Clinical Characteristics of Stress Cardiomyopathy (“Takotsubo Syndrome”) vs. Acute Anterior Myocardial Infarction: A Case Control Study in Women

The 12th Annual Scientific Meeting

386 Advanced Care Directives: Can We Do Better? Marlena V. Habal, Vaska Micevski, Sarah Greenwood, Diego H. Delgado, Heather J. Ross; Divisions of Cardiology/Transplant, Toronto General Hospital, Toronto, ON, Canada Introduction: Although advancements in heart failure pharmacotherapies and technologies have impacted survival and quality-of-life, there is a paucity of literature addressing patients’ decision-making processes or choices for care. Advanced Care Directives (ACDs) allow patients to increase their control over the care they receive at end-of-life and serve to direct their care when they are no longer capable of doing so. Objective: To examine the prevalence of patients’ awareness of, their understanding and utilization of advanced care directives in a heart function clinic (HFC) at a Canadian tertiary hospital. Methods: Consented HFC patients were interviewed using a semi-structured questionnaire consisting of 29 open and close-ended questions focused on ACDs and resuscitation choices. Quantitative data were analyzed using descriptive statistics and qualitative data using a constant comparative method. Results: Of the 42 study participants, 75% did not know what ACDs were, and fewer could recall having discussed them with their physician. Nearly 80% of participants would have liked their physician to discuss ACDs with them. Most participants had a Substitute Decision Maker (SDM) and a written will, however few had living wills. Few had documented resuscitation preferences and nearly half stated their SDM was unaware of their preference. More than 75% of participants wanted full resuscitation, however this was dependent on quality-of-life parameters such as awareness, cognition, independence, and communication. Amongst the 20 with an Implantable Cardioverter Defibrillator (ICD), 45% would want the ICD deactivated should their condition worsen and 25% were undecided. Only 2 participants could recall having discussed this option with their physician. Conclusions: There remains a lack of knowledge and use of ACDs among heart failure patients. This is likely due to infrequent or inadequate physician-patient discussions. Resuscitation preferences were dependent on quality-of-life parameters such as awareness, cognition, independence, and communication. Patient preferences highlight the importance of discussing ACDs and exploring resuscitation preferences early and often in heart failure.

387 A Comparison of Left Ventricular Longitudinal 2D Strain by Speckle Tracking and Cardiac Magnetic Resonance To Quantify Iron Overload in Patients with Thalassemia Major Patrick Garceau1, Naeem Merchant2, Shemy Carasso1, Edwards Jeremy1, Marshall Sussman2, Heather Ross1, Harry Rakowski1; 1Cardiology, University Health Network - Toronto General Hospital, Toronto, ON, Canada; 2Radiology, University Health Network - Toronto General Hospital, Toronto, ON, Canada Background: Cardiac disease related to transfusional iron overload is the leading cause of death in patients with b-thalassemia major. Identifying early myocardial iron deposition is important since significant cardiac involvement may predate a decrease in left ventricular systolic function. Cardiac magnetic resonance (CMR) is currently the only noninvasive examination to quantitate iron deposition within the myocardium. Methods: We measured longitudinal strain in 18 left ventricular (LV) segments in 19 patients with thalassemia major using 2 dimensional speckletracking imaging from long axis 4, 2, and 3-chamber views. These results were compared with qualitative (mild, moderate and severe iron deposition given myocardial appearance in T2 weighted images) and quantitative (T2 values (msec), available in 12 patients) iron deposition measurement within the myocardium by CMR. Results: Eleven patients (58%) demonstrated abnormal strain patterns including a ‘‘compensated dysfunction’’ pattern (normal average peak shortening [e21 6 3 %] with $ 4% standard deviation) demonstrating hypo (!15% shortening) and hypercontractile (O20% shortening) segments, or ‘‘low’’ strain pattern (low average peak strain [!e18%]). Only 8 patients (42%) had a normal strain pattern (normal average peak shortening [e21 6 3 %] with !4% standard deviation). When we considered patients with more than mild iron deposition by CMR (n 5 8; low myocardial signal on the T2 weighted sequence and / or T2 value ! 55 6 5 msec), an abnormal strain pattern was found in 8 patients (100%); 4 had a compensated and 4 had a low longitudinal strain pattern. The sensitivity and specificity of an abnormal strain pattern to identify iron deposition within the myocardium was 91% and 88%, respectively. Conclusions: Myocardial strain studies represent a new tool to assess clinically significant myocardial iron deposition in patients with Thalassemia major.

