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ETAT DE L’ART
‘ST+ Mimics’
Syndrome de takotsubo
…ou quand un poulpe vous brise le cœur
Nicolas PESCHANSKI MD, PhD @DocNikko
CHI Eure-Seine – CIRCE-NEV – INSERM U1096
Ce que l’on sait…
Japon, 1990…
Tremblement de terre à 80 km au sud-ouest de Tokyo
Registre (MACE)
5 SCA-ST+ à coronaires saines
Contractilité ≈ Aspect atypique
FEVG abaissée
Population à risque !!!
Âge moyen >>> SCA
100% femmes
Sato H, et al. Kodama K, Haze K, Hon M, eds. Clinical Aspect of Myocardial Injury:
From Ischaemia to Heart Failure. Tokyo: Kagakuhyouronsya 1990:56-64.
Clinique/Biologie/ECG = SCA ST+
Dysfonction VG (transitoire) associée
Nouveau syndrome : le takotsubo !
tsubo
tako
Tako-Tsubo !
Un nouveau syndrome – le takotsubo !
Un nouveau syndrome – le takotsubo !
Définition(s)
Circulation Journal
Official Journal of the Japanese Circulation Society
http://www.j-circ.or.jp
Diagnosis of Takotsubo Cardiomyopathy
– Mayo Clinic Criteria –
Dawn C Scantlebury, MD; Abhiram Prasad, MD
Takotsubo cardiomyopathy, also known as left ventricular apical ballooning syndrome and stress-induced cardio-
myopathy, is typically characterized by transient systolic dysfunction of the apical and mid-segments of the left
ventricle, in the absence of obstructive coronary artery lesions. Patients may present with symptoms and signs of
acute coronary syndrome, and the provider is challenged to differentiate between these conditions. In this review,
we guide the reader through the diagnostic pathway, focusing on differential diagnoses and diagnostic criteria for
takotsubo cardiomyopathy. (Circ J 2014; 78: 2129– 2139)
Focus Issue on Takotsubo Cardiomyopathy
2004-2008-20142130 SCANTLEBURY DC et al.
of severe chest pain and dyspnea lasting 2–3h. The chest painthe cardiomyopathy began to be recognized in the rest of the
Table 1. Mayo Clinic Criteria for ABS/TTC20
1. Transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid-segments with or without apical involvement; the regional wall
motion abnormalities extend beyond a single epicardial vascular distribution; a stressful trigger is often, but not always present.*
2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture.†
3. New electrocardiographic abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin.
4. Absence of:
a. Pheochromocytoma
b. Myocarditis
ABS, apical ballooning syndrome; TTC, takotsubo cardiomyopathy; ACS, acute coronary syndrome.
*There are rare exceptions to these criteria such as those patients in whom the regional wall motion abnormality is limited to a single coronary
territory.
† It is possible that a patient with obstructive coronary atherosclerosis may also develop ABS. However, this is very rare in our experience and
in the published literature, perhaps because such cases are misdiagnosed as ACS.
In both of the above circumstances, the diagnosis of ABS should be made with caution and a clear stressful precipitating trigger must be
sought.
Définition(s)
European Journal of Heart Failure (2016) 18, 8–27 REVIEW
doi:10.1002/ejhf.424
Current state of knowledge on Takotsubo
syndrome: a position statement from the task
force on Takotsubo syndrome of the Heart
Failure Association of the European Society of
Cardiology
Alexander R. Lyon1,2,*, Eduardo Bossone3, Birke Schneider4, Udo Sechtem5,
Rodolfo Citro6, S.Richard Underwood1,2, Mary N. Sheppard7, Gemma A. Figtree8,9,
10 11 12 13
Ce que l’on croit savoir…
Spasme microcirculatoire
Wittstein IS, et al. N Engl J Med 2005;352:539-48.
Redistribution des récepteurs β
Cevik C, et al. Am Heart J 2008;156:e31.0002-8703.
Défaillance du VG prédominant à l’apex
(β2 isoformes Gs)
Réponse augmentée à la stimulation 𝜮 à la base
(β1 isoformes G1)
Cardiotoxicité catécholergique
Akashi YJ, et al. Circulation 2008;118:2754-62.
