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EMGuideWire's Radiology Reading Room: Stress-Induced Cardiomyopathy

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EMGuideWire's Radiology Reading Room: Stress-Induced Cardiomyopathy

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.

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EMGuideWire's Radiology Reading Room: Stress-Induced Cardiomyopathy

  1. 1. John Symanski, MD, Laszlo Littmann, MD, Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore Gibbs, DNP Departments of Emergency Medicine and Internal Medicine Sanger Heart & Vascular Institute Carolinas Medical Center Stress-Induced Cardiomyopathy Michael A. Gibbs, MD, Lead Editor Carolinas Medical Center Imaging Mastery Project
  2. 2. Visit Our Educational Website www.EMGuidewire.com
  3. 3. Amyloid Dilated • Ischemic • Peripartum • Hypertensive • Iron overload Genetic • Hypertrophic • LV Noncompaction • ARVC1 Inflammatory (Myocarditis) • Viral • Giant cell • Eosinophilic • Chagas • COVID-19 Metabolic • Diabetic • Hypothyroid • Acromegalic • Cardiac Sarcoid Stress-Induced (Takotsubo) Tachycardia-Induced Toxic • Alcoholic • Chemotherapy-induced • Cocaine-induced • Other drug related 1Arrhythmogenic Right Ventricular Cardiomyopathy Classification Of Cardiomyopathies
  4. 4. Selected Embedded References: Wittstein IS. Neurohormonal Features of Myocardial Stunning Due To Sudden Emotional Stress. New England Journal of Medicine. 2006; 352:539-548. Eitel I. Clinical Characteristics and Cardiac MR Findings In Stress Cardiomyopathy. Journal of the American Medical Association. 2011; 306:277-286. Amsterdam EA. 2104 AHA/ACC Guidelines for the Management of Patients With Non-ST Segment Acute Coronary Syndrome. Circulation. 2014; DOI:10.1161/CIR.0000000000000134. Templin C. Clinical Features And Outcomes Of Stress (Takotsubo) Cardiomyopathy. New England Journal of Medicine. 2015; 373:10. Lyon AR. 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. European Journal of Heart Failure. 2016; 18:8-27. Pelliccia F. Pathophysiology of Takotsubo Cardiomyopathy. Circulation. 2017; 135:2426-2441. de Chazal HM. Stress Cardiomyopathy Diagnosis and Treatment. JACC State-of-the-Art Review. Journal of the American College of Cardiology. 2018; 72:1955-1971.
  5. 5. Stress-Induced (Takotsubo) Cardiomyopathy Cases Studies From Carolinas Medical Center
  6. 6. Case #1 44-Year-Old Female Develops Chest Pain After Getting Into An Argument With Her Best Friend.
  7. 7. Interpreted As Lateral STEMI An Taken For Emergent Cardiac Catheterization
  8. 8. Left Coronary System Right Coronary Artery Normal Coronary Arteries
  9. 9. Diastole Systole Left Ventriculogram
  10. 10. Apical Ballooning (*) With Hyperkinetic Basilar Segment (Arrows) Causing LVOT Obstruction LVOT = Left Ventricular Outflow Tract * Diastole Systole
  11. 11. Normal ECG 6 Months Later (Asymptomatic)
  12. 12. Diastole Systole
  13. 13. Diastole Systole Akinetic Apex With Ballooning Hyperkinetic Basilar Segment (Potential For LVOT Obstruction)
  14. 14. Case #2 66-Year-Old Female With A History Of Substance Abuse Becomes Upset After Experiencing A Relapse.
  15. 15. Diastole Systole TTE (Apical 4-Chamber) Images
  16. 16. Diastole Systole TTE (Apical 4-Chamber) Images Akinetic Apex With Ballooning Hyperkinetic Basil Segment And LVOT Obstruction Apex Apex
  17. 17. TTE (Apical 2-Chamber) Images Diastole Systole
  18. 18. TTE (Apical 2-Chamber) Images Akinetic Apex With Ballooning Hyperkinetic Basil Segment And LVOT Obstruction ApexApex Diastole Systole
  19. 19. TTE (Apical 3-Chamber) Images Diastole Early Systole Late Systole Note: Systolic Anterior Motion (SAM) With Septal Contact Apex
  20. 20. SAM-Associated Flow Acceleration In LVOT (Color Turbulence) And Mitral Regurgitation (Arrow)
  21. 21. Systolic Anterior Motion (SAM) Of The Posterior Leaflet Of The Mitral Valve Encroaches The Ventricular Septum Causing LVOT Obstruction & Mitral Regurgitation.
  22. 22. Case #4: 75-Year-Old Female Presenting With Chest Pain And Dyspnea, Troponin 2208. ECG #1: 15:00
  23. 23. Case #4: 75-Year-Old Female Presenting With Chest Pain And Dyspnea, Troponin 2208. ECG #2: 17:45
  24. 24. Case #4: 75-Year-Old Female Presenting With Chest Pain And Dyspnea, Troponin 2208. ECG #2: 17:45 Biphasic Precordial T Waves
  25. 25. Emergency Department Point-Of-Care Echocardiogram Apical 4 View
  26. 26. Emergency Department Point-Of-Care Echocardiogram Apical 4 View Akinetic Apex With Ballooning Formal Echocardiogram: Ejection Fraction 25% Apex