388 Family Support Factors and Congruence of Symptom Assessment between HF Patients and Caregivers Christina Quinn1, Sandra Dunbar1, Melinda Higgins1; 1Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA Introduction: Family support and factors within the family context are important for effective symptom management in heart failure (HF). Little information exists on how patients and family caregivers (FCG) are congruent or discordant when assessing HF symptoms. Family context factors such as type of partner support or family functioning may influence HF symptom assessment. Purpose: The purpose of this study was to



HFSA

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examine symptom assessment congruence (SAC) between HF patients and their FCG based on their partner support style and family functioning. Methods: HF patients and their FCG (n 5 50 dyads) were enrolled. Dyads completed measures of perceived frequency and severity of 14 common HF symptoms, measured on a 0e10 scale experienced over a seven-day period (Heart Failure Symptom Survey; HFSS); a measure of type of partner support (Active Engagement Questionnaire; APO); and a measure of family functioning (Family Assessment Device; FAD). Subscales of the APO determine type of partner support as either active engagement (AE) or overprotection (OP). The FAD measures general family functioning (GFF) with higher scores indicating less effective functioning. Descriptive statistics and Pearson’s correlations were used in the analysis of SAC between HF patient and FCG as categorized by partner support type and GFF scores. Results: HF patients were 70 6 10.4 years in age; 40% male; 36% African-American and NYHA class III (76%). FCG were 72% women; and, 50% spouses. HF patients rated their partner’s support type as AE (72%) and OP (18%). The mean score on the patients’ GFF was 1.91 6 0.45; 30% scored greater than 2 indicating moderate problems with family functioning. Pearson correlations of SAC were examined separately for type of partner support and for GFF. When patients perceived partner support type as OP, there was higher SAC than the support type of AE on 8 of the 14 symptoms. Patients with GFF scores less than 2 were more congruent on 8 of 14 symptoms. Clinically, those dyads with patients who had been diagnosed with HF less than 2 years were least congruent on 57% of symptoms. Conclusions: Dyads of patients who reported having an OP support type had higher congruence on a majority of symptoms. Dyads having an OP support type may have increased vigilance when assessing HF symptoms. Those patients with better family functioning were congruent on 57% of symptoms. Further study on the role of partner support type and family functioning may lead to new approaches to improve symptom assessment congruence and ultimately improve outcomes.

389 Non-Acute Reversible Cardiomyopathy: Clinical Characteristics, Time Course and Etiologic Considerations Theo E. Meyer1, Maggie M. Cabral1, Cathi Bartolini1, Gina Zichitella1, Karen BerniGiarusso1, Gerard P. Aurigemma1, Rajan Krishnamani1; 1Department of Medicine, University of Massachusetts, Worcester, MA Introduction: The time course of recovery of myocardial function in patients (pts) with left ventricular (LV) systolic dysfunction following the initial diagnosis is uncertain. A better understanding of the likelihood of recovery may have implications for the timing of ICD implantation. It is believed that pts $70 yrs old and those with a LVend-diastolic diameter (EDD) of $65 mm are unlikely to demonstrate significant improvement in ejection fraction (EF) with treatment. The aim of this study was to delineate the clinical characteristics and the time course of improvement in pts diagnosed with severe nonischemic cardiomyopathy (EF#30%) in whom the EF improved to $ 50%. Methods: Pts (n 5 66) were identified from our heart failure clinic data base (n 5 450). Pts with an ischemic, stress-induced or post-partum cardiomyopathy, myocarditis, and patients who received cardiac resynchronization therapy were excluded. All pts were on maximally tolerated ACE-inhibitors and beta blocker doses. Echo’s were repeated 3e6 months following the initial diagnosis. The time course of recovery was determined from the time of the first echo and halfway between sequential echos that showed EF 5 35e45% and EF $ 50%. Results: The mean baseline EF of the study population (M: F 5 2:1, aged 56 6 14 years, range 28e84 yrs) was 20 6 6%. Fifteen (23%) pts were $ 70 yrs old. The baseline mean EDD and end-systolic diameter (ESD) were 60 6 7 mm and 50 6 8 mm, respectively (range: 47e80 mm). Twenty two % of pts had EDD of $65 mm, 9% had an EDD $70 mm, and 43% of pts had ESD $50 mm. Mean EF at recovery was 55 6 4% and the EDD and ESD were 51 6 5 mm and 35 6 6 mm, respectively. The mean time to myocardial recovery was 14 6 11 months (range 2e48 months). Recovery was documented within 9 months of the initial diagnosis in 42% of pts and in 18 pts (27%) recovery took O18 months. About 80% of pts in whom alcohol or tachycardia was implicated showed recovery of LV function within 10 months. ICD devices were implanted in 7 pts. Conclusions: Age, EDD or ESD did not predict the likelihood or the time-course of recovery of LV function. Tachycardia-mediated and alcohol-induced cardiomyopathy appeared to recover most rapidly. The findings of this study questions the commonly held belief that myocardial recovery is unlikely if after 9 months of treatment the EF is !30%.

