Speaker 1: The content of this podcast is provided for general informational
purposes only and is not intended as nor should it
be considered a substitute for professional medical advice. Hello, this
is Karen Nickel, family nurse practitioner, and you are listening
to Itchy and Bitchy, a podcast that provides answers to
your many unanswered health questions. I have some very exciting
news to share with my wonderful listeners. For almost nine years,
I have been the host of Itchy and Bitchy formally
named Sweaty and pist. It is time for the podcast
to grow and evolve with new hosts and a slightly
different format. Growth and change is a good thing. People.
My dear friends, Stephen Miller and Keith Millica will be
the future hosts of Itchy and Bitchy. As hosts, they
will have a comprehensive approach to wellness with a focus
on connecting human health, animal health, and environmental health. To
provide a transition period for you, for me, and for
Stephen and Keith. We have a series of four episodes planned.
I will introduce Stephen Miller, a fellow nurse practitioner, in
the first of four episodes. In the next episode, I
will introduce you to Keith Nilika, a veterinarian. The third
episode will include all three of us as I interview
both Stephen and Keith. All three of us will also
be in the fourth episode, but this time the tables
will be turned and Keith and Stephen will be interviewing me.
I'm confident you will enjoy and learn from all that
they have to share. Stephen Miller is an acute care
nurse practitioner known for his expertise in diagnosing and treating
cardiovascular disease. He is highly respected for his patient centered approach,
consistently ensuring that each individual remains at the heart no
pun intended of their care. Committed to excellence. Stephen earned
his Doctor of Nursing Practice from Vanderbilt University, further strengthening
his clinical knowledge and leadership in advanced nursing practice. Most importantly,
from my point of view, anyway, we have been friends
from about twenty five years. Welcome Stephen, High Care. Stephen
and I are going to chat about something called Takatsubo
cardiomyopathy because I suspect that many of you have not
heard about this heart problem. So Stephen, let's first to
find cardiomyopathy. Let's start there.
Speaker 2: Yeah, so, cardiomyopathy is anything that decreases the function of
mild cardial tissue and can lead to weakening of the
lift and or later more severely congestive heart failure types
of symptoms.
Speaker 1: Yeah, not good. So what about Takatsubo cardiomopy? What makes
that different? What is it? Yeah?
Speaker 2: So, Tukatsubo is an interesting syndrome. It is otherwise also
known as broken heart syndrome. It is this temporary condition
that is triggered by intense emotional or physical stress. It
mimics something that we call acute coronary syndrome, which can
come with obstructive coronary artery disease. However, the difference for
Tucketsubo is that there is no obstructive coronary artery disease
or blockage in the arteries as the cause for this
particular event.
Speaker 1: It's so interesting. So what are the likely symptoms of
this problem?
Speaker 2: Most women will experience an intense emotional or intense psychological
stressor that triggers the events and.
Speaker 1: It presents a lot of women have those, by the way.
Speaker 2: Yes they too, and they present with what would be
like a typical heart attack, so coming in with chest
pain or unusual shortness of breath. Of course, you always
have to remember in women's symptoms are also atypical, so
a lot of those symptoms can present as jaw pain
or back pain. So some atypical and typical symptoms generally
examples of triggers for women for these events would be
some intense event like the death of a family member
or loved one, and acute illness, a surgery, stroke, and
sometimes other severe psychological stressors.
Speaker 1: So, yeah, I had a patient with Takatsubo and she
was in a very difficult relationship. She was really struggling
on how to make this relationship work, and the stress
was so immense that she ended up with Tukatsubo cardiom
my alpathy. Yeah.
Speaker 2: Yeah, I've seen a number of cases over the twenty
six years of practice in cardiology, and all with different
presentation situations. I have one patient who experienced her husband
injured himself and she had an episode right there in
her yard during his event, And so you know, it
can be. It's real, and the symptoms are real, and
the and oregon effects of it are very real. It's interesting.
Has a funny little name. Tucketsubo is something that is
named after the octopus strap.
Speaker 1: So something that catches octopus.
