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Takotsubo cardiomyopathy potential differential diagnosis in acute coronary syndrome

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Takotsubo Cardiomyopathy Potential Differential Diagnosis in Acute Coronary Syndrome

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Takotsubo cardiomyopathy potential differential diagnosis in acute coronary syndrome

  1. 1. TCM in ASC Diagnosis 1 TAKOTSUBO CARDIOMYOPATHY POTENTIAL DIFFERENTIAL DIAGNOSIS IN ACUTE CORONARY SYNDROME by [Name] Course: Professor’s Name Institution: Location of Institution: Date:
  2. 2. TCM in ASC Diagnosis 2 Takotsubo Cardiomyopathy Potential Differential Diagnosis in Acute Coronary Syndrome Introduction Takotsubo Cardiomyopathy (TCM) came to light in Japan in 1990 and has since then gained widerecognition all over the world. The term “takotsubo” comes from a Japanese word referring to an octopus trap (Hurst et al., 2010). The trap bears a resemblance to the apical bloating of the systole of the left ventricle in the early stage and dominant state of the disease. TCM can be described as being an important differentiated form of diagnosis for acute coronary syndrome (ACS). TCM is characterized by acute and reversible dysfunction of the left ventricle often aggravated by intense physical and emotional stress (Bär et al., 2009). Occasionally, although rarely, the ballooning of the right ventricle is also reported (Haghi et al,. 2010).On the other hand, ACS refers to a range of clinical manifestations that range from those associated with ST elevation myocardial infarction (STEMI) to those that are found in non ST elevation myocardial infarction (NSTEMI)(Chlus et al., 2016). Usually, it is associated with atherosclerotic plaque rupture or complete thrombosis(Chlus et al., 2016). Researchers state that the exact pathogenesis of TCM is yet to be known, yet there are various hypotheses that have been discussed to date and they include: Coronary artery spasm, myocardial micro-infarction, myocardial stunning that is induced by raised catecholamine, reperfusion injury and micro-vascular dysfunction (Yoshida et al., 2009; Guglin and Novotorova,2011). Takotsubo cardiomyopathy is a condition, which affects up to 2.2% of the population in Japan and up to 3% of people in the European nations (Yoshida et al., 2009). It is more prevalent in post-menopausal women,although younger men and women can be affected too. The most common symptom that presents itself, in most cases, is chest pain which occurs in 70- 90% of those affected (Minhas, Hughey and Kolias, 2015). There are other symptoms that are less common, such as pulmonary oedema and dyspnoea, which can occur in up to
  3. 3. TCM in ASC Diagnosis 3 20% of those suffering from TCM. It is very rare for cardiogenic shock, ventricular arrhythmias and cardiac arrests to occur (Citro et al., 2010). There are also certain cases where nonspecific symptoms may occur and they include weakness, cough, fever, and syncope. TCM has attracted the attention of the medical world since it is considered as a unique cardiomyopathy and has been seen as an important factor in the diagnosis of ACS. It makes up an estimated 1 to 2% of the patients who show signs of ACS (Citro et al., 2010). It is also understood that the estimate may be low due to elements associated with under recognition. This assignment will take an in-depth look at TCM as a possible differential diagnosis in ACS. Though exhibiting relatively similar symptoms at their onset, Takotsubo Cardiomyopathy and Acute Coronary Syndrome are two very distinct diseases. ACS is caused by a sudden blockage of blood flow to some parts of the heart muscle, usually caused by a blood clot(Kumar and Cannon, 2009). Depending on whether the blockage is partial or complete, the effects may be either unstable angina or myopic infarct respectively(Kumar and Cannon, 2009). When there is a complete blockage in the coronary arteries, the parts of the heart muscle which receive blood from those specific arteries may die, a situation referred to as infarction. The location of the blockage, the amount of time that blood flow is curtailed to the specific parts of the heart and the amount of damage that occurs in that part of the heart determines the type of ACS experienced. ACS can either be a myocardial infarction or an unstable angina. TCM, on the other hand, is caused by an unusual inflation of particular parts of the left ventricle. Depending on the ventricular part which experiences the inflation, TCM can be described as apical, midventricular, basal or focal(Chlus et al., 2016). It is caused by increased emotional or psychological stress and is most prevalent among postmenstrual women, though it does occur among younger women and men as well, in very little numbers(Chlus et al., 2016).
