Broken Heart Syndrome
Jeff Wager CRNA
Jeff Burnette MD
John Olayer CRNA
Outline
• Case study
• Description
– Takotsubo Cardiomyopathy
– Acute Coronary Syndrome
– AHA journal article
• Discussion
Something’s Not Right
• You may never see this syndrome
• Most patients do what they are supposed
to.
• Application in your practice setting
• Don’t take my sarcasm personally
Vigilance vs. Complacence
Vigilance
• Safe Passage- who else is going to do it?
• Anyone could be trained to do the tasks
• Crucial job of the nurse is the timely
recognition of trouble and calling the
Calvary
• Broken heart is what you will have if the
opportunity to prevent a bad outcome is
missed.
Is This Patient Okay
• Most people can tell if someone is actively
dying
• The middle of the continuum is difficult
• Less experienced nurses need guidance
and mentoring
• Chicken Little and Cliff Clavin
• Rarely will everything have an explanation
many things don’t need one
Complacence
• Most patients do fine
• Production pressure
• My job is just to get them transferred to the
next place
• Discontinuous care
• Burn out
• Not my problem
• Extremely annoying patients
Anxiety and Discretion
• Patients are inherently anxious.
• We should strive to reduce this as much
as is ethically possible.
• Inappropriate sharing of our “insider
knowledge” has the potential to scare
people away from seeking the healthcare
that they need.
• The media and trial lawyers don’t need
our help frightening patients.
Case Study
• 46 year old AAF presenting with pelvic
pain
• Scheduled for hysteroscopy and
diagnostic laparoscopy
• Past Medical History
– Hypertension
– Vertigo
– Heme positive stool
Pre-op Evaluation
• Overall unremarkable
• Slightly strange collection of symptoms
– Pelvic pain
– Heme positive stool- colonoscopy scheduled
following week
– Vertigo
Induction of Anesthesia
• Premedicated with versed immed prior to
transport to OR
• Routine IV induction and intubation
• Post intubation hypertension and
tachycardia-slightly more than average
• 180-190/100-110 and Hr to 120
• Immed treated with esmolol then lopressor
• Htn and tachycardia resolved
Uneventful Case
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Hemodynamically stable
No problems with ventilation/oxygenation
Easily extubated
?? Relative hypoxemia-quick desaturation
without oxygen mask
• Transport to pacu
• Someone else’s problem
Is This patient Okay
• Sao2 in pacu upper 80’s- low 90’s on 4
liters O2 NC
• PCXR- ? Bilateral infiltrates vs pulmonary
edema
• Breath sounds were clear
• Incentive spirometry initiated
• Still O2 dependent- admitted for
observation
Differential Diagnosis
• Blame Anesthesia- Is she awake, residual
weakness from muscle relaxation, iatrogenic
fluid overload, atelectasis, aspiration
• Patient history predicts increased O2
requirements post op- preexisting pulm dz?
• Narcosis-common problems are common
• Could her procedure be responsible
– Splinting from pain
– Lung surgery
Zebras
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Uncommon problems do exist
Pulmonary embolism
Negative pressure pulmonary edema
Diffusion atelectasis
And 1,000,000 other things you may never
have heard of
This Patient is not Okay
• Chest pain and shortness of breath after
admission to floor
• Abnormal EKG
• When you hear hooves
• Positive cardiac enzymes
• Echocardiogram-hypokinesis of anterior
wall with EF 40-45%
Acute Coronary Syndrome
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Heparin and nitroglycerin started
Straight to cath lab for angiography and ?
Coronary arteries were normal
Diagnosed with Takotsubo
cardiomyopathy with surgery being the
causative stressor.
Takotsubo Cardiomyopathy
• Stress induced cardiomyopathy
• Apical ballooning cardiomyopathy
• Transient left ventricular apical ballooning
syndrome
• Discovered in Japan and named for
octopus trap with similar shape to apically
ballooning heart.
• Caused by emotional or physical stress
Other Zebras
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Prinzmetals angina
Myocarditis
Cocaine abuse
Cardiac syndrome X
Demographics
• Postmenopausal women make up 70-80%
• May account for 2% of ACS presentations
• Prospective MICU study non cardiac pts
26 out of 92 had ballooning.
• Case Studies
– Oxycontin withdrawal after admission for
surgery
– Pre-op anxiety caught in OR before case
– Clinical doses of adrenergic agents
Stressors
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Any significant physical or emotional event
Death of a loved one
Financial or legal problems
Natural or man made disasters
Near drowning
Critical illness
Tigers or Gamecocks
Mayo Clinic Diagnostic Criteria
• Transient hypokinesis, akinesis, of
dyskinesis of the left ventricle mid
segments with or without apical
involvement. Wall dysfunction usually
extends beyond a single coronary artery
distribution. Stressful trigger usually
present.
• No obstructive cad or plaque rupture
Mayo Clinic Diagnostic Criteria
• New St elevation or T wave inversion or
modest increase in troponin
• Absence of pheochromocytoma or
myocarditis.
• All four required
Presentation
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Substernal chest pain
Dyspnea-pulmonary edema
Syncope
Shock-mitral regurg-LV outflow obstruction
Ekg changes anterior leads
Lethal arrhythmias
Thrombus-stroke
Treatment
• Per severity of symptoms
• Same as regular LV systolic dysfunction
– Afterload reduction-ACE inhibitors
– Arrhythmia prevention-beta blockers
– Diuresis
– ? Anti-coagulation
– Shock requires immed echo to r/o LVOT
– Long term adrenergic blockade to prevent
reoccurrence
Prognosis
• Systolic function usually recovers in 1-4
weeks with supportive therapy
• Mortality 0-8%
• Deaths usually from arrhythmias
Pathophysiology
• Several theories
– Multivessel coronary artery spasm
– Cardiac microvasular dysfunction
– Altered fatty acid metabolism
– Catecholamine toxicity with stunning and
microinfarction
Not Pumping Enough
• Inadequate forward flow
• Anything downstream of the aortic valve
doesn’t get enough
• Upstream of left ventricle gets too much
Acute Coronary Syndrome
• Retrosternal chest pain
– Pressure or tightness
– Radiates to shoulders, neck arms, jaw, back
or between shoulder blades
– Syncope, dizzy/lightheaded, nausea,
sweating
– Unexplained shortness of breath
Why does their chest hurt
• The supply of oxygen to the heart is less
than the demand.
• A resting heart extracts 75% of oxygen
delivered by coronary blood flow.
• Pain is a warning that heart cells are about
to start dying time is short
• Restoration of balance between supply
and demand is essential to save as much
muscle as possible
Talk or Treat
• Acute coronary syndrome presentation
should be treated as such until definitively
proven otherwise
• Send Clavin to lunch
• MONA
• 12 Lead EKG
• Cardiology consult-immed expert help
Circulation Article
• Journal of the American Heart Association
• Published Jan 9 2012
• “Grief over the death of a significant
person was associated with an acutely
increased risk of MI in the subsequent
days.”
• Rate of acute MI increased 20 times within
24 of learning of significant death and
remains elevated for one month.
Grief MI Risk
• Men more than women
• Younger more than older
• Increased with severity of loss
Talk and Treat
• Authors suggest providing social support
at time of bereavement
• Education
• Authors also suggest the possibility of
prophylactic agents for homodynamic and
thrombotic events