Pelliccia F, et al. Circulation. 2017;135:2426-41.
Surcharge en Ca++ médiée par libération de Rx libres
Stimulation des canaux calciques AMP-dépendants
Physiopathologie (on progresse…)
Pelliccia F, et al. Circulation. 2017;135:2426-41.
Pelliccia et al
Figure 4. Autonomic nervous system (ANS) activation and cardiovascular system.
ANS activation is mediated by release of norepinephrine (NE) and epinephrine (Epi) and occurs via the following m
(1) Release of norepinephrine by cardiac sympathetic nerve terminals (resulting in tachycardia and an increased force
(2) release of epinephrine into the circulation by the adrenal medulla, modulating both myocardium and peripheral
La physiopathologie
Physiopathologie (pour les nuls en poulpe)
Physiopathologie (pour les nuls en poulpe)
VG normal VG Takotsubo
Physiopathologie (pour tout le monde)
VG normal VG Takotsubo
Akashi JY, et al. Nat. Rev. Cardiol. 2015;12:387-97.
Très forte prédominance féminine
Âge moyen post-ménopausique
Facteur de stress physique ou émotionnel
Ce que l’on doit savoir…
Takotsubo ≠ rare & féminin !
Incidence/Prévalence
Âge 65-72 ans
Femmes 82-100 %
1,7 -2,3 % SCA
5-7 % SCA chez les femmes
Variation saisonnière/circadienne
Incidence x 2 à 4 l’été
Diurne/matinal
Wedekind H, et al. Herz. 2006;31(4):339-46.
Citro R, et al. JACC. 2009;54(2):180-81.
Templin C, et al. N Engl J Med. 2015;373:929-38.
the first reported case of takotsubo syndrome. Diastole (A) and systo
lar wall motion abnormality two weeks after the event (C and D). Co
Triggers
Tristesse
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Évènements
négatifs
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Colère
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Catastrophes
naturelles
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Peurs
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Le facteur émotionnel pas toujours négatif !
Schlossbauer SA, et al. Praxis. 2016;105:1185–1192.
Happy Heart Syndrome
Ghadri JR, et al. Eur Heart J. 2016;37(37):2823-9.
Agressions
physiques
fréquentes !
AVC
TC
Épilepsie
PRESS
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Phéochromocytome
CNA
Urosepsis
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Pancréatite
HD
Crohn
Hernies, occlusions
Péritonite
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
EA BPCO
AAG
IRB
EP
Laryngospasme
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Hémorragie
Accouchement
Anesthésie
Catecholamines
Dialyse
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Chirurgie
Cancers
Chimiothérapie
Fractures, plaies, …
Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
Défaillance cardiaque transitoire
Absence de lésion coronaire
Ce que l’on croit savoir…
Constatations angiographiques < 2010
Bybee K.A. et al. Circulation. 2008;18(4):397-409.
Dyskinésie/akinésie des zones apicale +/- moyenne du VG
Hyperkinésie de la base du VG
Résolution généralement en 1-2 à 3-4 semaines
Absence de spasme macro-circulatoire ou d’occlusion coronaire
Lyon AR, et al. Nat Clin Pract Cardiovasc Med. 2008;5:22-9.
Prasad A, et al. Am Heart J. 2008;155(3):408-17.
Nef HM, et al. Heart 2007;93:1309-15.
Prasad A, et al. Am Heart J. 2008;155(3):408-17.
Sharkey SW, et al. Circulation. 2005;111;472-9.
Templin C, et al. N Engl J Med. 2015;373:929-38.
Templin C, et al. N Engl J Med. 2015;373:929-38.
coronary intervention; STEMI, ST-segment elevation myocardial infarction; TNT, troponin T.
Lüscher TF, Templin C. Eur Heart J. 2016;37:2816-20.
