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)