Stress Cardiomyopathy – Evidence-based Chronic Disease Analysis

Analysis of the Chronic Disease – Stress Cardiomyopathy

Definition of Stress Cardiomyopathy

Stress cardiomyopathy refers to a condition caused by intense physical or emotional stress, resulting to severe or rapid weakness of the heart muscle. This condition was initially identified in Japan where it was characterized by dysfunction patterns of left ventricular. The condition was named Takotsubo cardiomyopathy, after a fishing pot containing wide base and narrow neck, utilized to trap octopus (Eitel et al., 2011). Stress cardiomyopathy condition is currently known by many other phrases that include broken-hearts syndrome, apical ballooning, stress cardiomyopathy, or ampulla cardiomyopathy. The condition can occur following different emotional stressors that include surprise, grief, extreme anger, and fear. The condition can also be triggered by a number of physical stressors that include acute asthma, seizure or stroke.The syndrome is normally characterized by chest pain, with most patients containing similar clinical presentation like that of acute coronary syndrome (Eitel et al., 2011).

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The cases of stress cardiomyopathy have been unknown until the last two decades. Based on the retrospective review, peoples suffering from this condition represented only 2% of all individuals experiencing acute coronary syndrome (ACS). Moreover, 90% of these individuals were women in their postmenopausal period. Reports show that most of thestress cardiomyopathy patients are aged 68-years, though, even young adults and children might beaffected (Komamura et al., 2014). Other reports showed that most stress cardiomyopathy men patients are in in-patients. This demonstrates thatthis condition is mostly initiated by physical stress among men. A research conducted to compare Japan and the United States stress cardiomyopathy patients’ shows that, only few patients from Japan had overt coronary disease (CAD). Nevertheless, there was no important variation in the rate of recurrence and long-term prognosis of stress cardiomyopathy,between Japanese and the United States patients. Stress cardiomyopathy condition is quite expensive to manage, especially on aspects related to tests needed to confirm the diagnosis. Moreover, patients may require assistance on daily life management, until they fully recover (Komamura et al., 2014).

Pathophysiology

The clinical studies evidence supports the theorization of excess catecholamine concentration as stress cardiomyopathy trigger.There is temporal association between a stressful psychological situation and the rapid onset of clinical symptoms of stress cardiomyopathy(Akashi, Nef& Lyon, 2015). The biopsy ofstress cardiomyopathy follow-up and acute cases has demonstrated typical morphological changes, which are similar to the catecholamines induced cardiotoxic effect. Myocardium electron microscopy demonstrates destructionto contractile proteins, with various different vacuoles sized vacuoles, different contents and enlarged myocytes diameter. Other observations include specified cytoplasma area and mitochondria clusters, with abnormal shape and size (Akashi, Nef& Lyon, 2015). Contraction bands with overload of cytoplasmic calcium and fixed cross-bridging myofilament have also been sporadically found.

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Nuclei of cardiomyocyte are also found to appear abnormal with changed location and size, characteristically, at the border of the cell. Swelling of cell is also observed and it is related with the basal lamina damage, but without signs of oncotic and necrosis death of cell related with ischaemic injury. The changes induced by acute catecholamine in myocardial appearance as well as the composition, contractile and cytoskeletal proteins arrangement are restored to normal after recovery. Characteristically, structural modifications resulting from overload of catecholamine include mild neutrophilic infiltration and reversible arrangements of intracellulars. The myofibroblasts presence is one of the early signsof stress cardiomyopathy and it might play a defensive role by reducing myocardial disarray (Akashi, Nef& Lyon, 2015).

