Takotsubo cardiomyopathy

Sai Soundarya*

DNB Internal Medicine Resident, Kauvery Heart City, Trichy, India

*Correspondence: [email protected]

Abstract

Takotsubo cardiomyopathy is a close differential diagnosis of acute coronary syndrome, and can present with chest pain and breathlessness. It is caused by emotional or psychological stress caused by the unexpected death of a relative or a friend, occurrence of natural disasters, strenuous physical stress etc.

This report describes a patient who presented to Kauvery Heart City on 26th December 2021 and was diagnosed to have Takotsubo cardiomyopathy

Key words: Takotsubo cardiomyopathy, emotional stress, Mayo criteria

Background

Takotsubo cardiomyopathy was a rare diagnosis for the past 20 years. But in recent years the number of reports on Takotsubo cardiomyopathy are considerably increasing. It is important to identify Takotsubo cardiomyopathy as it among the differential diagnoses for STEMI.

Case Presentation

A 49-years-old postmenopausal lady, living a sedentary lifestyle, and with no comorbid illness, was admitted with complaints of chest pain and breathlessness since the morning following the death of her husband, on the day prior to admission. She had taken the second dose of Covishield vaccination on the day prior to admission.

On arrival she was dyspneic, with a respiratory rate of 42/min.

On Examination

BP, 100/70 mmHg; P, 102/min; regular; SpO2, 94% in room air; RR, 42/ min; JVP, not elevated.

R: Breath sounds heard bilaterally, along with bilateral basal crepitations

CVS: S1, S2+

Arrival ECG

Takotsubo-cardiomyopathy

ECGshowed T inversion in inferolateral leads, with unifocal frequent ventricular premature contractions of right ventricular outflow tract origin since they have left bundle branch block configuration in chest leads with positive QRS complexes in inferior leads.

Investigations

Troponin T: positive

Bedside echo indicated the characteristic basal hyperkinesia and apical ballooning suggestive of stress cardiomyopathy with severe LV dysfunction.

ECHO image

Takotsubo-cardiomyopathy-2

Discussion

Takotsubo cardiomyopathy is a form of stresscardiomyopathy. It was first described in Japan in 1990 by Sato et al. The term Takotsubo is taken from the Japanese name for an octopus trap which has the shape that is similar to the systolic apical ballooning appearance of the left ventricle.

Pathophysiology of Takotsubo cardiomyopathy

The most commonly discussed possible mechanism of Takotsubo cardiomyopathy is stress induced catecholamine release with toxicity to them, and subsequent stunning of the myocardium [1].

The apical portions of the left ventricle have the highest concentration of sympathetic innervation found in the heart and may explain why excess catecholamines seem to selectively affect its function [2].

Relative preponderance of Takotsubo cardiomyopathy among post-menopausal women suggests that oestrogen deprivation causing endothelial dysfunction may play a role in Takotsubo cardiomyopathy.

The classical ECG findings in Takotsubo cardiomyopathy is ST segment elevation with T inversion in anterior leads resembling ACS-AWMI but without reciprocal ST depression. Prolonged QT interval is also noted in significant number of cases of Takotsubo cardiomyopathy. But this patient did not have the classical ECG findings of Takotsubo cardiomyopathy except for prolongation of QT interval (508 ms). Normal QTc interval is 360–460 ms in females.

The prevalence of QTc prolongation in patients with Takotsubo cardiomyopathy is variable, ranging from 26–51%. QTc prolongation in Takotsubo cardiomyopathy is considered to reflect a transient myocardial insult [3].

Diagnosis of Takotsubo cardiomyopathy

Modified Mayo criteria

Diagnosis requires the presence of all four of the following criteria

  1. Transienthypokinesis/ dyskinesis or akinesis of the LV midsegments with or without apical involvement; Regional wall motion abnormality extending beyond a single vessel distribution and a stressful trigger are often but not always present.
  2. Absenceof obstructive coronary disease or angiographic evidence of acute plaque rupture.
  3. New ECG abnormality (either ST segment elevation and or T wave inversion) or modest elevation of cardiac troponin level.
  4. Absenceof pheochromocytoma or myocarditis.

Treatment

Ingeneral, they are treated with antiplatelets, stains, anticoagulants, beta blockers and ACE inhibitors. Inotropes are to be avoided since catecholamine surge is the mechanism underlying Takotsubo cardiomyopathy.

Reference

  1. Boland TA, Lee VH, et al. Stress induced cardiomyopathy. Crit care Med. 2015;43(3):686–93.
  2. Dortman TA, et al. Takotsubo cardiomyopathy state of the art review. J Nucl Cardiol. 2009;16(1):122-34.
  3. Takasaki A, et al. Massive ST segment elevation andQTc prolongation in the emergency department. Circulation 2019;140:436-9.
Dr-Sai-Soundarya

Dr. Sai Soundarya

DNB Internal Medicine Resident

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