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An elderly patient with acute chest pain
 
Published on 2013-03-18 by WALID GHARZUDDINE
 
 
History and Findings
 

 

History:

77 year old woman was admitted to the hospital after she sustained a fall while she was ambulating at her home. Her initial radiographic workup in the emergency department revealed multiple fractures involving the distal radius bone extending into the carpal bones, the left seventh and eighth ribs, and a comminuted displaced fracture involving the surgical neck of the humerus. Brain CT showed no acute changes. The patient underwent arthroplasty of the left humerus. Two weeks into her prolonged hospital stay she developed acute onset dyspnea and hypoxia with lung edema, tachycardia 110. BP was 100/60 mmHg. She was stabilized on non-invasive positive pressure ventilation and diuretics. Three sets of troponin were 0.2, 0.25, 0.26 mg% respectively (normal: <0.03 mg%).

 ECG showed abnormal T waves (see figure).

Echocardiography: See videos.

1.   Video 1 is on admission prior to the cardiac symptoms

2.   Videos 2 and 3 are at the time of her symptoms

3.   Video 4 is 2 weeks later

Coronary angiogram done at a later date showed patent coronaries.

 
 
 
Echocardiogram one week prior to event | Apical 4 chamber view at time of event | Apical 3 chamber at time of event | Two weeks later showing improvement
 
 
 
 
 
Discussion
 

 

In view of the extensive wall motion abnormalities, modest rise in cardiac enzymes and mildly abnormal EKG the diagnosis of stress-induced cardiomyopathy was entertained.

Stress cardiomyopathy, also referred to as Takotsubo cardiomyopathy, transient apical ballooning or broken heart syndrome, is a disorder associated with transient left ventricular dysfunction. First described by Dote et al., who named it takotsubo because the shape of the left ventricle resembles a Japanese octopus trap.

Symptoms include acute chest pain and dyspnea accompanied by electrocardiographic changes, absence  of substantial coronary artery obstruction.such as ST‐segment elevation and T‐wave inversions, minimal elevation of cardiac enzyme levels and transient wall‐motion abnormalities which usually are not confined to a single coronary artery territory. Complete recovery of contractile function has been documented in nearly all cases over a period of days to weeks but the mechanisms of disease remain unclear.

The prevalence of stress cardiomyopathy among patients with symptoms suggestive of myocardial infarction is 0.7–2.5%, and it is found predominantly in postmenopausal women (90%). The prognosis of stress cardiomyopathy is favorable, although fatal complications, such as cardiogenic shock, malignant arrhythmias and free wall rupture of the left ventricle have been reported. The in-hospital disease-related mortality rate is about 2%.

No large studies have confirmed the etiology of stress cardiomyopathy, so determining the underlying cause has so far not been possible. Several pathological mechanisms have been proposed including:

·      Coronary artery vasospasm

·      Coronary microcirculation dysfunction

·      Obstruction of the left ventricular outflow tract

·      Catecholamine overload. Published data suggest that substantially elevated plasma catecholamine levels seen in stress cardiomyopathy patients could be particularly relevant, and result in catecholamine-related toxic effects.

There are no specific treatments for the left ventricular failure characterizing Takotsubo cardiomyopathy because cardiac function is normalized within a few weeks. When shock occurs, intraaortic balloon pumping is established as additional support for the circulation. The administration of cardiotonic agents is not appropriate because of the likelihood of exacerbating the condition. Similarly adrenoceptor blockers, which leave unopposed the potentially adverse effects of high local concentrations of catecholamines at adrenoceptors are better avoided. Given the findings in the animal model, treatment with a combined blocker seems rational, whereas treatment with a catecholamine as a cardiotonic seems contraindicated.

References and further reading:

Takotsubo Cardiomyopathy : A New Form of Acute, Reversible Heart Failure: Yoshihiro J. Akashi, David S. Goldstein, Giuseppe Barbaro and Takashi Ueyama

Circulation. 2008;118:2754-2762

 

 

Mechanisms of stress (Takotsubo) cardiomyopathy : :Holger M. Nef, Helge Möllmann, Yoshihiro J. Akashi and Christian W. Hamm

Nat. Rev. Cardiol. 7, 187–193 (2010)

Case compiled with the help of Wissam Alajaji M.D., second year cardiology fellow AUBMC.

 
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