Broken Heart Syndrome Jeff Wager CRNA Jeff Burnette
Broken 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 • Sao 2 in pacu upper 80’s- low 90’s on 4 liters O 2 NC • PCXR- ? Bilateral infiltrates vs pulmonary edema • Breath sounds were clear • Incentive spirometry initiated • Still O 2 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 O 2 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 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
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