Transcript The Broken Heart Syndrome

The Broken Heart
Syndrome
Primary Care Conference
May 30, 2007
Gregory L. Sheehy, M.D.
Case Report

AC is a 64 year old woman

History of right breast cancer, 1990

s/p mastectomy, chemotherapy and radiation)
complicated by recurrent RUE
lymphedema/lymphangitis.
Type 2 DM
 HTN
 Uric acid nephropathy
 Obesity

Case Report-Medications








Glyburide 1.25 mg daily
Metformin 1000 mg bid
Phenoxymethyl penicillin 1000 mg bid
Lisinopril 10/HCTZ 12.5 mg daily
Metoprolol XL 100 mg daily
Gemfibrozil 600 mg bid
Aspirin 81 mg daily
Allopurinol 300 mg daily
Case report-May 26, 2006

Because of risk factors (age,
hypercholesterolemia, hypertension, diabetes,
family history) a radionucleotide stress test was
performed and was negative
Case report-December 14, 2006




AC calls office, speaks with triage nurse
Patient is reported to be hysterical, crying,
sobbing and begging for a sedative
Her 35 year old son was just found dead in bed
Alprazolam 0.25 mg 1-2 tablets q 8hrs prn called
to local pharmacy
Case report- December 15, 2006





AC awakes from sleep early morning hours with
right chest pain
She then develops dyspnea, diaphoresis,
lightheadedness
EMS called
On paramedic arrival, patient in acute distress,
SBP 70s
Patient transferred to UW ER, vital signs similar,
IVF and dopamine initiated
Case report-data





Electrocardiogram revealed mild ST elevation in lateral
leads (see copy)
Initial troponin 1.5 (<0.3) with peak of 4.4
approximately 20 hours later
Echocardiogram showed “mild to moderate” reduction
in systolic function with a an ejection fraction of 40%
and an akinetic apex
Emergency cardiac cath demonstrated diffuse
nonocclusive coronary artery disease
Near complete recovery in 48-72 hours
What is “The Broken Heart
Syndrome”?

Other names:
Stress induced cardiomyopathy
 Transient apical ballooning
 Takotsubo Cardiomyopathy


A definition:

“Transient apical left ventricular dysfunction that
mimics myocardial infarction, but in the absence of
significant coronary artery disease.”
UpToDate, 2007
Broken Heart Syndrome



First described in Japan… “Takotsubo” is an
octopus trap (see diagram)1
More common in women than men
Onset typically triggered by an acute medical
illness or intense emotional/physical stress
(death in the family, domestic abuse, financial
catastrophy, natural disaster)
1). Tsuchihashi K et al, J Am Coll Cardiol 2001; 38(1): 11-8
Broken Heart Syndrome

Pathogenesis…still uncertain
Catecholamine excess1
 Coronary artery spasm
 Myocardial stunning
 “Aborted myocardial infarction” (transient
thrombosis and dissolution)2

1).Wittstein et al, NEJM 2005; 352(6): 539-48.
2). Ibanez et al, Mayo Clinic Proceedings, 2006; 81(6): 732-35.
Broken Heart Syndrome


Is this syndrome more common than we
realize?1
The good news- recovery is relatively rapid and
complete
1). Park et al. Stress Induced Cardiomyopathy in an ICU, Chest
2005; 128: 296.