  4. 4. TCM in ASC Diagnosis 4 TCM has been described as a transient cardiac syndrome that does not show any distinctive signs and symptoms, but whose manifestation often mimics that of ACS (Templin et al.,2015). Since TCM often involves the left ventricular akinesis, just like some ACS, there is the need to understand which of the two diseases is being diagnosed. Medical practice provides evidence that TCM can appear like either NSTEMI or STEMI, yet they are managed in different ways. In this regard, there are different electrocardiographic abnormalities that have been determined, which can be important in differentiating TCM from NSTEMI and STEMI without the presence of ST-elevation (Citro et al., 2009). The fact that TCM can mimic ACS, means that it is important to rule out a differential diagnosis to come up with the most appropriate strategy for treatment and more attention should be given to patients during the acute phase of the syndrome. TCM has imaging characteristics that are important when it comes to the process of its diagnosis. Although, there is no definite criterion in diagnosing TCM, Mayo Clinic suggestedcriteria in 2004 which was again revised in 2008(Chlus et al., 2016). All of these criteria must be present in diagnosing the syndrome; the presence of stressors prior to the onset of symptoms, abnormalities on ECG reading must be noted in comparison to the ECG of a normal heart, the levels of cardiac biomarkers must be raised or abnormal and the patient must completely recover and function normallywithin a short period of time (Madhavan et al.,2011). However, the above mentioned criteria cannot always be followed and has several limitations. It is, therefore, necessary to create the common criteria around the world for diagnosing TCM. There are cases when a patient may experience acute chest pain, which may be caused by ACS or TCM. ACS, as a term, involves a range of conditions which may not be easily distinguished from TCM (Ghadri et al., 2014). Such conditions include STEMI, NSTEMI and unstable angina. There are different guidelines that have been provided by National Institute of Care Excellence (NICE), on stable angina and NSTEMI, which help in the early
  5. 5. TCM in ASC Diagnosis 5 management of the condition, before one is discharged from the care facility. Although history and assessment may provide clues to a possible emotional or physical trigger, if one exists. First, it is important to check whether the patient has chest pain and, if they are pain- free, it is important to check when the last episode of pain occurred. The health care practitioner has to determine whether the pain in question is cardiac related, or not, through taking into consideration the history of chest pain, cardiovascular risk factors and history of ischemic heart disease(Kumar and Cannon, 2009). It is also important to assess the patient for any symptoms that may be indicative of ACS (Hurst et al., 2010). Such include pain in the chest and other areas and pain in the chest that is associated with vomiting, hemodynamic instability and severe sweating. At the same time, it is advisable that patients with chest pain, without raised troponin levels, should be reassessed to determine whether the chest pain that they experience is cardiac. In any case, where TCM is suspected, it is important to follow the procedure of managing chest pain (Pelliccia et al., 2015). Therefore, the care provider is expected to make use of their clinical conclusions to carry out further examination that is diagnostic in nature. These symptomology would alert urgent clinical assessment and rapid acquisition of resting ECG. These results of the findings should activate an ACS treatment pathway in accordance to European Society of Cardiology (ESC) guidelines, wherein urgent coronary angiography is indicated. When a patient has normal ECG with possible ACS and at the same time has no history of CAD and has normal troponin levels in the blood, it is advisable that the patient is initially taken through coronary CT angiography, to have an assessment of the anatomy of the coronary artery (Sharkey et al., 2010). This is referred to as level of evidence A. Level of evidence B can be performed through myocardial perfusion imaging through technetium 99 m so that myocardial ischemia can be excluded (Sharkey et al., 2010). It is possible to determine the difference in diagnosis of ACS and TCM due to significant differences in