Speaker 2: Yes, that's right. So when we look at echo cardiograms
and herzations for women who have tacosuba or men more
rarely men, you see this classic sort of ballooning of
the apex or bottom part of the heart, and so
you get this sort of narrow neck at the top
and ballooning of the ventricle. And that's where it essentially
gets its name from it and it's very typical and
very classic presentation. And once you see it on echo
or cardiac cathization, you know exactly what.
Speaker 1: It's pretty clear on that imaging that that's what's going on. Yeah,
oh good. Are there certain people who tend to get
this or have greater risk of developing takatsubo. Yeah.
Speaker 2: Ninety percent of the cases are women or female people,
particularly among postmenopausal women, as there is a strong trigger
from the hormonal shift that happens at menopause and declines
in estrogen levels around the age of fifty five, risk
goes up. And honestly, the majority of the cases that
I've seen over the years have been women in that
age group. There are also other sort of pre existing
conditions that can set someone up for having tucketsubas, so
like neurologic conditions, stroke, epilepsy, and then of course anxiety
and depression, and who doesn't have anxiety and depression, so
lots of people.
Speaker 1: It's really quite incredible and interesting that we now know
that estrogen is so heart protective and the lack of
estrogen is part of the reason women experience this way,
way way more than men.
Speaker 2: Sure, and when you take that into account for the
fact that during these events you get this intense surge
of fight or flight response, and so all of that
ramps up and causes this intense vase of constriction in
the coronary arteries and subsequent lack of blood supply to
the malcardium or heart muscle. So catecholamines are not our
friend in this situation.
Speaker 1: Gotcha, We're going to take a quick break, and after
this break we will talk about who is the likeliest
person to come up with the Takatsubo cardiomyopathy. We'll be
right back. Welcome back. So you mentioned a couple of
other things that put people at risk, but are there
other events that could trigger takatsubo.
Speaker 2: Oh yeah, yeah, so you look at sometimes surgical events,
people can have intense catecholamine released during surgery. Of course,
the death of a loved one, relationship breakups, which large
percentage of people go through divorce in the middle age
of a life. I've seen a number of cases in
our office of people who had were having intense arguments
with a loved one, a husband, or a family member.
And then of course intense fear can set off these
events of this surge of ctcola means or ctcolam mediated
events that people get.
Speaker 1: So so like if you were hiking and a bear
started running down the trail right at you and you
manage to survive.
Speaker 2: It the bear.
Speaker 1: Yeah, yeah, if you survive the bear, the fear from
that experience could trigger this. Yeah.
Speaker 2: Or if your husband were a bear, well, if.
Speaker 1: You're marrying a bear, that's a little weird, but hey,
but hey, to each his out. It happens. So you
mentioned the echo cardiogram or angiogram that there's clear physical
findings to help confirm your suspicion of takatsuba. Are there
any blood tests that you do for that?
Speaker 2: Yeah, So when someone presents. Say, for example, they come
in the emergency room and they have the presentation of
angina a Q cornary syndrome type of thing. We run
an EKG. So a basic EKG can show some ST
segment elevation or depression depending on where they are. Additionally,
you would get now high sensitivity traponents or troponin levels,
which often are elevated and not always peaked like they
might be with an acute occlusion of an artery, because
you have to remember this a transient occlusion. Back to
EKG again, we see ST segment elevation, ST segment depression,
T wave inversion, and even QT prolongation. So all of that,
putting that in English, just EKG changes that might show.
Speaker 1: Up that are typical for this problem.
Speaker 2: Pretty typical. Yeah, And then once level of suspicion is
high and screening testing is indicative, then you would move
on to something like a heart catherization and or echo cardiogram. Generally,
in this situation we would end up doing both. The
cardiac catheterization is particularly helpful because it helps us to
diagnose coronary disease or flow limiting.
Speaker 1: Rolling out that part that's right.
Speaker 2: Ideally and in Takatsubo, you would not see necessarily flow
limiting coronary disease. And then we also do what it's
called l V or left ventricula gram shoot die into
the left centrical and that's where we would see that
ballooning of the apex of the left fentricle.
Speaker 1: Interesting, So, say someone gets diagnosed with Takatsubo cardiomyopathy, is
there hope, what is the treatment for the condition.