Natural History of Stress Cardiomyopathy

Stress Cardiomyopathy was initially discovered in Japan in 1990 where it was reported by cardiovascular specialist in the country. This heart disease has since been accepted in the society across the world, with its unique independent disease entity. This is a significant entity which is different from other acute infarction of myocardial. Stress cardiomyopathy patients normally have a good prognosis, and nearly perfect recovery is recorded in about 96% of the cases. This means that the condition which is normally regarded as temporal has a small mortality rate, with each hospital recording a small number of mortality, mostly varying between one and two percent (Rivera, Bailen& Aguilar, 2011).Generally, the world mortality rate of the disease varies between 0 and 12%. The research has demonstrated high mortality rate among whites compared to Asians, with the older age having a high chance of death compared to other individuals. High rate of mortality is also recoded among people with other coronary diseases. Most deaths happen during the follow-up case. The research also shows that about 5% of the stress cardiomyopathy patients suffer cardiac arrest (Rivera, Bailen& Aguilar, 2011). Although their rate of long-term survival is the same compared to that of healthy people, stress cardiomyopathy patients contain a higher death risk at the onset. Generally, the mortality and morbidity rate are lower in stress cardiomyopathy patients compared to ACS, and the function of left ventricular could define the prognosis. The stress cardiomyopathy recurrence is considerably rare, though it has been reported in a number of occasions (Rivera, Bailen& Aguilar, 2011). The condition main complainant is chest pain and the symptoms recurrence rate is about 11 percent. This mostly happens during the follow-up period (Komamura et al., 2014). The recurrence time ranges from 3 months to 13years, where these incidences do not go beyond 13 years. There is currently reasonable doubt regarding the complete stress cardiomyopathy reversibility (Rivera, Bailen& Aguilar, 2011).

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Stress cardiomyopathycan result to complications though in rare cases. Some of the complicated cases include broken heart syndrome which can be very fatal. Nevertheless, majority may experience quick recovery from the broken heart syndrome, and its health effects may as well diminish with time. Other possible complication include pulmonary edema, where the lungs gets back-up fluid, hypotension or low blood pressure, heartbeat disruptions, and heart failure (Maoclinic.org, 2017). The condition is highly reported among the elderly people who are above 68 years, though it can as well occur among the younger population. Based on its low death rate and low rate of recurrence, stress cardiomyopathy patients are highly probable to live for long. This means that, this is not a permanent condition and once treated one can live longer. The condition only turns to be worse among individuals with other heart conditions. Stress cardiomyopathy is believed to be initiated by stress and physical conditions. In this regard, the patient may need therapeutic measures to reduce the rate of recurrence. The condition also may jeopardize individual physical ability and thus, one may need assistance, especially when in acute stage of the condition (Maoclinic.org, 2017). The condition also creates stress in the family, especially since it is highly associated with chronic heart diseases that kill. In case a family does not have proper knowledge regarding the condition, it is highly likely to get anxious. It may also be distress for having an extra role of helping the patient in various chores.

Subjective Data: Clinical Presentation

Normally the patients are presented to the doctor complaining of chest pain. The doctor is then required to conduct an assessment to collect subjective data. This includespatient personal details such as age, gender, health history, especially on cardiovascular related illness. The doctor should also source information regarding past surgery, or lungs problem. Patient’s stress condition or psychological wellbeing is also evaluated (Maoclinic.org, 2017). The doctor will then perform physical analysis of the patient, which will include taking the heart rates, temperature, weight, breathing rate, and all other necessary details. Extra assessments based on the patient symptoms will include heart x-ray, blood tests, ultrasound analysis, and blood vessels analysis.

Objective Data: Clinical Presentation

Symptoms of stress cardiomyopathy which include dyspnea and chest pain are very similar to those of ACS. In addition, the ECG changes and the raised cardiac biomarkers are also recorded in ACS. In this regard, a doctor must focus on differentiating the two by making the right diagnosis. This is done by conduction more specific tests that can easily create a difference between the two (Rivera, Bailen& Aguilar, 2011). This includetests that show pictures of the heart, for instance echocardiogram test that gives visual detail of the heart functionality, and the blood test that determine the enzyme content that increases in the blood when a patient has stress cardiomyopathy. Clear diagnosis will then be made based on this information.