Table 1 International Takotsubo Diagnostic Criteria (InterTAK Diagnostic Criteria)
1. Patients show transienta
left ventricular dysfunction (hypokinesia, akinesia, or dyskinesia) presenting as apical ballooning or midventricular, basal,
or focal wall motion abnormalities. Right ventricular involvement can be present. Besides these regional wall motion patterns, transitions be-
tween all types can exist. The regional wall motion abnormality usually extends beyond a single epicardial vascular distribution; however, rare
cases can exist where the regional wall motion abnormality is present in the subtended myocardial territory of a single coronary artery (focal
TTS).b
2. An emotional, physical, or combined trigger can precede the takotsubo syndrome event, but this is not obligatory.
3. Neurologic disorders (e.g. subarachnoid haemorrhage, stroke/transient ischaemic attack, or seizures) as well as pheochromocytoma may serve as
triggers for takotsubo syndrome.
4. New ECG abnormalities are present (ST-segment elevation, ST-segment depression, T-wave inversion, and QTc prolongation); however, rare
cases exist without any ECG changes.
5. Levels of cardiac biomarkers (troponin and creatine kinase) are moderately elevated in most cases; significant elevation of brain natriuretic peptide
is common.
6. Significant coronary artery disease is not a contradiction in takotsubo syndrome.
7. Patients have no evidence of infectious myocarditis.b
8. Postmenopausal women are predominantly affected.
a
Wall motion abnormalities may remain for a prolonged period of time or documentation of recovery may not be possible. For example, death before evidence of recovery is
captured.
b
Cardiac magnetic resonance imaging is recommended to exclude infectious myocarditis and diagnosis confirmation of takotsubo syndrome.
4 J.-R. Ghadri et al.
Définition 2018
Ghadri JR, et al. Eur Heart J. 2018;39(22):2032-2046.
Récupération ad-integrum
Ce que l’on croyait savoir…
Eitel I, et al. JAMA. 2011;306(3):277-86.
IRM
InterTAK
C’est grave !
Mortalité
1 à 2 % (0-8%)
Récidive 10%
(1,8%/an/pt)
Akashi YJ, et al. Circulation 2008;118:2754-62.
Elesber A, et al. JACC 2007;50(5):448-52.
Patel SM, et al. J Card Fail. 2013;19:306-10.
C’est pour nous !
Si c’est grave…
Douleur thoracique 75%
Dyspnée 20%
Malaise 5%
Syncope 2%
Pilgrim TM, et al. Int Journal Card 2008;124:283-92.
Présentation clinique
Complications immédiates
OAPc 15-20%
Choc cardiogénique 1-10%
IM aiguë 5%
Péricardite <2%
Rupture septale,VG,VD <1%
Thrombus IV (embole systémique)
Mort subite 0,2-2% Buchholz S, et al. Postgrad Med J. 2007;83(978):261-4.
Prasad A, et al. Am Heart J. 2008;155(3):408-17.
Impossible à différencier d’un SCA !
Et l’ECG alors…
Vraiment…?
Madias C, et al. Heart Rhythm. 2011;8(4):555-61.
H0 H12
H12… et 1’
Dib C, et al. Am Heart J. 2009;157:933-8.
Toshiaki E, et al. JACC. 2010;55(22):2514-17.
Kosuge M, et al. JACC. 2010;55:2514-6.
Mugnai G, et al. J Electrocardiol. 2015;48:79-85.
Stimulation Σ + +
Catécholamines circulantes
BNP 2-3 x > MI (soit 7 à 30 x norme)
Et la bio …?
Wittstein IS, et al. N Engl J Med 2005;352:539-48.
Catécholamines circulantes
Nadir MA, et al. Am J Cardiol. 2011;107(5):662-7.
Biomarqueurs cardiaques
Peptides natriurétiques
Prasad A, et al. Am Heart J. 2008;155(3):408-17.
Biomarqueurs cardiaques
Peptides natriurétiques
Troponine
Biomarqueurs cardiaques
Troponine
Burgdorf C, et al. Peptides. 2012;34:389-94.
Spécial dédicace…
Mansencal N, et al. Arch Cardiovasc Dis. 2010;103:447-53.
Nef HM, et al. Heart 2007;93:1309-15.
Traitement(s)…?
Isogai T, et al. Heart 2016;102:1029-35.