  6. 6. TCM in ASC Diagnosis 6 inverted T waves. T waves’ inversion in precordial leads can suggest severe ischemia under the left ventricular wall; this can be attributed to critical stenosis of the LAD (Hoyt et al., 2010). Yet such observations have also been determined under the TCM which has new electrocardiographic abnormalities. Different strategies that have been applied, with the aim of differentiating ACS from TCM and one such tool is the electrocardiogram (ECG), which shows anomalies in more than 95% of patients with TCM, during the acute phase of the syndrome (Pilgrim & Wyss., 2008). According to Delgado et al (2011) there is a variation in presentation of the electrocardiogram in patients with TCM. It is shown that ST-segment elevation is evident in one-third of the patients and the anterior lead is most common, in such cases. However, one can see the T-wave inversion as well as ST-T wave variations that are nonspecific (Delgado et al., 2011). The use of electrocardiogram may indicate certain changes that are seen during the acute phase of the syndrome such asdeep symmetric T wave inversion and prolonged QT interval are present in more than 90% of TCM cases(Pilgrim and Wyss, 2008). This may even take some months to resolve. Even though the long QT is evident, torsades de pointes in most cases is hardly reported. People with ST-segment elevation are faced with a high risk of going through coronary angiography, which is important when it comes to diagnosis of TCM (Madhavan et al., 2009). Although, these ECG characteristics help in diagnosing TCM and ACS,no ECG criteria have been identified that reliably discriminate between TCM and STEMI(Scantlebury and Prasad, 2014). Furthermore,imaging studies and other measures are needed to rule out ACS to get a definitive diagnosis. The ability of medical practitioners, in distinguishing these characteristics, will assist medical professionals not to fall into the trap of misdiagnosing the condition. Even though initial ECG in patients that have TCM is usually nonspecific, it is possible that ST segment elevation can be found in pre cordial lead in 50% of patients, at
  7. 7. TCM in ASC Diagnosis 7 initial onset(Scantlebury and Prasad, 2014). Additionally, it is understood that one is unlikely to find reciprocal ST segment depression in the inferior wall (Haghi et al., 2010). Taking into consideration comparison with patients who have other deformities, inverted T waves can be observed more often in patients who show signs of an apex dilation that is balloon like. Furthermore, patients with TCM also show abnormal forms of Q waves that are usually transient in most patients and can be resolved within a short period of time which can be a day, or in some cases, several days. However, in patients with myocardial infarction, a pathologic Q wave is frequently unresolved. When it comes to patients with chest pain that suggests a possibility of ACS, it is recommended practice that they are put through a process of 12-lead ECG. After a period of ten minutes, they must be evaluated in order to detect any ischemic changes (Krishnamoorthy et al., 2015). In any case where the ECG that has been performed is not correctly indicative of what the patient could be suffering, yet the medical practitioner has a high suspicion that ACS might be the main problem, a series of ECGs must be carried out at 15 minutes intervals in the first hour, with the main aim of determining any forms of ischemic changes. Therefore, regular ECGs are significant as distinctive changes have now been defined and the potential for deterioration of the QT interval is important in risk stratification and may assist in distinguishing TCM from ACS.Although, no evidence is reported that QT interval calculation can help diagnose accurately at presentation. The medical understanding is that inverted T waves in most cases appear in patients with ACS, but can also be noted in patients with TCM. It is possible to determine the difference in diagnosis of ACS and TCM due to significant differences in inverted T waves.T wave’s inversion in precordial leads can suggest severe ischemia under the left ventricular wall; this can be attributed to critical stenosis of the LAD (Hoyt et al., 2010). Yet such observations have also been determined under the TCM which has new electrocardiographic anomalies. Different diagnosis is essential to differentiate TCM from ACS. This ensures that
