Takotsubo ~ Stress Cardiomyopathy
Alys H. Nawawi, MS PTLead Physical Therapist
GSPP at PPMCFebruary 28, 2011
OBJECTIVES
Understand the pathophysiology of Takotsubo or stress cardiomyopathy Identify signs and symptoms Perform appropriate PT and OT assessment and interventionsConsider the effects of Psychological Distress and Type D personality on cardiovascular outcomesConsider the Mind Body connection
Nomenclature
Stress cardiomyopathy
Transient left ventricular apical ballooning syndrome
Takotsubo or Tako-Tsubo cardiomyopathy (TTC)
Broken heart syndrome
History
Term “stress cardiomyopathy” first introduced in 1980 by Cebelin and Hirsch.
Autopsy in victims (who died as direct result of assault without sustaining internal injuries) showed evidence of contraction band necrosis in the myocardial tissue suggesting the “lethal potential of stress” .
Definition
“Transient left ventricular dysfunction triggered by stress, with left ventricular regional wall motion abnormalities extending beyond a single epicardial coronary artery distribution and without any coronary lesion. “
Mansecal N, El Mahmoud R, Dubourg O. Occurrence of Tako-Tsubo Cardiomyopathy and Chronobiological Variation. J. Am. Coll.Cardiol. 2010;55;500-501
Takatsubo = Octopus trap
Comparison
Proposed Diagnostic Criteria
First proposed at the Mayo Clinic in 2004 and modified in 2008.
All four must be present
Worldwide consensus needs to be reached
Akahashi Y, Nef H, Möllman H, Ueyama T. Stress Cardiomyopathy. Annu. Rev. Med. 2010. 61:271-286
Proposed Diagnostic Criteria
a) Transient hypokinesis, akinesis or dyskinesis in the LV mid-segments with or without apical involvement ; regional wall abnormalities extending beyond a single epicardial vascular distribution; the presence (often but not always) of a stress trigger.
Proposed Diagnostic Criteria
b) The absence of obstructive coronary disease or angiographic evidence of acute plaque rupture.
Proposed Diagnostic Criteria
c) New electrocardiomyographic abnormalities ( ST-segment elevation and/or T-wave inversion ) or modest elevation of cardiac troponin levels in the serum.
Proposed Diagnostic Criteria
d) The absence of pheochromocytoma or myocarditis.
Patient backgrounds and Characteristics
(n = 88)
Age 67 +/- 13
Gender (male/female) 12/76
OnsetChest pain 59 ( 67%)
Dyspnea 6 (7%)
Shock 4 (5%)
ECG abnormalities 18 (20%)Tsuchihashi K, Ueshima K , Uchida T, et al. 2001 Transient left
ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris –Myocardial Infarction Investigations in Japan. J. Am. Coll. Cardiol. 38: 11-18
So what happens? Not really sure!Thought to be caused by exaggerated
sympathetic stimulation resulting in surge of catecholamines
Several theories of mechanism of action:1. Epicardial coronary artery spasm causing
vasoconstriction of coronary arteries2. Sympathetic stimulation of
microcirculation leading to microvascular spasm and decreased blood flow
3. Direct cardiotoxic effects of excessive catecholamine release resulting in disturbed calcium-regulatory system
Image of Apical Ballooning
Clinical Course
Supportive care because LV function usually recovers relatively quicklyComplications (rare)
Hemodynamic instabilityAtrial and ventricular arrythmiasHeart failureCardiogenic shockLV thrombus formation ( requires anticoagulation)
Therapy Considerations
Pharmacological ManagementDopamine
Dobutamine
More commonly: Aspirin, ACE inhibitors, calcium channel blockers, β-blockers, diuretics
IABP in case of severe LV dysfunction
Therapy Considerations
Patients may develop CHF due to myocardial stunning
SOB
Fatigue
JVD
Decreased O2 sat
Rales
“ …To fret thy soule with crosses and with cares;
To eate thy heart through comfortlesse dispaires;
To fawne, to crowche, to waite, to ride, to ronne,
To spend, to give, to want, to be undonne ...”
Mother Hubberd’s TaleEdmund Spenser ( 1552? -1599)
Possible triggering Factors
N = 88Retrospective investigationPsychological backgrounds: (20%)
Accidents in family membersRelations’ death or funeralQuarrel or alcohol intakeVigorous excitation ( watching TV, sex) Unusual exercise
Tsuchihashi K, Ueshima K , Uchida T, et al. 2001 Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris –Myocardial Infarction Investigations in Japan. J. Am. Coll. Cardiol. 38: 11-18
Severe StressorsAkahashi Y, Nef H, Möllman H, Ueyama T. Stress
Cardiomyopathy. Annu. Rev. Med. 2010. 61:271-286
Emotional Stress:AccidentDeath or severe illness/injury of family, friend or petEarthquakeFinancial LossInvolvement in legal proceedingsMove to new residencePublic SpeakingReceiving bad news : diagnosis of major illness, divorce, spouse leaving for warSevere argumentSurprise party
Severe StressorsAkahashi Y, Nef H, Möllman H, Ueyama T. 2010
Stress Cardiomyopathy. Annu. Rev. Med. 61:271-286
Physical StressSuicide attemptCocaine UseNoncardiac surgery or procedureOpiate withdrawalRecovery from general anesthesiaSevere illness Severe painStress test
Type D Personality
The Type D (distressed) personality:
A general propensity to distress that is defined by high scores on the “negative affectivity” and “ social inhibition” traits
General Distress and Cardiac Outcomes
Depression, anxiety, anger and posttraumatic stress are specific markers of distress that have been related to cardiac disorder and may partially account for the association of depression, and anxiety with myocardial infarction, poor cardiac prognosis and autonomic cardiac dysregulation.
Denollet J, Schiffer A, Spek V. 2010. A General Propensity to Psychological Distress Affects Cardiovascular Outcomes: Evidence from Research on the Type D ( Distressed) Personality Profile. Circ Cardiovasc Qual Outcomes. 3: 546-557.
Therapy Considerations
Effect of Anxiety on learning: Reduction in ability to process information
Consider methods and approaches of patient education
Consider our behaviors with and approaches to patient anxiety and how we may have positive effect on affect and mood
Lifestyle Modification
Effects of Exercise to modulate physical pain and depression
Behavioral Considerations:SmokingDietAlcohol Physical Activity
Effect of Anxiety, Anger on making lifestyle changesResistance to changeSuboptimal complianceHostility“ Acting out “
“ ..In deep discovery of the mynds disease,
Is not the hart of all the body chiefe,And rules the members as it selfe
doth please?Then with some cordialls seeke first to
appeaseThe inward languour of my wounded
hart,And then my body shall have shortly
ease … “
Amoretti and Epithalamion Edmund Spenser ( 1552? -1599)