Speaker 2: When the blood flow to the heart is temporarily blocked
and a patient has an event and then you see
some weakening of the left fentricle and you don't see
any flow limiting disease and you've determined it's a takatsubo.
The prognosis is really quite excellent because with medical therapy
then you can see significant improvements. So prognosis is excellent.
Outcomes bad outcomes are pretty rare. It's about a mortality
rate of about one percent to three point two percent,
and that includes you know, things like life they're threatening,
a arrhythmias and that kind of thing.
Speaker 1: And that might happen because the heart's baggy.
Speaker 2: It's it's boggy, and it's not pumping efficient right right,
and so when we help people through the acute phase
of takasuba with medications, and we give medicines to help
decrease the work of the left ventricle and medications that
help improve ventricular remodeling, then we start to see the
heart go back to its normal shape.
Speaker 1: And so what kind of medications are those? What typically
would you start?
Speaker 2: So it's interesting there are treatments considered to be supportive
because certainly in this situation you would not do any
kind of intervention. You wouldn't need to do intervention as
far as stints or angioplasti or anything like that. But
treatment is tailored to what we call hemodynamic phenotype or
an English basically the person's hemodynamic presentation and what their
body can tolerate. As far as adding on GDMT or
guideline or directed therapy, there are no guidelines currently because
there aren't any randomized controlled trials looking at standards of
care for these patients.
Speaker 1: Maybe because it's mostly women.
Speaker 2: You know, one can only.
Speaker 1: But listen my listeners hear me say this all the time. Now, Yeah,
that didn't get studied because it's a women problem.
Speaker 2: So yes, the truth of what you're saying is that
historically when women are under represented in population studies, and
so the data historically has been skewed to the male population.
And that's very accurate.
Speaker 1: But you would use medications you would use often in
heart failure of other causes, so that like beta blockers and.
Speaker 2: Yeah yeah, so things like data blockers like matopra law
in which we would use in acute cornery center ace
inhibitors ARBs. Those things are helpful. Definitely some type of
aspirin and or plavix because clearly if that person had
a tendency toward having a Takatsubo event, you would want
to make sure they're protected moving forward. They don't need
another insult. The interesting thing about that is that reoccurrence
rates are actually pretty low, but they do happen. They're
about one point five percent.
Speaker 1: Yeah, so if somebody has this, they can feel it's
terrible that it, but they can feel pretty good about
regaining heart function, yes to normalish levels to normal. Yeah.
Speaker 2: Yeah, So we repeat an echo cardiogram when they come back,
and as a general rule, their ejection fractions improve and
mil cardial function returns to normal. So and that usually
happens somewhere between three to six weeks.
Speaker 1: Oh, okay, the ejection fraction tells us how well the
left ventricle, the bottom left chamber is squeezing. Yeah, so
we're looking to see if they've regained the function that
we want to see in that left.
Speaker 2: Bottom Nay, yeah, that's absolutely correct. So the ejection fraction
is the percent of blood pump from the left ventricle
with each contraction, and it's normally somewhere between fifty to
seventy percent, somewhere in that range. A lot of these
people will see their ejection fractions during their event decline
into the thirties twenties, but then with proper medication, then
you can see those that ventricular recovery occur.
Speaker 1: So it's hopeful for the people who experiences that they'll
recover function pretty quickly and the chances of it happening
again are pretty slim. Do you, ever, as a cardiology practitioner,
do you send them for cognitive behavioral therapy or anything
that would help avoid another event if an emotional stressor
especially was one of the triggers for the event.
Speaker 2: Yes, So a lot of people who have intense emotional
reaction around events in life benefit may benefit from certain
medications for their anxiety or you know, if they're bipolar
or whatever underlying psychiatric issue is going on, and so
it's a very good idea to get these people connected.
I've actually historically given a couple of the patients treated
them with SSRIs and there is a slim amount of
evidence there serotonin reuptake inhibitors. So yes, behavior those.
Speaker 1: Are things like prozac, pax paxel lexapro. Yeah, just for
our listeners, Yeah.