  27. 27. Definition First described in Japan in 1990 as Takotsubo Syndrome, it is also known as stress-induced cardiomyopathy, broken heart syndrome, apical ballooning syndrome, and acute reversible LV dysfunction.
  28. 28. The Most Widely Used Diagnostic Criteria Are Those From The European Society Of Cardiology
  29. 29. Pathophysiology
  30. 30. Pathophysiology
  31. 31. Complications • Acute heart failure • Torsade de pointes VT related to QT prolongation • Left ventricular outflow tract obstruction (LVOTO) • Mitral regurgitations (MR) • Both LVOTO and MR may lead to cardiogenic shock • Apical akinesis increases the risk of thromboembolism • Myocardial rupture (rare)
  32. 32. Epidemiology • Stress cardiomyopathy occurs predominantly in postmenopausal women. • Data from three registry studies: 1Templin C. 2Schneider B. 3Citro R. New Engl J Med 2015. Int J Cardiol 2013. J Am Geriatr Soc 2012. % Female Mean Age N=1,7501 90% 67 years N=3242 91% 68 years N=1903 92% 66 years
  33. 33. From The Original 2001 Japanese Case Series [n=71] Tsuchihaski K . Journal of the American College of Cardiology. 2001; 38:11-18. Female 84% Median age 67 ± 13 years Associated acute precipitants:  Medical event  Emotional event 43% 27% In-hospital complications:  Pulmonary edema  VT/VF  Cardiogenic shock 22% 9% 15%
  34. 34. Emotional Triggers1 • Death of a loved one • Tragic news • Assault, violence, robbery • Natural disasters • Sudden financial loss • A sense of doom, danger, or desperation 1Roughly 30% of cases have no identifiable trigger. • Public speaking • Court appearance • Personal conflict • Panic, fear, anxiety
  35. 35. Physical Triggers1 • Critical illness • Acute injury • Surgery • Several pain • Acute neurologic event • Heart failure exacerbation • Asthma exacerbation • Pheochromocytoma crisis • Hypertensive emergency • Preeclampsia • Cocaine, methamphetamine use • Large dose of catecholamines, e.g.: continuous albuterol 1Roughly 30% of cases have no identifiable trigger.
  36. 36. 19 Patients
  37. 37. 182 Patients
  38. 38. Clinical Manifestations • The typical history patient with stress cardiomyopathy is a postmenopausal women who presents with acute or subacute: • The physical exam reveals a tachypneic, tachycardic patients with signs of heart failure. A systolic ejection murmur (due to LVOTO and MR) is often heard. Chest Pain 75% Shortness of Breath 50% Dizziness 25% Syncope 5-10%
  39. 39. ECG Hallmarks On Presentation • Most commonly (80%) the ECG mimics acute anterior STEMI, but: • Less prominent ST elevation • Less reciprocal ST depression • No abnormal Q waves • ST depression in aVR is more common than in STEMI • Less commonly: diffuse ST depression and/or T-wave inversion 24-48 Hours Later • Diffuse T-wave inversion in  6 leads; aVR and V1 are usually spared • Frequently giant negative T waves • Markedly prolonged QT • Occasionally: the spiked helmet sign
  40. 40. ECG Hallmarks
  41. 41. 80-Year-Old Female: Prior ECG QTc = 484 ms
  42. 42. I II III F 1 2 3 4 5 6 II Requested by: Comment: Hospital Day #2 For Chest Pain QTc = 570 ms
  43. 43. I II III F 1 2 3 4 5 6 II Requested by: Comment: 25 mm/s 10 mm/mV 0.16-150 HzE-Scribe DICOM Module 1.3.6 Atrium Health Mercy Hospital Day #3 For Chest Pain QTc = 586 ms
  44. 44. I II III F 1 2 3 4 5 6 II I have personally reviewed the EKG tracing and my findings are listed above: FEDOR, JOHN M MD 11/12/2020 11:54:03 Requested by: Comment: 25 mm/s 10 mm/mV 0.16-150 HzE-Scribe DICOM Module 1.3.6 CMC One Month Later: Asymptomatic QTc = 461 ms
  45. 45. 65-Year-Old With Status Asthmaticus And Acute Chest Pain ECG ON PRESENTATION: ST ELEVATION IN V2-V4 ECG 48 HRS LATER: LARGE GLOBAL TWI, LONG QT EMERGENT CATHETERIZATION: NORMAL CORONARY ARTERIES APICAL BALLOONING
  46. 46. See Appendix 1 At The End Of This Presentation: “Stress-Induced Cardiomyopathy ECG Case Studies.” Created by the master ECG educator, Dr. Laszlo Littmann.
  47. 47. Biomarkers • Cardiac troponin T or I elevated in >90% of patients, although with lower levels than a classic acute coronary syndrome (ACS) • Cardiac natriuretic peptides (BNP and pro-BNP) are always elevated, with higher levels correlating with the degree of wall motion abnormality and usually greater than that seen with ACS • Peak biomarker levels occur at 48 hours
  48. 48. Biomarkers