Assessment and Diagnosis

In case a doctor suspects that a patient is suffering from stress cardiomyopathy, the doctor subjects the patient to a number of tests and assessments to make diagnosis. The first assessment will involve gathering the patient medical history information and the performing normal physical examination. The doctor will want to know more about the patient medical history, particularly on heart diseases in the past. Normally, individuals with stress cardiomyopathy normally do not have any history of heart related diseases symptoms prior to their diagnosis with stress cardiomyopathy. The assessment will also focus on determining whether the patient have had any recent stressful experience that include death of the loved one, or any other loss that would cause grief (Mayo Clinic, 2017). The other diagnosis test is done using electrocardiogram (ECG). Technician in this noninvasive test will put wires on the chest of the patient, which documents the electrical impulses that make the patient heartbeat. The ECG keeps records of the electrical signals that the doctor can use to determine heart structure or rhythms irregularities. The doctor may also demand for an echocardiogram to determine whether there is heart enlargement, if there is stress cardiomyopathy sign, or if the heart has its normal shape. This test which is noninvasive comprises of chest ultrasound showing detailed pictures of function and structure of the heart.

The waves of ultrasound are transmitted, where by, their echoes are documented with transducer, which is a device located outside the patient’s body. The transducer information is then passed into a computer where moving images are developed on a video screen. Blood tests are also used in the diagnoses of stress cardiomyopathy. The blood of majority of people suffering from stress cardiomyopathy contains an increased level of particular enzymes (Rivera, Bailen& Aguilar, 2011). Thus, blood test may be done to check on the content of these enzymes to assist in making elimination. A chest X-ray is another test that is highly likely to be ordered. The X-ray focuses on determining whether the heart has enlarged or contains the shape of stress cardiomyopathy. It also determines if there is any issue in the lungs that could be contributing to stress cardiomyopathy like symptoms. Another test that the doctor may consider ordering is the cardiac magnetic resonance imaging (MRI) where the patient is subjected into magnetic field via a long tube like machine (Mayo Clinic, 2017). A detailed picture is produced by the magnetic field to assist the doctors to examine the heart. Another possible test that can add to the diagnosis of stress cardiomyopathy is coronary angiogram. In a coronary angiogram, the blood vessels are injected with form of dye visible via x-ray machine. Then, series of images are rapidly taken by the X-ray machine, which provides the doctor with a detailed image at the inner parts of the blood vessels. Since stress cardiomyopathy frequently mimics the heart attack symptoms and signs, it would be helpful to perform coronary angiogram swiftly to assist in ruling out heart attack(Mayo Clinic, 2017).

Plan for Management of Stress Cardiomyopathy

Stress cardiomyopathy management mainly contains symptomatic and supportive treatment. At the beginning, the patient is managed like a myocardinal infarction, which includes provision of urgent coronary angiography with basic coronary intervention view. The treatment of all patients suffering from coronary artery disease begins with aspirin, angiotensin-converting enzyme (ACE) inhibitors, and low molecular weight heparins; diuretics and β-blockers can be started if necessary. More supportive care should be provided for patients with congestive heart failure with vasodilators and diuretics. It is important to note that stress cardiomyopathy treatment mainly remains empirical. With initial effective medical support, individuals suffering from stress cardiomyopathy demonstrate good echocardiographic and clinical improvement, as well as great prognosis.

Stress cardiomyopathy patients should as well be monitored for development of mechanical, heart failure and arrhythmias complications. Patients with severe haemodynamic require intra-aortic balloon counterpulsation and vasopressor agents. Apical thrombus can develop,making temporary anticoagulation necessary. Based on the patient condition, the patient may fit in the inpatient care, where he or she will be taken care of by the nurses and other medical professionals (Ramaraj, 2007). In case the patient is in the follow-up group, the patient will fit in outpatient services, where she or he will be visiting for progress assessment. This will include ensuring cardiomyopathy resolution, normally with serial echocardiograms. The doctor will thus advise for yearly follow-up clinic due to the known natural history and long-term effect of the disease, to assist the patient in attaining the treatment goals.

