The Broken The Broken Heart SyndromeHeart Syndrome

Primary Care ConferencePrimary Care Conference

May 30, 2007May 30, 2007

Gregory L. Sheehy, M.D.Gregory L. Sheehy, M.D.

Case ReportCase Report

AC is a 64 year old womanAC is a 64 year old woman History of right breast cancer, 1990History of right breast cancer, 1990

s/p mastectomy, chemotherapy and s/p mastectomy, chemotherapy and radiation) complicated by recurrent RUE radiation) complicated by recurrent RUE lymphedema/lymphangitis.lymphedema/lymphangitis.

Type 2 DMType 2 DM HTNHTN Uric acid nephropathyUric acid nephropathy ObesityObesity

Case Report-MedicationsCase Report-Medications

Glyburide 1.25 mg dailyGlyburide 1.25 mg daily Metformin 1000 mg bidMetformin 1000 mg bid Phenoxymethyl penicillin 1000 mg bidPhenoxymethyl penicillin 1000 mg bid Lisinopril 10/HCTZ 12.5 mg dailyLisinopril 10/HCTZ 12.5 mg daily Metoprolol XL 100 mg dailyMetoprolol XL 100 mg daily Gemfibrozil 600 mg bidGemfibrozil 600 mg bid Aspirin 81 mg dailyAspirin 81 mg daily Allopurinol 300 mg dailyAllopurinol 300 mg daily

Case report-May 26, Case report-May 26, 20062006

Because of risk factors (age, Because of risk factors (age, hypercholesterolemia, hypertension, hypercholesterolemia, hypertension, diabetes, family history) a diabetes, family history) a radionucleotide stress test was radionucleotide stress test was performed and was negativeperformed and was negative

Case report-December Case report-December 14, 200614, 2006

AC calls office, speaks with triage AC calls office, speaks with triage nursenurse

Patient is reported to be hysterical, Patient is reported to be hysterical, crying, sobbing and begging for a crying, sobbing and begging for a sedativesedative

Her 35 year old son was just found Her 35 year old son was just found dead in beddead in bed

Alprazolam 0.25 mg 1-2 tablets q 8hrs Alprazolam 0.25 mg 1-2 tablets q 8hrs prn called to local pharmacyprn called to local pharmacy

Case report- December Case report- December 15, 200615, 2006

AC awakes from sleep early morning AC awakes from sleep early morning hours with right chest painhours with right chest pain

She then develops dyspnea, She then develops dyspnea, diaphoresis, lightheadednessdiaphoresis, lightheadedness

EMS calledEMS called On paramedic arrival, patient in acute On paramedic arrival, patient in acute

distress, SBP 70sdistress, SBP 70s Patient transferred to UW ER, vital Patient transferred to UW ER, vital

signs similar, IVF and dopamine signs similar, IVF and dopamine initiatedinitiated

Case report-dataCase report-data Electrocardiogram revealed mild ST Electrocardiogram revealed mild ST

elevation in lateral leads (see copy)elevation in lateral leads (see copy) Initial troponin 1.5 (<0.3) with peak of 4.4 Initial troponin 1.5 (<0.3) with peak of 4.4

approximately 20 hours laterapproximately 20 hours later Echocardiogram showed “mild to moderate” Echocardiogram showed “mild to moderate”

reduction in systolic function with a an reduction in systolic function with a an ejection fraction of 40% and an akinetic apexejection fraction of 40% and an akinetic apex

Emergency cardiac cath demonstrated Emergency cardiac cath demonstrated diffuse nonocclusive coronary artery diseasediffuse nonocclusive coronary artery disease

Near complete recovery in 48-72 hoursNear complete recovery in 48-72 hours

What is “The Broken Heart What is “The Broken Heart Syndrome”?Syndrome”?

Other names:Other names: Stress induced cardiomyopathyStress induced cardiomyopathy Transient apical ballooningTransient apical ballooning Takotsubo CardiomyopathyTakotsubo Cardiomyopathy

A definition:A definition: ““Transient apical left ventricular Transient apical left ventricular

dysfunction that mimics myocardial dysfunction that mimics myocardial infarction, but in the absence of infarction, but in the absence of significant coronary artery disease.”significant coronary artery disease.”

UpToDate, 2007UpToDate, 2007

Broken Heart SyndromeBroken Heart Syndrome

First described in Japan… “Takotsubo” First described in Japan… “Takotsubo” is an octopus trap (see diagram)is an octopus trap (see diagram)11

More common in women than menMore common in women than men Onset typically triggered by an acute Onset typically triggered by an acute

medical illness or intense medical illness or intense emotional/physical stress (death in the emotional/physical stress (death in the family, domestic abuse, financial family, domestic abuse, financial catastrophy, natural disaster)catastrophy, natural disaster)

1). Tsuchihashi K et al, 1). Tsuchihashi K et al, J Am Coll CardiolJ Am Coll Cardiol 2001; 38(1): 11-8 2001; 38(1): 11-8

Broken Heart SyndromeBroken Heart Syndrome

Pathogenesis…still uncertainPathogenesis…still uncertain Catecholamine excessCatecholamine excess11

Coronary artery spasmCoronary artery spasm Myocardial stunningMyocardial stunning ““Aborted myocardial infarction” Aborted myocardial infarction”

(transient thrombosis and dissolution)(transient thrombosis and dissolution)22

1).Wittstein et al, NEJM 2005; 352(6): 539-48.1).Wittstein et al, NEJM 2005; 352(6): 539-48.2). Ibanez et al, Mayo Clinic Proceedings, 2006; 81(6): 732-2). Ibanez et al, Mayo Clinic Proceedings, 2006; 81(6): 732-

35.35.

Broken Heart SyndromeBroken Heart Syndrome

Is this syndrome more common than Is this syndrome more common than we realize?we realize?11

The good news- recovery is The good news- recovery is relatively rapid and completerelatively rapid and complete

1). Park et al. Stress Induced Cardiomyopathy in an 1). Park et al. Stress Induced Cardiomyopathy in an ICU, Chest 2005; 128: 296.ICU, Chest 2005; 128: 296.