Sunday, January 27, 2013

Case History : Takotsubo Cardiomyopathy

I was in Singapore the last 3 days, attending the now world famous annual affair, The Singapore PCR-Live, a regional meeting of like minded  interventional cardiologists all over the world to discuss current  advances in techniques in coronary angioplasty and stenting.

My usual problem in Singapore is always over 'makan'. It is probably easier to find 'halal' food in Beijing or London than in Singapore. So over the short ' in between lecture' lunch break I  find myself rummaging at the buffet table for anything 'halal'. Cauliflower soup does not look palatable but probably is 'halal'. So be it.

"Is this sea food?", asked a tall Middle-Eastern looking man behind me.
" No it is not but it is 'halal ", I retorted , with a smile [ OMG, I am not alone in this crowd ], with some relief.
" You are Muslim, where are you from?"
" Kuala Lumpur, just 400 kilometres up north from here!, Are you from Iraq or Iran?", I retorted, excited.

It turned out he is Kurdish from Iraq, now domiciled in Sweden over 20 years. He is in Singapore to present his series of patients and study on Takotsubo cardiomyopathy, or what we term commonly as the 'broken heart syndrome'. Quite a rare occurrence. I have seen probably only once in my 30 years or so of clinical practice.

"By the way Doc, I take pork. I am just allergic to sea food. I am non-practising Muslim for sometime now", he announced to me rather with some pride.
Now it is my turn to be 'broken hearted'.
In the midst of hundreds of like minded individuals at the brand new Marina Bay Sand Convention Centre, I find myself 'alone again in the crowd'.

We are are just like ships passing  by in the night.
We lead our own lives and at the end  of our 'time'  go to that 'hole in the ground'.
Whether you are an 'unbeliever' or a 'believer' or increasingly nowadays,' a non-practising Muslim' like this Kurdish cardiologist, you will meet with your Maker and will be made to account for whatever you do in this life.
HIS opening gambit , asked via HIS angels, Nukal and Nakil, would be: 
Man Rabbuka ? [ who is your Lord? ].
 [ ]

No, I was not really 'broken hearted'. 
I was just feeling sad for him. In his intelligence, he cannot fathom his 'loss' !
He just cannot appreciate the chaff from the grain.
That meeting of like minded people in Sinapo discussing the  intricacies of forms in its various minutiae, but missing out on the substance....

No! I was not broken-hearted, just feeling  yet  again 'alone in a crowd'.
A privilege feeling.....some degree of sadness combined with a feeling of 'marhabah'.

Next time a Muslim-like face ask "is this sea-food?", I need to put my  best 'political correctness jacket' on  and say, "No. Sir, this is just a vegetable soup! ". 



2. A personal encounter with " Takotsubo Cardiomyopathy "

Some 10 years back I was called to ER at 2 am to attend to  Mr R E, a third cousin of mine, some 3 years my senior in his late forties presenting with sudden onset chest pain and breathing difficulty. His presenting EKG suggest an acute massive anterior wall infarct [ 'heart attack' ]. He was admitted to CCU. Emergency Primary Infarct Angioplasty, meaning pushing patients straight to the cath lab and opening up the blocked arteries there and then, was not 'in vogue' yet at that time in Kuala Lumpur and at my hospital. He was given streptokinase, a blood clotting thrombolysis  agent, intravenously to break down his "?? blood clot ". Nonetheless he was behaving rather atypically in CCU, since despite thrombolysis and full medical therapy, his pain and breathlessness remained persistent and in fact increased a little and the EKG did not show improvement at all.

At angiogram the next morning, I was surprised to see that all his coronary vessels are patent perfectly. It could still be a heart attack with transient 100 % blockade , successfully reopened by the intravenous Streptokinase, but this is highly unlikely as there was no evidence of  residual.narrowing at all in his 'supposedly' diseased vessel.

R E has had a very stormy relationship with his wife over the past few months and at the point in time of this  hospital presentation, on the verge of a  difficult 'divorce'. This is his second marriage.
I have no doubt that , R E must have been my first brush with 'Takatsubo cardiomyopathy".

Unlike most cases of Takatsubo cardiomyopathy, R E was unlucky. His heart took  so much severe damage during the attack, the function did not recover due to much muscle loss, and his left ventricular function was permanently depressed to an 'ejection fraction  just slightly over  30 %. [ normal is 55 - 80 % ]. He has to be given anti heart failure oral medication the rest of his remaining life.

He remarried 2 years later to a new partner but his 'broken heart' did not recover.
Sadly, he died of worsening heart failure just 3 years ago.

Innalillah hiwainna ilai hirojiun
From HIM we come, to HIM we return.......

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