Engaging Patient with Stress Cardiomyopathy

The main barrier to stress cardiomyopathy management is diagnosis. Stress cardiomyopathy condition resembles ACS and thus, it is considerably hard to make the right diagnosis. The situation worsens when the hospital where the patient is rushed does not have the right facilities to make advance tests that assist in making a clear cut between the two. The disease management may therefore be impossible when the wrong treatment is given. Another major barrier is the root cause of the problem. Stress cardiomyopathy is normally caused by stressful events among other factors (Ramaraj, 2007). It may therefore be considerably hard to handle the situation in case the patient stressful condition persists. The patient has to be free of the situation that initiated the condition. Stress events have also been cited as the major cause of recurrence. In this regard, patients may need extra psychological assistance for effective recovery. The main facilitator is that stress cardiomyopathy is a temporal condition and once diagnosed, the patient can effectively managed using medication, with slim chances of death and recurrence. Though gradual, proper case management, including follow-ups can easily result to complete healing (Ramaraj, 2007).

Patient activation should happen during the interpretation of the patient assessment result. During this time the doctor should clearly explain the condition to the patient and make the patient understand what may need to be done to ensure proper treatment. This includes briefing on the patient contribution in the treatment process. The main thing in stress cardiomyopathy treatment is overcoming the stressful situation with strong mind and taking the provided medication as required. The patient should also know the disease impact in the short- and long-run and what may need to be known about it (Dahlviken, Fridlund&Mathisen, 2015). This gives the patient the courage to fight the condition. Knowing that complete treatment of the condition is possible gives patient the strength and vigor needed to enhance quick recovery. Empowerment involves providing the patient with the mechanism of overcoming the condition and winning. This includes providing proper medical care and counseling, social support, group support and effective follow-up. This makes the patient hopeful and thus, trying to gather inner strength to rejuvenate personal strength to be able to continue with the fight (Dahlviken, Fridlund&Mathisen, 2015).

The five evidence based strategies to promote patient activation and empowerment include holistic nursing, which involves seeing the patient as whole. This is an approach that is based on the perspective of patient, and acknowledging subjective experience of an individual regarding values, health beliefs, and health. The concept refers to interconnected environment, body, context, mind, emotion, relationships, spirit, and socio-culture. This assists highly in treating the underlying cause of the stress cardiomyopathy (Dahlviken, Fridlund&Mathisen, 2015). Awareness and disease education is another evidence based strategy that can be used to enhance patient activation and empowerment. Patient demonstrates fear and anxiety every time they have a condition that seems serious, but do not have enough knowledge or information about it. This may even be worse in a situation such as stress cardiomyopathy that is motivated by stress. It is therefore important for doctors to give all possible information to ensure that patients are aware of the situation and that they understand every treatment procedure and they are fully involved (Dahlviken, Fridlund&Mathisen, 2015).

Counseling is another strategy that has been proven to be effective in activating and empowering stress cardiomyopathy patients. The counseling helps in relieving the patients from any stressful condition that could have initiated the situation or in overcoming mental distress emanating from the new development. This makes them get peaceful mind and inner power to fight the condition (Dahlviken, Fridlund&Mathisen, 2015). Stress cardiomyopathy has a possibility to recur and especially in the presence of the first trigger. Clinical follow-up of up to 13 years is regarded as the best way to reassure patients that they are fine. The follow-up may also assure patients that there are people who are ready to take care of them in case of any problem. This eliminates fear and anxiety; aspects that can as well trigger recurrences. Family and social support is another strategy that is proven to have a great impact in activating the patient and empowering them (Rivera, Bailen& Aguilar, 2011). Family members should be there to support them and to encourage them to recover completely. Social support especially among those who have had previous experience with the disease and have overcome, gives patient hope of concurring in the end. Thus, they play a great part in empowering the patients and activating them. Social support can also be very educative (Rivera, Bailen& Aguilar, 2011).

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