Takotsubo cardiomyopathy

The amuse-bouche today was a case of Takotsubo cardiomyopathy. A few points:
•It is also known as :Stress-induced cardiomyopathy, apical ballooning syndrome, or broken heart syndrome
•Characterize d by transient systolic dysfunction of the apical and/or mid segments of the left ventricle
–mimics myocardial infarction with ST segment changes
–absence of obstructive coronary artery disease
•Typically presets w. RSCP, but occassionaly with new onset dyspnea
–Women >> Men
–Often at time of intense physical or emiotional stress
•Pathogenesis not well understood
–? Catecholamine surge
–? Vasospasm

See a nice brief article in CMAJ here.

Acute Cardiac Tamponade

Today's morning report case was of a patient with cancer presenting with sudden onset dyspnea and a new pericardial effusion. We had a great discussion about cardiac tamponade. A few points:
Cardiac tamponade is a clinical syndrome with a few defining characteristics:
-hemodynamic instability (hypotension, tachycardia)
-dyspnea
-pulsus paradoxus >10 mmHg
-jugular venous distention
- reduced heart sounds

The primary physiologic abnormality is compression of all cardiac chambers as a result of increasing intrapericardial pressure, which is mostly determined by the rapidity of fluid accumulation, rather than the absolute size of an effusion.

The diagnostic modality of choice is doppler echocardiography. In the presence of an effusion, some echocardiographic signs of tamponade:
- Early diastolic collapse of the right ventricle
- Late diastolic collapse of the right atrial free wall

• Less specific than RV collapse unless lasting for >30% of cardiac cycle

-Left atrial collapse

• Only in 25% of cases, but is highly specific

-Accentuated respiratory variation in peak mitral and tricuspid inflow velocities

-Reduction/absence of the normal decrease in inferior vena cava diameter during inspiration

See here for a good NEJM review
See here for the JAMA acticle "Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?"

Auricular cartilage calcification

The amuse-bouche today was auricular cartilage calcification in adrenal insufficiency taken from the NEJM images in medicine series.

Auricular cartilage calcification and even true ossification of the auricular cartilages have been described in association with:
–mechanical tissue injury
–exposure to cold
–inflammatory conditions
–endocrinopathies including adrenal isufficiency

See more from NEJM here.

Hemoptysis

Morning report today was a great case of hemoptysis. See here for a prior post with links to a few good review articles.

Digitalis Effect

Today our amuse-bouche was an ECG with typical changes from digoxin.
The classic digitalis effect has 4 typical findings on ECG:
1.T-wave changes

• Virtually any: flattening, inversion, other abnormal waveforms such as peaking of the terminal portion (seen in about 10% of patients)
  

2.QT-interval shortening

3.Sagging or “scooped” ST-segment with concomitant ST-segment depression

• More pronounced in leads with tall R waves (e.g. lateral leads)
  

4.Increase in the U-wave amplitude

It is important to remember that these do not correlate with toxicity as they can be seen at levels well within normal therapeutic range.

For a good review on this and the other important arrythmias assiociated with digoxin toxixicy, see here.

Systolic heart failure

Today in morning report we had a case of new grade 4 systolic heart failure. See here for a prior post on diagnosis. We talked briefly at the end about device therapies, see here for a prior post on the topic, with links to some of the major trials.

von Recklinghausen disease

Today the amuse-bouche was a case of von Recklinghausen disease, better known as neurofibromatosis type 1.

A few points about NF-1:

•It is a neurocutaneous syndrome resulting from a mutation in NF1 gene
–Autosomal dominant inheritance

–1/2 are familial; 1/2 new mutations
–New mutations primarily in paternal chromosomes
–Complete penetrance but variable expression

•At least 2 of the following features needed to make the diagnosis:
–6 or more café-au-lait macules
–2 or more neurofibromas of any type or one plexiform neurofibroma
–Freckling in the axillary or inguinal regions
–Optic glioma
–2 or more Lisch nodules (iris hamartomas)
–A distinctive bony lesion such as sphenoid dysplasia or thinning of the long bone cortex

–A first-degree relative (parent, sibling, or offspring) with NF1 based upon the above criteria

See here for a good review paper in the Lancet

Palliative feeding

Today in morning report we talked about a few palliative issues, but the issue of feeding at the end of life came up. See here for a prior post on that contains a link to a good review article on the topic of nutrition and hydration at the end of life.

Vertigo

Morning Report today was a case of vertigo, likely Benign Paroxysmal Positional Vertigo.

A prior post on differentiating the central and peripheral casues of vertigo here. See the bootom for more info on the Eply manuvers.