ST+ Mimics
ST+ Mimics
Grave
ST+ Mimics
Grave
Défaillance
cardiaque aiguë
ST+ Mimics
Grave
Défaillance
cardiaque aiguë
Urgence
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgences 2019

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ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgences 2019

  • 1. ETAT DE L’ART ‘ST+ Mimics’ Syndrome de takotsubo …ou quand un poulpe vous brise le cœur Nicolas PESCHANSKI MD, PhD @DocNikko CHI Eure-Seine – CIRCE-NEV – INSERM U1096
  • 2. Ce que l’on sait…
  • 3. Japon, 1990… Tremblement de terre à 80 km au sud-ouest de Tokyo
  • 5. 5 SCA-ST+ à coronaires saines Contractilité ≈ Aspect atypique FEVG abaissée Population à risque !!! Âge moyen >>> SCA 100% femmes Sato H, et al. Kodama K, Haze K, Hon M, eds. Clinical Aspect of Myocardial Injury: From Ischaemia to Heart Failure. Tokyo: Kagakuhyouronsya 1990:56-64.
  • 6. Clinique/Biologie/ECG = SCA ST+ Dysfonction VG (transitoire) associée
  • 7. Nouveau syndrome : le takotsubo !
  • 9. Un nouveau syndrome – le takotsubo !
  • 10. Un nouveau syndrome – le takotsubo !
  • 11. Définition(s) Circulation Journal Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp Diagnosis of Takotsubo Cardiomyopathy – Mayo Clinic Criteria – Dawn C Scantlebury, MD; Abhiram Prasad, MD Takotsubo cardiomyopathy, also known as left ventricular apical ballooning syndrome and stress-induced cardio- myopathy, is typically characterized by transient systolic dysfunction of the apical and mid-segments of the left ventricle, in the absence of obstructive coronary artery lesions. Patients may present with symptoms and signs of acute coronary syndrome, and the provider is challenged to differentiate between these conditions. In this review, we guide the reader through the diagnostic pathway, focusing on differential diagnoses and diagnostic criteria for takotsubo cardiomyopathy. (Circ J 2014; 78: 2129– 2139) Focus Issue on Takotsubo Cardiomyopathy
  • 12. 2004-2008-20142130 SCANTLEBURY DC et al. of severe chest pain and dyspnea lasting 2–3h. The chest painthe cardiomyopathy began to be recognized in the rest of the Table 1. Mayo Clinic Criteria for ABS/TTC20 1. Transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid-segments with or without apical involvement; the regional wall motion abnormalities extend beyond a single epicardial vascular distribution; a stressful trigger is often, but not always present.* 2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture.† 3. New electrocardiographic abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin. 4. Absence of: a. Pheochromocytoma b. Myocarditis ABS, apical ballooning syndrome; TTC, takotsubo cardiomyopathy; ACS, acute coronary syndrome. *There are rare exceptions to these criteria such as those patients in whom the regional wall motion abnormality is limited to a single coronary territory. † It is possible that a patient with obstructive coronary atherosclerosis may also develop ABS. However, this is very rare in our experience and in the published literature, perhaps because such cases are misdiagnosed as ACS. In both of the above circumstances, the diagnosis of ABS should be made with caution and a clear stressful precipitating trigger must be sought.
  • 13. Définition(s) European Journal of Heart Failure (2016) 18, 8–27 REVIEW doi:10.1002/ejhf.424 Current state of knowledge on Takotsubo syndrome: a position statement from the task force on Takotsubo syndrome of the Heart Failure Association of the European Society of Cardiology Alexander R. Lyon1,2,*, Eduardo Bossone3, Birke Schneider4, Udo Sechtem5, Rodolfo Citro6, S.Richard Underwood1,2, Mary N. Sheppard7, Gemma A. Figtree8,9, 10 11 12 13
  • 14. Ce que l’on croit savoir…
  • 15. Spasme microcirculatoire Wittstein IS, et al. N Engl J Med 2005;352:539-48.
