Silent left ventricular apical ballooning and Tako-tsubo cardiomyopathy and it's prevalence in the ICU

I have published already on Tako - tsubo cardiomyopathy (LVAB or TCC ) . If you go in the search engine you will find that post  , it was presented as a MC question.( Differentiating between the three morphological types.

I know, I may be boring you to death, but my suspicion after looking at multiple echos of various institutions, I was surprised on the high prevalence of this disorde , without its classic risk factors, consistent with what's being reported in the literature

Recent studies have reported a variable, but surprisingly high,incidence of undiagnosed LVAB in some intensive care settings. An incidence of 28% in medical ICU patients was reported in a South Korean study that screened 92 consecutive patients by echocardiography and 5.6% of the medical ICU patients who required echocardiography for clinical and hemodynamic reasons. Harm was caused by using inotropes with worse outcomes.

A more recent study in  the September issue of  The European Society Cardiology Heart Failure .the incidence of silent LVAB suggestive of TCC was substantially lower in this study than recently reported in other international ICU settings .A total of 116 patients were enrolled of whom four had LVAB (3.5%,95% confidence interval 0.9–8.6%). The authors conclusion was: a larger, multi-centre study, prospectively screening for LVAB may help understand any variation between centers and regions, with important implications for ICU management.

I think this number is probably to low and as shown on the diagram,  so many risk factors now are identified that most likely none of the studied population groups are similar in risk factor pofile;  they will have a different pre- test probabilities for risk of LVAB. Also regional /geographic /ethnic factors may play a role.It's a little bit of a similar story with ATTR- amyloidosis,  which is grossly under diagnosed, and patient are not being treated with new drugs directed at transthyretin tetramer folding and deposition in the myocardium.

Nevertheless, when I was still doing bedside medicine no patient came in the ICU/CCU  without getting an immediate echocardiogram ( complete study with TDI) ,  particularly if there was any evidence of hemodynamic instability. It's truely not all about fluids and vaspressors only.

We know there is a substantial population we will harm with blindly throwing them on vasopressors/inotropes as discussed above  . One specific example  were excessive doses of epinephrine causes harm, for  example is the Kounis Syndrome  ( Kounis syndrome and Epinephrine; the ATAK Complex )  ATAK constitutes a challenging contemporary complex in anaphylaxis associated with TCC. It is vital to use epinephrine correctly and monitor vital signs and ECGs for patients with acute anaphylaxis.(see Kounis syndrome link above)

It also makes me wonder if high and repeated doses of epinephrine are truly the right therapy for example in PEA arrest  or could they be more harmful ?

Reference images :Current state of knowledge on Tako-tsubo syndrome: a position statement from the task force on Takotsubo syndrome of the Heart Failure Association of the European Society of
Cardiology

Cardiac amyloidosis increasingly common in US

New research suggests the incidence of cardiac amyloidosis in the U.S. is trending up, bringing with it high rates of morbidity and mortality.

Scientists have long assumed the instance of cardiac amyloidosis—the deposition and buildup of immunoglobulin light chains (AL) or transthyretin (ATTR) in heart tissue—is on the rise, Brett W. Sperry, MD, and colleagues wrote in the American Journal of Cardiology. Recent years have seen a rise in awareness of the disease, more novel treatment options and improved noninvasive diagnostic imaging modalities, but the hospitalization trends for amyloidosis remain unclear, especially for AL type.

Sperry, of the Mid America Heart Institute at Saint Luke’s Hospital and University of Missouri-Kansas City in Kansas City, Mo., combed National Inpatient Sample data with his team to identify 156,914 patients hospitalized with amyloidosis between 2005 and 2014. Patients were on average 70 years old and more often white men, and 34.7% of the pool presented with concomitant heart failure.

The researchers noted the overall number of hospital admissions in patients with amyloidosis more than doubled during the study period—from 9,296 in 2005 to 21,740 in 2014. During the peak in 2014, 62 of every 100,000 hospital admissions was related to amyloidosis.

“The explanation for the more than doubling of the rate of hospitalization in those with amyloidosis is likely multifaceted,” Sperry et al. wrote in AJC. “One possibility is that the incidence and prevalence of amyloidosis are increasing due to a growing awareness of the disease. Alternatively, the aging of the population may contribute to these observed trends.”

Over time, patients admitted with amyloidosis tended to be older and have more medical comorbidities, the authors said. They also had longer lengths of stay than those without the disease (7.5 vs. 6.2 days), were less likely to be discharged home (43.6% vs. 48.7%) and were more likely to die while hospitalized (7.4% vs. 4.9%). Patients with concomitant heart failure fared worse in terms of mortality, too.

Sperry and colleagues said it’s impossible to differentiate between AL and ATTR amyloidosis in the NIS, but said it seems likely that ATTR is contributing more to the rise in amyloidosis given the increase in older and black patients over time with a decrease in concomitant multiple myeloma. AL amyloidosis diagnoses, on the other hand, have remained relatively stable for the past seven decades while prevalence has increased, likely because older patients are living longer.

Though their study was inherently limited by the possibility of NIS inaccuracies and human error, the authors said their study was able to shed light on some of the lesser-known characteristics of amyloidosis in the U.S.

“Given the increasing prevalence of hospitalizations in patients with amyloidosis, enhanced diagnostic and treatment options have the potential to improve care for a growing population of patients,” they wrote.

I will comment that almost every other shift , I am suspicious that I see at least once a patient that could have ATTR-wt amyloid  ( far more common then AL-amyloid)