Speaker 2: That's right, and so yes, a good referral to mental
health specialty is vital. Cardiac rehab is another really vital
part of recovery. A lot of people when they have
this event, feel utterly exhausted. So the heart deconditions really
rapidly when you have an event, and people will notice
unusual fatigue for weeks after, shortness of breath for weeks after,
while the ventricle is recovering and their bodies are having
get readjusted because they're now new medications on board with
all kinds of side effects that they have to deal with.
But certainly cardiac rehab is highly recommended for these folks.
Speaker 1: Yeah, that's great. I just think this is a really
interesting subject and one that I don't think gets talked
about a lot, and so I appreciate you filling in
all that information that most of us don't know. I
really appreciate that. Is there anything you would like to
share about who you are or what you hope to
bring to the listening audience as a future host?
Speaker 2: Yeah, I think this will be super fun and exciting.
I'm definitely after twenty six years of practice, I've got
lots of experience with all manner of people and on
multiple levels. And I think the ability to bring that
rich history of practice into conversation with people and present
data in an appropriate way, that's another thing through my
especially through my doctorate work. So we have studied that
and God spent a lot of money and degrees learning
how to gather up that data and present it in
a way that people can understand. And so I think
the ability to do that should be able to we
should be able to enhance people well.
Speaker 1: I think the listeners over the last almost nine years,
I do talk about studies in most of my episodes.
I don't go into pee values and all that, but
I think it's helpful for people to know what's being studied,
what the results were, you know, how many people were
in the study, right, that kind.
Speaker 2: Of thing, helping people tease through that's really important.
Speaker 1: Yeah, I think so too.
Speaker 2: And historically, you know, with women, the population of women
in studies within medicine have been underrepresented, and so maybe
we have missed the mark on finding pathways for women
in healthcare.
Speaker 1: Yeah. I mean the fact that ninety percent of the
patients who experiences are women and we don't have information
really on the best way to treat that and we're
in twenty twenty six is sort of incredible.
Speaker 2: There are no guidelines.
Speaker 1: Yeah, yeah, that's yeah. Well, I won't go on my tirade.
I promise all my listeners are going, oh, thank god. Well,
I'm so glad you're here. I'm so glad Keith is
going to be here with us. And I also want
to point out that you're a musician and Keith is
an artist, and so they you know, have similar experiences
that I have as a musician. So they bring that
to the table as well, which I think is a
really good fit for this podcast.
Speaker 2: Sometimes it takes an artistic mind to take something so
technical and look at different ways of getting across to peace,
and certainly music being so scientific, but yet so creative
and colorful, and it taps into our right brain, and
so it allows us the ability to extend beyond the
sort of robotic care that I think people really just
don't want.
Speaker 1: We love our right brain, Yes, it love it.
Speaker 2: I am working to preserve mine every day. I know
it's important and a lessons saying all of that.
Speaker 1: See, it's so good, Keith painting, painting, My gosh, it's
so important. Right brain is so good, it is. Well,
thank you so very much, Stephen. I'm excited that you're
coming on board, and I appreciate your time and knowledge
about Takatsubo.
Speaker 2: Well, thank you, Karen. We love you very much and
consider you family and we're so excited to do these
next few episodes with you, and it'll be fun and
continue to honor your work through this podcast to your listeners.
I think that's a brain child of yours and we're
just thrilled to be able to carry it forward.
Speaker 1: I appreciate that very very much. I appreciate that well,
MANI thanks to all of you out there for listening,
and wherever you listen to this podcast, please leave a
review and rate the podcast. Your reviews and ratings really
do matter. Also, make sure you follow the show so
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encourage you to visit our Facebook page imb Podcast, where
you can give us a like or leave comments or
questions for me. Our website is itchymbitchi dot com, where
there are blogs with some of our subjects available for
you to read. Thank you to Forrest winsl my son,
our producer and composer of our theme music and the
person who does all the behind the scenes work to
make this podcast possible. Thank you so much, Forrest. And
Forrest continues to thrive at Peabody Music Conservatory and is
finishing up his final semester the Master's program, and he
has informed us that he has been admitted to the
Peabody Doctoral Program to receive a Doctor of Musical Arts
in Composition. His dad and I are so so very
happy for him. It's fun to see his immense musical
talents recognized. If you want to listen to what he's creating,
you can go to his website Forrestwinsle dot com. Remember
that your health is in your hands.