation
Uptodate.com
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PrognosisPrognosis• In-hospital mortality rates: 0-8%• Normal ventricular function typically returns in 1-
4 weeks• Study of 100 patients
o Mean follow up 4.4 +/- 4.6 yearso 31 patients had continued chest paino 10 had recurrenceo 17 died (no difference compared to age/gender matched population)
Uptodate.com
Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol. 2007;50(5):448.