  8. 8. TCM in ASC Diagnosis 8 the form of treatment is appropriate and directed towards positive outcomes (Prasad et al., 2014). To determine the difference between TCM and ACS, one has to study admission ECGs in some patients. The patients must be observed in the care facility within 48 hours from the onset of symptom and if they have had inverted T waves equal to or greater than 1 mm (Summers et al., 2010). When such investigation is carried out, it is possible to determine that, maximal amplitude and numbers of the inverted T waves were more in patients with TCM. The patients with ACS had a lower number as well as maximal amplitude. The electrocardiographic changes that occur in TCM have indicated their similarities to those found in the anterior AMI (acute myocardial infarction) (Singh et al., 2014). This is different to that which takes place in patients with ACS, where non STEMI patients have more commonT waves than ST segment changes. The inverted T waves are usually followed by ST segment elevation which in most cases exists in leads that face the site of myocardial ischemia. The artery connected to the ischemia and the perfusion territory can be determined through following the distribution of the inverted T waves. In patients who have TCM and ACS, inverted T waves can occur without ST-segment elevation at a presentation of ECG, when one focuses on the T waves changes in leads III, aVR and V1 can lead to differentiation between ACS and TCM. However, ECG criteria alone are inadequate to differentiate ACS syndrome from TCM. In general, during presentations, the biomarkers of cardiac myonecrosis are usually elevated in more than 90% of TCM cases (Pilgrim and Wyss, 2008). Usually, the biomarker levels, in most of the cases, go high within 24 hours after their presentation, yet the levels are usually lower than that which would be anticipated on the basis of abnormalities on wall motion, as well as findings in the electrocardiogram (Parkkonen et al.,2014). However, there are various cases in which the level of biomarkers is significantly raised in the absence of myocardial damage. When troponin levels are measured and found to be elevated in any
  9. 9. TCM in ASC Diagnosis 9 individuals suspected to have ACS, it is important to eliminate other causes that could lead to raised troponin. Examples include aortic dissection, pulmonary embolism, myocarditis, renal failure and TCM that leads to avoidable unnecessary cardiac testing. This must be done before the patient is diagnosed with ACS (Kumar et al., 2010). It is always important to follow the correct guidance provided by NICE when a patient shows signs of high troponin levels, until the most accurate and firm diagnosis is reached. The levels of cardiac-specific troponin are usually measured at the point of presentation or 3 to 6 hours from the onset of the symptoms in patients who show high signs of ACS. This is done to monitor if there are marked elevations of troponin levels which clearly distinguishes TCM from ACS, however, there are no specified levels used as a cut off measurement biomarkers in distinguishing ACS from TCM. In cases of patients with normal troponin levels six hours after admission, additional readings of troponin levels should be gathered beyond the six hours (Deshmukh, 2016). There are cases when the time of symptom is difficult to determine. Hence, it is recommended that the time of presentation should be used as the time of onset, when assessing the value of troponin. Cardiac biomarkers are important when it comes to prognosis. The troponin is determined in two aspects; the magnitude and the presence, both which are very important in the short and long term prognosis of the syndrome. It is advisable that one should engage in the remeasuring process, on the third or even fourth day. This is done on patients with ACS, as dynamics of necrosis, or as an index of the infarct (Dib et al., 2009). Noticeably,a rapid but small rise in cardiac biomarkers is noted on patients with TCM syndrome, while cardiac biomarkers in patients with STEMI take longer to rise but peak higher. Therefore, troponin levels and prevalence over time can be used to differentiate ACS from TCM
  10. 10. TCM in ASC Diagnosis 10 The most recent case study, carried out on 97 patients from Japan with TCM, showed a 10% incidence of coronary artery disease (Kurisu et al., 2009). There was another case study, which described seven patients who had presentations consistent with TCM and had epicardial coronary artery or more than 70% of stenosis (Citro et al., 2013). There are several areas within which imaging options are possible and they range from angiography wherein coronary anatomy can be evaluated and cardiac magnetic resonance, under which, an assessment of tissue characterization can be carried out. Percutaneous Coronary Intervention (PCI) is an important element which is used to improve outcome in patients who have acute ST elevation. In carrying out the task highlighted above, there are certain technical and adjunctive medications that are important during the periprocedural period. It is important to