Myocardial Ischaemia National Audit Project - University College ...

is an acute heart failure syndrome in patients with acute chestpain and ECG changes. It seems likely that between 2000 and3000 cases occur each year in the UK.The typical patient is a post-menopausal woman (who makeup about 90% of all cases) who, within minutes or hoursof extreme physical or emotional stress (hence the use of‘Broken Heart syndrome’), develops acute cardiac chest pain,breathlessness, and features of heightened sympatheticnervous activity (racing heart, headache, sweatiness). The ECGduring the acute episode usually shows ST-elevation and/or Twave inversion, consistent with, but in these particular casesnot caused by, coronary artery obstruction. The corrected QTinterval is frequently prolonged, sometimes to levels that mightprovoke sudden cardiac arrest (>500ms). Often evidence of heartmuscle damage is revealed – serum cardiac enzymes, such astroponin, are elevated, though not to the higher levels seen withmyocardial infarction due to coronary disease.Patients with such symptoms and ECG changes are usuallytaken straight to the angiography laboratory as part of aprimary PCI service (where the majority will be shown to havesuffered coronary thrombosis and obstruction). However,in Takotsubo Cardiomyopathy the coronary arteries areeither completely normal, or have non-obstructive coronarydisease which cannot account for the abnormal contractilefunction of the heart shown using echocardiography orventriculography. For while the coronary arteries appearnormal or mildly affected, the entire left ventricular apex ishypo- or akinetic – contracting poorly or not at all – and thisdysfunction frequently extends symmetrically upwards toinvolve the mid-ventricular muscle while the upper portionscontinue to contract vigorously. This gives a characteristicpicture (see Figure 3) of ‘virtual’ apical ballooning on cardiacimaging, and instead of having an inverted conical shape theleft ventricle takes on an appearance that is similar to theJapanese fisherman’s octopus pot, the tako tsubo. Atypicalpatterns are also recognised, with basal hypocontractility andapical preservation (inverted Takotsubo), and a mid-ventricularvariant. Crucially this ventricular contractile dysfunctioncannot be explained by a problem in a single coronary artery; itextends beyond a single coronary artery territory.A number of cardiac complications have been recognisedduring the early phase, and these relate directly to the severityof the acute heart failure syndrome. These include atrial andventricular arrhythmias, pericarditis, pulmonary oedema,cardiogenic shock, cardiac rupture, cardiac arrest and thereis a recognised mortality of 2% during the acute phase.Apical thrombus is detected in 5-7% cases with associatedthromboembolic complications. That being said, in many casesthe heart recovers good function within weeks and months.A role for MINAPThere is a lot to learn about this condition, not least theprecise cause and the best treatment. Using new fields addedto the MINAP dataset it should be possible to determine thefrequency of the condition in the UK, the types of individuals itaffects, their long-term prognoses and, through observation,associations of treatments in hospital and at discharge withlong-term outcome.Figure 3: Left venticulogram-showing the left ventricle of the heart in a contracted (right ) and relaxed (left) state inTakotsubo CardiomyopathyMINAP Eleventh Public Report 201215