CODE BLUE IN THE MORTUARY…

The announcement over the hospital P.A. made everyone stop for a second.

‘CODE BLUE IN THE MORTUARY.  CODE BLUE IN THE MORTUARY.’

15 minutes later a 63 year old lady is brought into the Resus area of ED with central crushing chest pain.

She has no previous medical history and was in the mortuary to see the body of her son who’d just died from a subarachnoid haemorrhage.

Her ECG is shown below (click to enlarge):

Tako-tsubo Cardiomyopathy

She’s taken to angiography as a ‘code STEMI’ where’s she’s found to have normal coronary arteries.

Tako-tsubo Cardiomyopathy

Only described in Japan within the last 20 years, Tako-tsubo has become increasingly recognised, possibly in no small part due to the increased use of angiography in Cardiology.

Mayo Clinic criteria for tako-tsubo cardiomyopathy (widely but not universally accepted)

1. New ECG changes (St elevation or T wave inversion) or moderate troponin rise.
2. Transient akinesis / dyskinesis of left ventricle (apical and mid-ventricular segments) with regional wall abnormalities extending beyond a single vascular territory.
3. Absence of coronary artery stenosis >50% or culprit lesion.

Why is it called Tako-tsubo Cardiomyopathy?

The left ventricle, with its apical akinesia looks remarkably like a basket used in japan to catch Octopi.

Ventriculogram and Takotsubo

Takotsubo ventriculogram

What causes Tako-tsubo?

Classically it occurs in a post-menopausal woman experiencing sudden emotional stress.

Cathecholamine Surge

• Microvascular Spasm.
• Sympathetic nervous system activation.
• Underlying  LVOTO.

A sudden surge in cathecholamines is agreed to be the cause, but the reason why this surge causes a characteristic wall motion abnormality remains a matter for debate.  The most widely held view is that the catecholamines cause microvascular spasm, although left ventricular outflow obstruction is likely to play a part.  The sympathetic nervous system is also implicated – the condition can be prevented in a laboratory by cardiac sympathectomy, the apical distribution explained as it has the highest density of sympathetic nerve fibres. Similar cardiac histopathological features are seen in patients who’ve had a subarachnoid haemorrhage.

So what do we do in the ED?

Tako-tsubo cardiomyopathy is indistinguishable from a STEMI in the ED.  No criteria can be safely used to differentiate between the two conditions.  You should activate your local code STEMI protocol.

Tako-tsubo has a better prognosis than STEMIs with a similar ECG but it is certainly not benign.

References:

• ClinicalCases Blogspot with Dr Ves: Takotsubo cardiomyopathy broken heart syndrome
• Akashi YJ, Goldstein DS, Barbaro G, Ueyama T.Takotsubo cardiomyopathy: a new form of acute, reversible heart failure.Circulation. 2008 Dec 16;118(25):2754-62.PMID: 19106400
• Abdulla I, Ward MR.Tako-tsubo cardiomyopathy: how stress can mimic acute coronary occlusion.Med J Aust. 2007 Sep 17;187(6):357-60. PMID: 17874985
• Banning et al. Takotsubo cardiomyopathy BMJ 2010;340:c1272.
• Salim S. Virani, MD, A. Nasser Khan, MD, Cesar E. Mendoza, MD, Alexandre C. Ferreira, MD, and Eduardo de Marchena, MD Takotsubo Cardiomyopathy, or Broken-Heart Syndrome Tex Heart Inst J. 2007; 34(1): 76–79. [Reference]
• Taokutsubo Website