Category: Critical Care
-Nonischemic cardiomyopathy, classically seen in post-menopausal women preceded by an emotional or physical stressor
-Named for characteristic appearance on echocardiography and ventriculography with apical ballooning and contraction of the basilar segments of the LV – looks like a Japanese octopus trap or “takotsubo" (pot with narrow neck and round bottom)
-Clinical presentation usually similar to ACS with chest pain, dyspnea, syncope, and EKG changes not easily distinguished from ischemia (ST elevations – 43.7%, ST depressions, TW inversions, repol abnormalities) and elevation in cardiac biomarkers (though peak is typically much lower than in true ACS)
** Diagnosis of exclusion – only after normal (or near-normal) coronary angiography **
-Care is supportive and prognosis is excellent with full and early recovery in almost all patients (majority have normalization of LVEF within 1 week)
-Supportive care may include inotropes, vasopressors, IABP, and/or VA ECMO in profound cardiogenic shock
** LVOT Obstruction **
-occurs in 10-25% of patients with Takotsubo’s cardiomyopathy
-LV mid and apical hypokinesis with associated hypercontractility of basal segments of the LV predisposes to LV outflow tract obstruction
-Important to recognize as it is managed differently:
-may be worsened by hypovolemia, inotropes, and/or systemic vasodilatation
-mainstay of treatment is avoidance of the above triggers/exacerbating factors while increasing afterload
*phenylephrine is agent of choice +/- beta blockade
Take Home Points:
***Diagnosis of exclusion!!! Presentation very similar to ACS and ACS MUST be ruled out
* Treatment is supportive and similar to usual care for cardiogenic shock. Can be severe and require mechanical circulatory support!
*10-25% have LVOT obstruction. Manage with phenylephrine +/- beta blockade
Weiner MM, Asher DI, Augoustides G, et al. Takotsubo Cardiomyopathy?: A Clinical Update for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth. 2017;31(1):334-344. doi:10.1053/j.jvca.2016.06.004.
Kounis Syndrome (Part I)
- Kounis & Zavras (1991) described the syndrome of allergic angina and allergic myocardial infarction, currently known as Kounis syndrome (KS). Braunwald (1998) noted vasospastic angina can be induced by allergic reactions, with mediators such as histamine and leukotrienes acting on coronary vascular smooth muscle.
- Two subtypes have been described: type I, occurring in patients without predisposing factors for CAD often caused by coronary artery spasm and type II, occurring with angiographic evidence of coronary disease when the allergic events induce plaque erosion or rupture.
- This syndrome has been reported in association with a variety of medical conditions, environmental exposures, and medication exposures. Entities such as Takotsubo cardiomyopathy, drug-eluted stent thrombosis, and coronary allograft vasculopathy also appear to be associated with this syndrome.
- Clinical presentation includes: symptoms and signs of an allergic reaction and acute coronary syndrome: chest pain, dyspnea, faintness, nausea, vomiting, syncope, pruritus, urticaria, diaphoresis, pallor, palpitations, hypotension, and bradycardia.
Kounis GN, Kounis SA, Hahalis G, et al. Coronary artery spasm associated with eosinophilia: another manifestation of Kounis syndrome? Heart Lung Circ 2009;18:163–164.
Mytas DZ, Stougiannos PN, Zairis MN, et al. Acute anterior myocardial infarction after multiple bee stings. A case of Kounis syndrome. Int J Cardiol 2009;134:e129–e131.
Keywords: Nonatherosclerotic Coronary Artery Disease (PubMed Search)
Nonatherosclerotic Coronary Artery Disease
- Nonatherosclerotic coronary artery disease (NACAD) is a term used to describe a category of diseases, which include: spontaneous coronary artery dissection (SCAD), coronary fibromuscular dysplasia (FMD), ectasia, vasculitis, embolism, vasospasm, or congenital anomaly.
- NACAD is an important cause of myocardial infarction (MI) in young women, but is often missed on coronary angiography.
- A small retrospective study of women <50 years of age with ACS found that 54.8% had normal arteries, 30.5% atherosclerotic heart disease (ACAD), 13% nonatherosclerotic coronary artery disease (NACAD), and 1.7% unclear etiology.
- NACAD accounted for 30% of MI’s with SCAD & Takotsubo cardiomyopathy accounting for the majority of cases.
Saw J, Aymong E, et al. Nonatherosclerotic Coronary Artery Disease in Young Women. Canadian Journal of Cardiology. 2014/07 Vol 30:Issue 7, pgs 814-819.
Keywords: Brain-heart syndrome, Neurogenic Stress Cardiomyopathy (PubMed Search)
Keywords: takotsubo cardiomyopathy, stress cardiomyopathy, broken-heart syndrome (PubMed Search)
Takotsubo cardiomyopathy a.k.a. stress cardiomyopathy is an acute reversible disorder characterized by left ventricular (LV) dysfunction most commonly affecting postmenopausal women
The LV adopts the shape of an octopus trap (“takotsubo”) describing the narrow neck and broad base globular form during systole
Symptoms include precordial chest pain, dyspnea, or heart failure presenting with pulmonary edema mimicking ACS
Mayo Clinic Diagnostic Criteria
- Suspicion of AMI based on symptoms and STEMI on ECG
- Transient hypokinesia or akinesia of the middle and apical regions of LV
- Functional hyperkinesia of the basal region of LV
- Normal coronary arteries (luminal narrowing <50%)
- Absence of recent head injury, ICH, HCOM, myocarditis, or pheochromocytoma
Treatment is symptomatic and determined based on complications during the acute phase; occasionally requiring IABP or ECMO
Prognosis is better than those with ACS, however initial LVEF is similar to those seen with ischemic heart disease
Castillo Rivera AM, Ruiz-Bailen M, Rucabado Aguilar L. Takotsubo Cardiomyopathy – a clinical review. Medical Science Monitor. 17 (6): RA 135-47, 2011 Jun.