Broken Heart SyndromeBroken 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

• 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

• 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

• 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

• 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

• 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

• 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