understand that PCI is a non-surgical technique that can be applied when treating any form of obstructive coronary artery disease or infarction (Dundon et al., 2009). To determine the nature of the disease that is suffered, one has to look at the indications, as well as contraindications for PCI. Should a patient show any signs of STEMI, an immediate angiography with PCI must be carriedas a therapeutic management. However, in TCM patients this is used to assess the wall motion abnormalities as this may improve in hours and maybe missed if coronary imaging is delayed resulting to misdiagnosis and mismanagement of the syndrome (Haghi et al.,2010). Coronaryangiography can be considered if the procedure can be performed within the recommended door to balloon guidelines. Furthermore, such procedure must not be applied at the expense of delaying lifesaving reperfusion therapy from patients with STEMI if the patient is assessed and diagnosed where coronary angiography is not available. Conclusion Thus, despite similarities in symptoms, ASC and TCM are two very distinct ailments with different causes and different implications for patients’ health. The onset of both
  11. 11. TCM in ASC Diagnosis 11 syndromes is preceded by chest pains, a factor that has increased the chances of misdiagnosis especially that of TCM as ACS, mostly in patients who have inverted T waves under the first ECG.This has the potential of leading to inappropriate treatment, as well as presentation. However, initial tests of troponin levels in patient blood samples may be used to determine whether a patient has suffered from ASC or TCM. In ASC, there is either total or partial damage of tissues within the heart, which leads to the release of troponin, leading to increased levels of the latter in the blood in ASC patients as compared to TCM patients. There are lower levels of troponin among TCM patients as there is no actual damage to heart tissues, as the ailment involves mainly an inflation and ballooning of specific parts of the right ventricle. However, ECG changes and troponin level measures alone are not sufficient to differentiate TCM syndrome from ACS. It is, therefore, important to note that diagnosing TCM demands coronary angiography, continuous assessment of left ventricle systolic functionality (through initial general evaluation by echocardiography or ventriculography followed by an overall assessment by echocardiography) and electrocardiogram. Identifying the difference between the two syndromes is important as different treatment or management is provided for each of them.In selecting treatment for patients at greater risk of complications, risk stratifications are to be considered. It is worth noting that TCM is less life threatening, often taking about a day to heal, compared to ASC which in many cases is fatal. This makes it necessary for further study into the differences between the two syndromes to enable early detection and reduce misdiagnosis of either of them as the results could be fatal.
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  15. 15. TCM in ASC Diagnosis 15 Scantlebury, D. and Prasad, A. (2014). Diagnosis of Takotsubo Cardiomyopathy. Circulation Journal, 78(9), pp.2129-2139. Sharkey, S.W., Windenburg, D.C., Lesser, J.R., Maron, M.S., Hauser, R.G., Lesser, J.N., Haas, T.S., Hodges, J.S. and Maron, B.J., 2010. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. Journal of the American College of Cardiology, 55(4), pp.333-341. Singh, K., Neil, C.J., Nguyen, T.H., Stansborough, J., Chong, C.R., Dawson, D., Frenneaux, M.P. and Horowitz, J.D., 2014. Dissociation of early shock in takotsubo cardiomyopathy from either right or left ventricular systolic dysfunction. Heart, Lung and Circulation, 23(12), pp.1141-1148. Summers, M.R., Lennon, R.J. and Prasad, A., 2010. Pre-morbid psychiatric and cardiovascular diseases in apical ballooning syndrome (tako-tsubo/stress-induced cardiomyopathy): potential pre-disposing factors?. Journal of the American College of Cardiology, 55(7), pp.700-701. Templin, C., Ghadri, J.R., Diekmann, J., Napp, L.C., Bataiosu, D.R., Jaguszewski, M., Cammann, V.L., Sarcon, A., Geyer, V., Neumann, C.A. and Seifert, B., 2015. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. New England Journal of Medicine, 373(10), pp.929-938. Yoshida, T., Nishizawa, T., Yajima, K., Tsuruoka, M., Fujimaki, T., Oguri, M., Kato, K., Hibino, T., Ohte, N., Yokoi, K. and Kimura, G., 2009. A rare case of tako-tsubo cardiomyopathy with variable forms of left ventricular dysfunction: a new entity. International journal of cardiology, 134(2), pp.e73-e75.

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