  • 16. Redistribution des récepteurs β Cevik C, et al. Am Heart J 2008;156:e31.0002-8703. Défaillance du VG prédominant à l’apex (β2 isoformes Gs) Réponse augmentée à la stimulation 𝜮 à la base (β1 isoformes G1)
  • 17. Cardiotoxicité catécholergique Akashi YJ, et al. Circulation 2008;118:2754-62. Pelliccia F, et al. Circulation. 2017;135:2426-41. Surcharge en Ca++ médiée par libération de Rx libres Stimulation des canaux calciques AMP-dépendants
  • 18. Physiopathologie (on progresse…) Pelliccia F, et al. Circulation. 2017;135:2426-41. Pelliccia et al Figure 4. Autonomic nervous system (ANS) activation and cardiovascular system. ANS activation is mediated by release of norepinephrine (NE) and epinephrine (Epi) and occurs via the following m (1) Release of norepinephrine by cardiac sympathetic nerve terminals (resulting in tachycardia and an increased force (2) release of epinephrine into the circulation by the adrenal medulla, modulating both myocardium and peripheral
  • 20. Physiopathologie (pour les nuls en poulpe)
  • 21. Physiopathologie (pour les nuls en poulpe) VG normal VG Takotsubo
  • 22. Physiopathologie (pour tout le monde) VG normal VG Takotsubo Akashi JY, et al. Nat. Rev. Cardiol. 2015;12:387-97.
  • 23. Très forte prédominance féminine Âge moyen post-ménopausique Facteur de stress physique ou émotionnel Ce que l’on doit savoir…
  • 24.
  • 25. Takotsubo ≠ rare & féminin ! Incidence/Prévalence Âge 65-72 ans Femmes 82-100 % 1,7 -2,3 % SCA 5-7 % SCA chez les femmes Variation saisonnière/circadienne Incidence x 2 à 4 l’été Diurne/matinal Wedekind H, et al. Herz. 2006;31(4):339-46. Citro R, et al. JACC. 2009;54(2):180-81. Templin C, et al. N Engl J Med. 2015;373:929-38. the first reported case of takotsubo syndrome. Diastole (A) and systo lar wall motion abnormality two weeks after the event (C and D). Co
  • 26. Triggers Tristesse Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
  • 27. Évènements négatifs Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
  • 28. Colère Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
  • 29. Catastrophes naturelles Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
  • 30. Peurs Schlossbauer SA, et al. Praxis. 2016;105:1185-92.
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  • 49. Table 1 International Takotsubo Diagnostic Criteria (InterTAK Diagnostic Criteria) 1. Patients show transienta left ventricular dysfunction (hypokinesia, akinesia, or dyskinesia) presenting as apical ballooning or midventricular, basal, or focal wall motion abnormalities. Right ventricular involvement can be present. Besides these regional wall motion patterns, transitions be- tween all types can exist. The regional wall motion abnormality usually extends beyond a single epicardial vascular distribution; however, rare cases can exist where the regional wall motion abnormality is present in the subtended myocardial territory of a single coronary artery (focal TTS).b 2. An emotional, physical, or combined trigger can precede the takotsubo syndrome event, but this is not obligatory. 3. Neurologic disorders (e.g. subarachnoid haemorrhage, stroke/transient ischaemic attack, or seizures) as well as pheochromocytoma may serve as triggers for takotsubo syndrome. 4. New ECG abnormalities are present (ST-segment elevation, ST-segment depression, T-wave inversion, and QTc prolongation); however, rare cases exist without any ECG changes. 5. Levels of cardiac biomarkers (troponin and creatine kinase) are moderately elevated in most cases; significant elevation of brain natriuretic peptide is common. 6. Significant coronary artery disease is not a contradiction in takotsubo syndrome. 7. Patients have no evidence of infectious myocarditis.b 8. Postmenopausal women are predominantly affected. a Wall motion abnormalities may remain for a prolonged period of time or documentation of recovery may not be possible. For example, death before evidence of recovery is captured. b Cardiac magnetic resonance imaging is recommended to exclude infectious myocarditis and diagnosis confirmation of takotsubo syndrome. 4 J.-R. Ghadri et al. Définition 2018 Ghadri JR, et al. Eur Heart J. 2018;39(22):2032-2046.
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