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Stress Cardiomyopathy Presented by Brittney Howard, PA-S Advised by Bill Grimes, Dmin, PA-C Me and Granny What is Stress Cardiomyopathy? • Cardiac syndrome • Reversible • Left ventricular apical ballooning • Mimics myocardial infarction • Signs & Symptoms Onset following extreme stress Chest pain Dyspnea ST-segment elevation T wave changes Elevated cardiac biomarkers Background • First recognized in Japan during 1990s • Originally known as takotsubo-like left ventricular dysfunction due to apical response during syndrome • Colloquially known as Broken Heart Syndrome Takotsubo-Like Left Ventricular Dysfunction takotsubo fishing pot left ventricular apical ballooning www.grangeblanche.hautetfort.com Why is Stress Cardiomyopathy Important? • Mimics myocardial infarction • Differentiate from grief response • Educate patients on favorable prognosis • Protect patients from exposure to unnecessary treatments Stress Cardiomyopathy vs. Myocardial Infarction Stress Cardiomyopathy Normal coronary arteries, no blockage Results in stunning of cardiac muscle Reversible condition Myocardial Infarction Caused by blockages in coronary arteries Results in death of cardiac muscle Permanent, irreversible damage Possible Causes of Stress Cardiomyopathy? • Catecholamine excess? • Lack of estrogen? • Or both? Diagnostic Criteria Proposed by The Mayo Clinic 1. 2. 3. 4. Transient loss or decreased movement of the left ventricular apical and mid-ventricular segments with regional wall-motion abnormalities extending beyond a single region supplied by a coronary vessel Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture New EKG abnormalities - either ST-segment elevation or T-wave inversion Absence of recent significant head trauma, intracranial bleeding, pheochromocytoma, obstructive epicardial coronary artery disease, myocarditis, and hypertrophic cardiomyopathy Decreased Left Ventricular Function • Ejection fraction in healthy individual • >0.55 • Average ejection fraction at presentation • 0.39 - 0.49 • Average ejection fraction at follow-up • 0.60-0.79 Treatment Modalities • Alpha Blockers • Help small blood vessels remain open • Beta Blockers • Reduce catecholamine effects • Short-term Anticoagulants • Prevent thrombus formation until function improves • Supportive Treatment • ACE inhibitor, aspirin, IV diuretics • Contraindications • Synthetic catecholamines • Thrombolysis in ST-segment elevation • ACE inhibitors in increased pressure gradients The Future of Stress Cardiomyopathy » Importance of ESTROGEN in stress response » Identifiable DIAGNOSTIC measures » RECOGNITION in medical community » More EDUCATION about differences of cardiac symptoms in women vs. men The Take Home Message • Primarily affects postmenopausal females • Often precipitated by severe stress • Severe reversible left ventricular dysfunction • Mimics myocardial infarction • Increased catecholamines and lack of estrogen thought to play a role • Alpha and beta blockers the best treatment REFERENCES Bybee KA, Kara T, Prasad A, Lerman A, Barsnes s GW, Wright RS, et al. Systematic review: transient l eft ventricular apical balloonin g: a syndrome that mimics STsegment elevation myocardial infarction. Ann Intern Med. 2004; 141(11):858-65. Grawe H, Katoh M, Kuhl HP. Stress cardiom yopathy mimickin g acute coronary syndrome: case presenta tion and review of the lit erature. Clinical Research in Cardiolo gy. 2006; 95(3):179 -185. John Hopkins Medicine. Frequentl y asked quest ions about broken heart syndrome. Available at: http://www.hopkinsmedicine.or g/asc/faqs.html . Accessed Februar y 10, 2007. Korlakunta H L, Thambidorai SK, Denne y SD, Khan IA. Transient left ventricular apical ba lloonin g: a novel heart syndrome. Int J Cardiol. 2005; 102(2):351 -3. Matsuoka K, Okubo S, Fujii E, Uchida F, Kasai A, Aoki T, et al. Evaluati on of the arrhythmo genecit y of stress-induced yopathyΣ from the time course of t he 12-lead s urface electr ocardio gr am. Am J Cardiol. 2003; 92(2):230 -3. Reichman, Judith. Estro gen and your heart: Does it help or hurt ? November 2005. Available at: http://www.msnbc.msn.com/id/100 34785/. Accessed Februa ry 12, 2007. Soni A, LeLorier P. Sudden death in nondilated cardiom yopathies: patho physiolo gy and prevention. Curr Heart Fail Rep. 2005; 2(3):118 -23. Ueyama T1. Emotional stress -induced Takotsubo cardiom yopathy: animal model and molecular mec hanism. Ann N Y Acad Sci. 2004; 1018:437 -44. Ueyama T2, Senba E, Kasamatsu K, Hano T, Yamamoto K, Nishio I, et al. Molecular mechanism of emotional stress -induced and catecholamine -induced h eart attack. J Cardiovasc Pharm acol. 2003; 41:S115 -8. Questions?