1. The Broken Heart Syndrome Primary Care Conference May 30, 2007 Gregory L. Sheehy, M.D.

2. Case Report AC is a 64 year old woman AC is a 64 year old woman History of right breast cancer, 1990 History of right breast cancer, 1990 s/p mastectomy, chemotherapy and radiation) complicated by recurrent RUE lymphedema/lymphangitis. s/p mastectomy, chemotherapy and radiation) complicated by recurrent RUE lymphedema/lymphangitis. Type 2 DM Type 2 DM HTN HTN Uric acid nephropathy Uric acid nephropathy Obesity Obesity

3. Case Report-Medications Glyburide 1.25 mg daily Glyburide 1.25 mg daily Metformin 1000 mg bid Metformin 1000 mg bid Phenoxymethyl penicillin 1000 mg bid Phenoxymethyl penicillin 1000 mg bid Lisinopril 10/HCTZ 12.5 mg daily Lisinopril 10/HCTZ 12.5 mg daily Metoprolol XL 100 mg daily Metoprolol XL 100 mg daily Gemfibrozil 600 mg bid Gemfibrozil 600 mg bid Aspirin 81 mg daily Aspirin 81 mg daily Allopurinol 300 mg daily Allopurinol 300 mg daily

4. Case report-May 26, 2006 Because of risk factors (age, hypercholesterolemia, hypertension, diabetes, family history) a radionucleotide stress test was performed and was negative Because of risk factors (age, hypercholesterolemia, hypertension, diabetes, family history) a radionucleotide stress test was performed and was negative

5. Case report-December 14, 2006 AC calls office, speaks with triage nurse AC calls office, speaks with triage nurse Patient is reported to be hysterical, crying, sobbing and begging for a sedative Patient is reported to be hysterical, crying, sobbing and begging for a sedative Her 35 year old son was just found dead in bed Her 35 year old son was just found dead in bed Alprazolam 0.25 mg 1-2 tablets q 8hrs prn called to local pharmacy Alprazolam 0.25 mg 1-2 tablets q 8hrs prn called to local pharmacy

6. Case report- December 15, 2006 AC awakes from sleep early morning hours with right chest pain AC awakes from sleep early morning hours with right chest pain She then develops dyspnea, diaphoresis, lightheadedness She then develops dyspnea, diaphoresis, lightheadedness EMS called EMS called On paramedic arrival, patient in acute distress, SBP 70s On paramedic arrival, patient in acute distress, SBP 70s Patient transferred to UW ER, vital signs similar, IVF and dopamine initiated Patient transferred to UW ER, vital signs similar, IVF and dopamine initiated

7. Case report-data Electrocardiogram revealed mild ST elevation in lateral leads (see copy) Electrocardiogram revealed mild ST elevation in lateral leads (see copy) Initial troponin 1.5 (<0.3) with peak of 4.4 approximately 20 hours later Initial troponin 1.5 (<0.3) with peak of 4.4 approximately 20 hours later Echocardiogram showed “mild to moderate” reduction in systolic function with a an ejection fraction of 40% and an akinetic apex Echocardiogram showed “mild to moderate” reduction in systolic function with a an ejection fraction of 40% and an akinetic apex Emergency cardiac cath demonstrated diffuse nonocclusive coronary artery disease Emergency cardiac cath demonstrated diffuse nonocclusive coronary artery disease Near complete recovery in 48-72 hours Near complete recovery in 48-72 hours

8. What is “The Broken Heart Syndrome”? Other names: Other names: Stress induced cardiomyopathy Stress induced cardiomyopathy Transient apical ballooning Transient apical ballooning Takotsubo Cardiomyopathy Takotsubo Cardiomyopathy A definition: A definition: “Transient apical left ventricular dysfunction that mimics myocardial infarction, but in the absence of significant coronary artery disease.” “Transient apical left ventricular dysfunction that mimics myocardial infarction, but in the absence of significant coronary artery disease.” UpToDate, 2007

9. Broken Heart Syndrome First described in Japan… “Takotsubo” is an octopus trap (see diagram) 1 First described in Japan… “Takotsubo” is an octopus trap (see diagram) 1 More common in women than men More common in women than men Onset typically triggered by an acute medical illness or intense emotional/physical stress (death in the family, domestic abuse, financial catastrophy, natural disaster) Onset typically triggered by an acute medical illness or intense emotional/physical stress (death in the family, domestic abuse, financial catastrophy, natural disaster) 1). Tsuchihashi K et al, J Am Coll Cardiol 2001; 38(1): 11-8

10. Broken Heart Syndrome Pathogenesis…still uncertain Pathogenesis…still uncertain Catecholamine excess 1 Catecholamine excess 1 Coronary artery spasm Coronary artery spasm Myocardial stunning Myocardial stunning “Aborted myocardial infarction” (transient thrombosis and dissolution) 2 “Aborted myocardial infarction” (transient thrombosis and dissolution) 2 1).Wittstein et al, NEJM 2005; 352(6): 539-48. 2). Ibanez et al, Mayo Clinic Proceedings, 2006; 81(6): 732-35.

11. Broken Heart Syndrome Is this syndrome more common than we realize? 1 Is this syndrome more common than we realize? 1 The good news- recovery is relatively rapid and complete The good news- recovery is relatively rapid and complete 1). Park et al. Stress Induced Cardiomyopathy in an ICU, Chest 2005; 128: 296.