versus STsegment elevation MI A case series Ashwini Davison Justin Dunn Jason Mock Deepa Rangachari May 13 2009 Types of Trials Controlled Study Randomize Control Trial RCT type of scientific experiment most commonly used in testing the efficacy or effectiveness of healthcare ID: 684880
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Slide1
Takotsubo Cardiomyopathy versus ST-segment elevation MI—A case series
Ashwini DavisonJustin DunnJason MockDeepa RangachariMay 13, 2009Slide2
Types of TrialsControlled Study
- Randomize Control Trial (RCT) – type of scientific experiment most commonly used in testing the efficacy or effectiveness of healthcare services or technologies. With sufficient numbers, this ensures that both known and unknown confounding factors are evenly distributed between treatment groups.Considered the most reliable form because they eliminate spurious causality and bias.
Observational Study
Cohort study - group of people who share a common characteristic or experience within a defined period.
Case Control - Studies used to identify factors that may contribute to a medical condition by comparing subjects who have that condition with patients who do not have the condition but are otherwise similar
Case Series Slide3
Definition of Case SeriesDescriptive research study that tracks patients with a known exposure given similar treatment or examines their medical records for exposure and outcome. Also known as clinical seriesCan be retrospective or prospective
Smaller number of patients than more powerful case-control or RCTsSlide4
Case SeriesProvide information when other types cannot or should not be undertakenCase series may be confounded by selection bias, which limits statements on the causality of correlations observed
Results of case series can generate hypotheses that could be useful in designing further studiesIn this article the authors use a case series to ask the question what clinically (in the ED) can be used to differentiate Takotsubo cardiomyopathy versus ST-segment elevation myocardial infarctionSlide5
Introduction to ArticleElectrocardiographic ST-segment elevation: Takotsubo
cardiomyopathy versus STEMIAMERICAN JOURNAL OF EMERGENCY MEDICINE, 2009Slide6
What is Takotsubo cardiomyopathy?Also known as left ventricular apical ballooning syndrome, ampulla CM, stress CMDevelop anginal symptoms and CHF in times of stressExtreme: acute pulmonary edema, cardiogenic shockSlide7
EKG & LabsST segment and/or T wave abnormalitiesSimilar to what’s seen in STEMISerum markers may be elevatedSlide8
Cath & ventriculogramCatheterization: abnormal LV function, but NORMAL coronary arteries
Diastole
SystoleSlide9
Diagnostic criteria (Mayo)1) transient LV apical akinesis or dyskinesis2) absence of obstructive CAD3) new EKG abnormalities in absence of concurrent conditionsSlide10
Discussion of this Case SeriesSlide11
How Patients Were SelectedReviewed 12 consecutive cases of Takotsubo CM that presented to UVA3 case excluded because of incomplete dataThen took 9 consecutive cases of STEMI for comparison18 cases total (9 TCM, 9 STEMI)—same time period
Comparisons made between 2 groupsSlide12
Demographic Results
DescriptorTakotsuboSTEMI% that were female8944
Average age (years)
68.2
65.1
% with chest pain
88.9
100
% with
dyspnea
55.6
77.8
% with nausea/vomiting
33.3
88.9
% with diaphoresis
55.6
100Slide13
EKG Comparisons
EKG abnormalityTakotsuboSTEMIST-segment elevation66.7%100%
Inferior
0
55.6
Lateral
11.1
33.3
Anterior
55.6
33.3
ST-segment depression
33.3%
77.8%
Inferior
22.2
33.3
Lateral
11.1
22.2
Anterior
0
33.3
T wave inversion
66.7%
33.3%
QT prolongation
451
ms
433 msSlide14
Other comparisonsCXR findings were similar in both groupsInitial troponin elevation similarSTEMI peak troponin 7.34 vs TCM with 4.91EF on echo—32.7% in Takotsubo, vs 25.2% in STEMISlide15
Discussion of ArticleSlide16
DesignNot really a case series by definition—used control group (STEMI patients)A number of case series were published prior (all with 9 or more pts), and a systematic review published in 2006.
Appears to be a case series of Takotsubo compared with a case series of STEMIs.Slide17
StrengthsUsed consecutive patients to help reduce selection bias in both groups (though did exclude 3 from case group)All patients were (we assume) at the same institutionSlide18
WeaknessesTime frame? Unclear how long to select patients; also unclear how STEMI pts selected.Too few patients—9 in each group.
No distribution of values given, no hard data—only means/percentages, no medians. No p values or confidence intervalsSlide19
Weaknesses3 people eliminated in case group for “incomplete data”—contribute to selection bias?No risk factors noted in either
groupUnclear if any question was answered.Slide20
ConclusionsTakotsubo CM often mimics ACSAnginal chest pain with acute heart failureThis retrospective case series shows its difficult to distinguish the 2 in the ERSlide21
Take Home MessagePhysicians need to be aware of this alternative diagnosis to a STEMIStill need to watch for dysrhythmias & cardiogenic shock withIdeally, if Takotsubo CM suspected
cardiac catheterization should be chosen over fibrinolyticsSlide22
Further Discussion Dr. Hunter Young, former Barker ACS