Cath Lab Digest - January 2008 - (Page 26)

26 CLINICAL UPDATE JANUARY 2008 Takotsubo cardiomyopathy include chest pain and/or dyspnea in most patients. Patients may also experience nausea, near-syncope, syncope or hypotension. Some patients have a more dramatic presentation, which may include left ventricular failure, pulmonary edema, lethal arrhythmias such as complete heart block and ventricular fibrillation, and cardiogenic shock.3 Electrocardiographic changes seen in Takotsubo cardiomyopathy mimic those of acute coronary syndrome. STsegment elevation or depression, particularly in the precordial leads, is seen. T waves may be inverted, sometimes deeply. In many patients, the QT interval may be prolonged beyond 500 ms.4 Giant inverted T waves with QT prolongation may persist for 2 or more months in some patients.5 Cardiac biomarkers, including troponin and CPK, are elevated but do not reach the high levels typically seen in acute myocardial infarction.1 Figure 4. ECG at discharge At cardiac catheterization, minimal or no coronary artery disease is seen. Left ventriculography demonstrates an akinetic or dyskinetic ventricle with systolic ballooning of the apex, while the base of the heart is preserved and often hypercontractile. The ejection fraction may be decreased and the left ventricular end diastolic pressure (LVEDP) may be elevated.6 Increasing reports are found in the literature of variations in the patterns of the apical ballooning of the left ventricle as well as involvement of the right ventricle.7,8 Some of the most commonly reported triggers include the unexpected death of a spouse or child, being in an accident or witnessing an accident, house fires, losing significant amounts of money, public speaking and intense quarreling. Hypothermia, earthquake and lightening strikes have been implicated. Physical stressors that have been reported to cause Takotsubo cardiomyopathy include acute respiratory distress, sepsis, non-cardiac surgery and cerebrovascular accident.9 Reported triggers can be seen in Table 1. Takotsubo cardiomyopathy, or transient left ventricular apical ballooning, has also been identified in the critically ill medical patient in the intensive care unit.10 Patients who have developed this sudden onset of apical ballooning, identified by echocardiography, were admitted to the unit because of hypoxia, respiratory failure, sepsis, hemoptysis and coma. Criteria for Diagnosis There are no widely accepted criteria for the diagnosis of Takotsubo cardiomyopathy at this time. Bybee et al6 from the Mayo Clinic have proposed criteria for the clinical diagnosis of this disorder (Table 2). Researchers from Brown University in Providence, RI, have developed a registry of patients in the United States with Takotsubo cardiomyopathy with the http://www.Medtronic.com

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Cath Lab Digest - January 2008 Central Baptist Hospital Contrast Media Use in High-Risk Patients An Ergonomic Survey of Cath Lab Repetitive Stress Injuries Contents Clinical Editor’s Corner Takotsubo Cardiomyopathy, a.k.a., Transient Left Ventricular Apical Ballooning Syndrome: An Acute Coronary Syndrome Imposter Searching for the Key to D2B STEMI Intervention News STEMI Interventions: Commentary The Massachusetts Stent Study The Value of Educating Staff Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab SICP* Chapter Updates The Society of Invasive Cardiovascular Professionals Holds an RCIS Review Course at New Cardiovascular Horizons 18:20 To Denver — One Student’s First Clinical Experience CEU Education Center Meetings Calendar What Do You Think? Clinical & Industry News Classifieds The Ten-Minute Interview with…Heather Vardon, RN Advertisers Index

Cath Lab Digest - January 2008

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