1. ”FIRST AND FINEST” Takotsubo’s; An Apical Eclipse of the Heart LT Tyler House, DO LCDR Justin Lafreniere, MD LCDR Gregory Fuhrer, MD Naval Medical Center Portsmouth

2. ”FIRST AND FINEST” Disclaimer I have nothing to disclose The views and opinions expressed herein do not necessarily state or reflect those of the Naval Medical Center Portsmouth, DoD, or the United States Government

3. ”FIRST AND FINEST” Case 65 year old Filipina female with Stage IV NSCLC presented with 3 weeks of progressive dysphagia Associated Symptoms - Dysphagia is with both liquids/solids without odynophagia - Vomiting - Cough - Palpitations Patient briefly admitted for 2 days, 3 weeks prior for food impaction s/p EGD with stricture noted

4. ”FIRST AND FINEST” Past Medical History - Stage IV NSCLC on maintenance Avastin Q 3 wks - Completed chemo/radiation March 2011 - Bradycardia with Pacemaker October 2012 - Atrial fibrillation s/p ablation 2010 - Anxiety Past Surgical History - L VATS with wedge resection July 2012 - RUL resection June 2011 Case

5. ”FIRST AND FINEST” –Vitals and physical exam on presentation unremarkable –EGD -> severe stricture noted, biopsy taken –EGD discussed -> patient informed that stricture was suspected to be malignant -> noted by husband to become very anxious afterwards –Following hours patient developed chest pain, dyspnea, tachycardia and hypotension –Heparin initiated due to high pre-test probability for PE Case

6. ”FIRST AND FINEST” –EKG unchanged, Troponin 0.906ng/ml, CXR pulmonary edema pattern –POC U/S -> depressed LV function, apical ballooning Diastole Systole Case

7. ”FIRST AND FINEST” LHC -> normal coronary arteries with apical ballooning Case

8. ”FIRST AND FINEST” Diastole Systole Case

9. ”FIRST AND FINEST” –BP continued to decline and perfusion indices worsened –Cardiogenic shock due to Takotsubo’s Cardiomyopathy diagnosed as cause of hypotension and hypoxia –Given the fulminant cardiogenic shock and stage IV lung cancer, the patient was placed on comfort care and died soon thereafter Case

10. ”FIRST AND FINEST” Takotsubo’s Discussion Reversible cardiomyopathy 90% women, 90% post-menopausal Triggers “Catecholamine Theory” “stimulus trafficking” Mimics Acute Coronary Syndrome Akashi Y, Goldstein D, et al. Takotsubo Cardiomyopathy: A New Form of Acute Reversible Heart Failure. Circulation., 2008; 118:2754-2762

11. ”FIRST AND FINEST” Takotsubo’s Discussion New EKG findings and/or modest troponin elevation Transient hypokinesia of middle and apical regions of LV with hyperkinetic basal region (LV gram or echo) Normal coronary arteries by arteriography Absence of other etiology Akashi Y, Goldstein D, et al. Takotsubo Cardiomyopathy: A New Form of Acute Reversible Heart Failure. Circulation., 2008; 118:2754-2762

12. ”FIRST AND FINEST” Point of Care Ultrasonography Rapid evaluation of heart, lungs and IVC Early and appropriate management is critical POC U/S facilitates early diagnosis, early treatment Hypokinetic LVDilated RA/RV Volpicelli G, Lamorte A, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013; 39:1290-1298.

13. ”FIRST AND FINEST” Takotsubo’s Treatment and Prognosis Supportive May require hemodynamic support 96% recovery rate Rarely cardiogenic shock and death Could this have been prevented??

14. ”FIRST AND FINEST” Breaking Bad News (BBN) ASCO “Breaking Bad News Symposium” Residents and Medical Students untrained Research suggests BBN is teachable “SPIKES” Baile WF, Buckman R et al. SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000; 5:302-311.

15. ”FIRST AND FINEST” Key Points TCM is precipitated by an acute stressor, and may rarely lead to cardiogenic shock and death POC Ultrasound is invaluable tool in rapid diagnosis and management of cardiopulmonary failure Residency programs should invest time in the teachable skill of “breaking bad news”

16. ”FIRST AND FINEST” Questions? “The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician” American Medical Association, first code of medical ethics, 1847