390 Clinical Characteristics of Stress Cardiomyopathy (‘‘Takotsubo Syndrome’’) vs. Acute Anterior Myocardial Infarction: A Case Control Study in Women Joseph L. Bouchard1, Timothy Fitzgibbons1, Adhar Seth1, Dennis A. Tighe1, Theo E. Meyer1, Gerard P. Aurigemma1; 1Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA Background: The treatment and outcome of stress cardiomyopathy (SC) differs from that of acute anteroapical myocardial infarction (AAMI), but the initial presentation and diagnostic approach is usually similar. As SC overwhelmingly afflicts women, we compared initial clinical characteristics of women with SC with those of women presenting with AAMI, with the aim of developing prospective criteria to distinguish between SC and AAMI. Methods: Cases: 27 women with SC were identified (2002e2007). Control: 25 consecutive women with validated AAMI. Clinical characteristics, including initial biomarkers and EKG, cardiac diagnostics, and details

S118 Journal of Cardiac Failure Vol. 14 No. 6S Suppl. 2008 of hospitalization reviewed. Results: (see Table and Figure) At presentation, SC had longer QTc and lower EF (on initial imaging) than AAMI. However initial biomarker levels could not distinguish between the 2 groups. SC

AAMI

N 5 27 66 6 14 151.5 6 44 63.9 6 3.1 1.75 6 0.25

N 5 25 66 6 15 162.6 6 36 62.9 6 3.3 1.79 6 0.22

Past Medical History Coronary artery disease (%) Hypertension (%) Hypercholesterolemia (%) Diabetes (%) Heart Failure (%) Psychiatric history (%) Chronic obstructive pulmonary disease/ Asthma (%) Current smoker (%) Former smoker (%)

0 44 37 11 0 26 26 21 42

24y 56 52 28 16y 20 28 29 29

Medications on admission Beta Agonist (%) Beta Blocker (%)

19 11

16 52y

86 6 20 41 35 43 489 6 56

77 6 19 32 32 39 436 6 33y

Age (years) Weight (lbs) Height (inches) BSA (m2)

Presenting EKG Heart Rate (beats/minute) ST elevation (%) ST elevation in precordial leads (%) T wave Inversions (%) Mean QTc (milliseconds)

ballooning), variants have been reported in which the apex is spared and only mid-ventricular or basal segments are affected. Excessive sympathetic stimulation is believed to underlie the pathogenesis of SCM, but it is unknown whether direct catecholamine infusion can reproduce the clinical features of this disorder. Methods/Results (Table): Of the 98 patients diagnosed with SCM at our institution, 8 were identified who developed the clinical features of SCM following the intravenous (IV) administration of catecholamines or beta adrenergic receptor agonists. Six of the patients received drug during a diagnostic test or an outpatient procedure, one patient received an overdose of norepinephrine in the ICU, and one patient attempted suicide with IVepinephrine. All patients except one had clinical heart failure. All patients had normal coronary arteries by angiography. Despite severe LV dysfunction on admission (EF 5 29 6 9%), troponin I was disproportionately low (4.1 6 4.0 ng/ml; Mean 6 STD). All 3 variants of SCM were observed in this series: The figure below demonstrates the apical ballooning pattern on the left, the midventricular pattern in the middle, and the basal ballooning pattern on the right. All patients fully recovered and had normal LV function at followup (EF 5 62 6 3%). Conclusion: IV catecholamines can result in all 3 variants of SCM, reinforcing the hypothesis that this syndrome is sympathetically mediated.

Table: SCM Following IV Catecholamines and b Agonists Age Patient (Years) Gender

Initial Biomarkers CPK (U/L) MB (ng/ml) Troponin (ng/ml)

189 6 141 22 6 23 2.8 6 3.7

292 6 581 35 6 114 11.8 6 34

Initial Echo Left ventricular ejection fraction (%)

32 6 10

44 6 15y

yp ! 0.05 Conclusions: The demographics and initial clinical data of women with SC is virtually indistinguishable from those with AAMI, implying that the initial diagnostic approach to SC patients should be similar. Treatment with beta blockers does not necessarily prevent TSC.

391 Apical and Non-Apical Variants of Stress Cardiomyopathy Following Intravenous Catecholamine Administration Jacob Abraham1, James O. Mudd1, Hunter C. Champion1, Ilan S. Wittstein1; 1 Medicine, Johns Hopkins University School of Medicine, Baltimore, MD Background: Stress cardiomyopathy (SCM) is a syndrome of transient left ventricular (LV) dysfunction precipitated by acute stress. While the majority of patients present with apical and mid-ventricular dysfunction with sparing of the base (apical

1 2 3 4 5 6 7 8

46 51 30 24 48 44 20 68

Male Female Female Female Female Female Male Female

Drug Infused Dobutamine Dobutamine Epinephrine Epinephrine Epinephrine Epinephrine Epinephrine Norepinephrine

Killip Peak Tn I Admit Class (ng/ml) EF (%) I II IV II III III III IV

0.17 0.46 0.47 2.0 5.63 12 7.4 4.6

35 20 15 20 35 35 40 35

SCM Variant Apical Midventricular Apical Apical Basal Basal Basal Basal