  49. 49. Diagnostic Imaging Echocardiography Classic pattern: circumferential LV akinesis involving the entire cardiac apex along with adjacent basilar hypercontractility Coronary Angiography  The decision to proceed with a coronary angiogram should be made on an individual basis  Elderly patients may have underlying CAD not causing acute ischemia (bystander disease)  A ventriculogram is diagnostic of stress cardiomyopathy and particularly helpful for the midventricular form that may be difficult to visualize with echocardiography Coronary Computed Tomography Angiography Used to exclude high-grade coronary culprit lesions in patients with limited acoustic windows and contraindications to CMR Cardiac Magnetic Resonance  CMR allows visualization of myocardial edema, inflammation, and scarring with the use of delayed gadolinium enhancement  During the acute phase, T2-weighted CMR shows edema as high signal intensity
  50. 50. Cardiac MRI: Gadolinium Enhancement • Gadolinium containing contrast is widely used in cardiac MRI to assess the integrity of the myocardium • Gadolinium is typically taken up and rapidly washed out from healthy myocardial cells • In the presence of disease (e.g.: acute and chronic ischemia, prior infarct, myocarditis, cardiomyopathies) gadolinium remains in abnormal cardiomyocytes, thus causing late phase enhancement gadolinium enhancement (LGE) on T1 images
  51. 51. * = Pericardial Effusion; ➤ = Apical Akinesis
  52. 52. ➤ = Mid Left Ventricular Akinesis
  53. 53. ➤ = Basilar Akinesis
  54. 54. ➤ = Basilar Akinesis * = Pleural Effusions; ➤ = Apical Akinesis ➤ = RV Apex Akinesis
  55. 55. 2014 ACC/AHA Non-STEMI Guidelines
  56. 56. STRESS-INDUCED CARDIOMYOPATHY ECG CASE STUDIES Dr. Laszlo Littmann, MD Department of Internal Medicine Carolinas Medical Center November 2020 APPENDIX 1
  57. 57. ECG Hallmarks On Presentation • Most commonly (80%) the ECG mimics acute anterior STEMI, but: • Less prominent ST elevation • Less reciprocal ST depression • No abnormal Q waves • ST depression in aVR is more common than in STEMI • Less commonly: diffuse ST depression and/or T-wave inversion 24-48 Hours Later • Diffuse T-wave inversion in  6 leads; aVR and V1 are usually spared • Frequently giant negative T waves • Markedly prolonged QT • Occasionally: the spiked helmet sign
  58. 58. 65-Year-Old With Status Asthmaticus And Acute Chest Pain ECG ON PRESENTATION: ST ELEVATION IN V2-V4 ECG 48 HRS LATER: LARGE GLOBAL TWI, LONG QT EMERGENT CATHETERIZATION: NORMAL CORONARY ARTERIES APICAL BALLOONING
  59. 59. • Following an acute CNS event: • Subarachnoid hemorrhage • Large ICH • Status epilepticus • Emotional stress: • Takotsubo cardiomyopathy • Any type of adrenergic stress: • Hypertensive emergency • Pheochromocytoma attack • Pulmonary edema • Severe asthma attack • Severe trauma “CEREBRAL T WAVES” The ECGs All Look Alike! Large Near-Global T-Wave Inversion And Marked QT Prolongation: A Stereotypical Delayed ECG Response To Stress Cardiomyopathy
  60. 60. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED DRAMATICALLY PROLONGED QT Day 2: Stress-Induced Cardiomyopathy
  61. 61. GLOBAL T WITH PROLONGED QT NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED DRAMATICALLY PROLONGED QT Day 2: Subarachnoid Hemorrhage
  62. 62. GLOBAL T WITH PROLONGED QT NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED DRAMATICALLY PROLONGED QT Day 2: Subarachnoid Hemorrhage
  63. 63. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED PROLONGED QT Day 2: Massive ICH
  64. 64. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED DRAMATICALLY PROLONGED QT After An Episode Of Status Epilepticus
  65. 65. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED; PROLONGED QT Day 2: Acute Pulmonary Edema
  66. 66. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR SPARED DRAMATICALLY PROLONGED QT Following An Acute COPD Exacerbation
  67. 67. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR SPARED DRAMATICALLY PROLONGED QT Following An Episode Of Hypertensive Crisis
  68. 68. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED DRAMATICALLY PROLONGED QT ICU Patient With Respiratory Failure & Shock
  69. 69. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED PROLONGED QT Following An Acute Episode Of Cocaine Toxicity
  70. 70. What Is The Significance Of Recognizing The “T-QT Pattern”? • If the clinical history and the ECG are typical for stress response, the large negative T waves do not necessarily indicate ischemia • Unnecessary cardiac catheterization can be avoided • Antithrombotic and anti-ischemic treatment may be avoided • In acute heart failure if stress cardiomyopathy is a reasonable consideration, the typical “T-QT pattern” can further support this possibility
  71. 71. If You Have Interesting Cases Of Stress-Induced Cardiomyopathy We Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To: michael.gibbs@atriumhealth.org Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

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