Don’t Go Breaking My Heart: Imaging & Prognosis in Takotsubo’s

Don’t Go Breaking My Heart: Imaging & Prognosis in Takotsubo’s Peter Liu, M.D., U Ottawa Heart Institutewith Advice from Andrew Crean, M.D. Takotsubo: Stress Cardiomyopathy Japanese octopus fishing pot -a ‘takotsubo’ (artwork by DrDavid Northridge, Consultant Cardiologist, Edinburgh Royal Infirmary). Case History•69 yofemale, presented with 6 hr of L shoulder and arm pain–Long standing hypertension, panic disorder–ECG showed ST elevationin leads V2-V5–hsTn= 490 ng/L (Nml< 50 ng/L)–NTproBNP= 4,300 ng/L (pg/ml)–Echo showed hypokinesisof lateral and inferior walls•Coronary Angiogram = Minor lesions only•Additional history–Brother died 3 days ago –Pt is now the sole survivor of 6 siblings left ECG: Presentation ECG: Day 3 post Presentation LV Gram & Echo: Stress Takotsubo Day 1 LV AngioDay 2 Echocardiogram Postal stamp depicting Diagorascarried on the shoulders of his two sons (1937).Monument to Diagorasfamily at the Greek island of Rhodes (a Dawson DK. Heart 2018; 104:96-102. Ballooning Patterns in Takotsubo Figure1Overalldistributionoftakotsubotypesin‘happyheartsyndrome’vs.‘brokenheartsyndrome’(P=0.21).PosthocP-valuesforcomparisonwithintakotsubotypesshowedasignificantlyhigherprevalenceofthemidventriculartakotsubosyndrometypeinpatientswith‘happyheart’vs.‘brokenheart’(P=0.030),whilenosignificantdifferenceswereseeninapical(P=0.15),basal(P=1.0),orfocal(P=1.0)takotsubosyndrometypes.Inter-TAK. European Heart Journal (2016) 37, 2823–2829 European Heart Failure Association Diagnostic Criteria•1. Transient regional wall motion abnormalities of left ventricular or right ventricular myocardium, which are frequently, but not always, preceded by a stressful trigger (emotional or physical).•2. The regional wall motion abnormalities usually extend beyond a single epicardialvascular distribution, and often result in circumferential dysfunction of the ventricular segments involved. •3. The absence of culprit atherosclerotic coronary artery disease including acute plaque rupture, thrombus formation, and coronary dissection or other pathologic conditions to explain the pattern of temporary left ventricular dysfunction observed (eg, hypertrophic cardiomyopathy, viral myocarditis). •4. New and reversible electrocardiography abnormalities (ST-segment elevation, ST depression, left bundle branch block, T-wave inversion, and/or QTcprolongation during the acute phase (3 months). •5. Significantly elevated serum natriuretic peptide (B-type natriuretic peptide or N -terminal pro B-type natriuretic peptide) during the acute phase. •6. Positive but relatively small elevation in cardiac troponin measured with a conventional assay (ie, disparity between the troponin level and the amount of dysfunctional myocardium present). •7. Recovery of ventricular systolic function on cardiac imaging at follow-up (3–6 months). InterTAKDiagnostic Criteria Our Case2524-1211-- 72 Cancer Inflammation Anatomic Variations of TakotsuboCM T2 ratio & T2 mapping T2 mapping•Observer independent•Not ratio based•Quantitative result of LV T2 relaxation time in milliseconds – T2 SPAIR•Observer dependent•Ratio based•Assumes uniform signal correction across image Abnormal FA Metabolism:Ischemic Memory & MicrovascDysf’n Warisawa. Circulation Journal Vol.80, March 2016 MØ Fe2O3Uptake in Takotsubo ScallyC, Dawson DK, et al. Circulation 2019 (in press) Monocyte Profiles in TakotsuboPts ScallyC, Dawson DK, et al. Circulation 2019 (in press) LV Dysfunction•In the International TakotsuboRegistry:–9.9% of patients developed cardiogenic shock,–17.3% of patients required invasive or noninvasiveventilation, –8.6% of patients had cardiopulmonary resuscitation.The incidence of cardiac arrest among hospitalized patients with TCM was approximately 5%.Independent predictors of acute heart failure include advanced age, low LVEF at presentation, higher admission and peak troponin levels, and a physical stressor Templin, Hellermann, et al. N EnglJ Med 2015; 373:929-38 LVOTO •It is more common with the apical ballooning pattern and it may be provoked or exacerbated by catecholamine drugs used to treat hypotension.•In a series of 136 patients with TCM, 13 patients developed dynamic obstruction to LVOT Arrhythmia•Arrhythmia is common in patients with SIC.•New atrial fibrillation has been reported in 5% to 15% of cases•Ventricular arrhythmia occurs in 4% to 10% of patients during the acute phase.•Potentially lethal arrhythmia, including ventricular fibrillation, torsadesde pointes, and ventricular tachycardia in less than 5% of patients. Thrombo-embolism•In 541 patients German Italian Stress CardiomyopathyRegistry:–12 patients (2.2%) developed LV thrombi –all female –presenting with an apical ballooning pattern–all treated with oral anticoagulation therapy –2 patients suffered a cerebrovascular accident before treatment initiation.•A high troponin was an independent predictor of LV thrombi. Normal echo in ‘recovery’ 2 weeks post admission3 months post admission Subtle strain abnormalities persist, even at 3 months Not So Benign a Prognosis Templin, Hellermann, et al. N EnglJ Med 2015; 373:929-38 Long Term Follow Up of Takotsubo Scally2018. DOI: 10.1161/CIRCULATIONAHA.117.031841 Functional Capacity & QoLin TakotsuboPatients Scally. Circulation. 2017 Nov 11 Risk of Recurrence•TCM may recur in 5% to 22% of cases.•A recent meta-analysis based on 31 cohorts indicated that –cumulative incidence of recurrence was approximately 5% at 6 years –annual rate of recurrence was approximately 1% to 2%.•Nearly all cases of recurrence occurred in women.•The recurrence rate was inversely correlated with ACEi/ARB prescription, but not with beta-blocker prescription.•The International TakotsuboRegistry reported that the rate of recurrence was 1.8% per patient-year, with a span of 25 days up to 9.2 years after the first event Conclusions•Takotsuboor stress-induced cardiomyopathy is characterized by “reversible” myocardial injury with distinctive regional wall motion abnormalities of the left ventricle. •It has a strong predilection for postmenopausal women, but men, young women, and children can all be affected.•Diagnosis made on clinical criteria A Takotsubomoment…..