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The other great masquerader takotsubo cardiomyopathy the indian practittioner nov 2014

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The other great masquerader takotsubo cardiomyopathy the indian practittioner nov 2014

  1. 1. The Indian Practitioner q Vol.67 No.11. November 2014 Case Report 707 Introduction T he word ‘Takotsubo’ originates from the Japanese term for “octopus trap” because the shape of the ballooned cardiac apex in systole in takotsubo cardiomyopathy appears so. Takotsubo cardiomyopathy is also known as stress cardiomyopathy, apical balloon- ing syndrome or broken heart syndrome.1 It is now in- creasingly being recognised as a cause of acute transient reversible left ventricular dysfunction. High index of suspicion is important in order to avoid incorrect treat- ment and because of the potential reversibility of this condition. A case of a middle aged survivor of takotsubo cardiomyopathy is reported here. Case Report A 54 year old known hypertensive and diabetic, anatomy professor was brought with history of giddi- ness followed by collapse during a lecture followed by unresponsiveness 15 minutes back. She had one episode of generalised tonic clonic seizure during transport and another in the ICU, both lasting for 1 to 2 minutes. No history of chest pain, breathlessness, palpitations, head- ache, excessive sweating, missed meal, recent medication or similar episode previously. On examination, pulse and blood pressure were not recordable, respiratory rate was 26/min, oxygen saturation post intubation was 74% and falling. External jugular veins did not appear engorged. Systemic examination revealed muffled heart sounds with bilateral diffuse coarse inspiratory crepts. Rest of the examination was unremarkable. The Other Great Masquerader:Takotsubo Cardiomyopathy Bhosle D,* Adukia S,** Patil R,*** Chavan C,**** *MD (Medicine), Professor; **MBBS, Post-graduate student; ***MBBS, Post-graduate student, Department of Medicine; ****MD, DNB (Medicine), DNB (Cardiology). Bharati HospitalAnd Research Center, Katraj, Dhankawadi, Pune-Satara Road, Pune-411043, Maharashtra. Corresponding author: Dr. Deepak Bhosle,AmrapaliApartment, Flat No 4, S. No 126, Plot No. 13, Katraj, Pune- 411046. Email- dgbhosle@gmail.com Mobile: +91 9960907461 Abstract Takotsubo cardiomyopathy is a rare entity that mimics acute myocardial infarction or congestive heart fail- ure. It is characterised by acute, transient, reversible left ventricular dysfunction that can mimic an acute coronary event at presentation. Coronary arteries are however, often normal on cardiac catheterisation. Patients are usually postmenopausal women who experience acute physical or emotional distress. For years this syndrome has been mistaken for acute myocardial infarction owing to a typical presentation with chest pain, electrocardiographic abnormalities, elevated cardiac enzymes and focal left ventricular wall motion abnormalities. Clinical diagnosis is difficult and demands a high index of suspicion. Recently proposed Mayo criteria might help in diagnosis. Delay in diagnosis should not result in delay in treatment. We report a case involving a post menopausal female who had an attack of takotsubo cardiomyopathy with a favourable outcome. Keywords: Reversible cardiomyopathy, Mayo criteria for takotsubo cardiomyopathy, Catecholamine in- duced ventricular dysfunction.
  2. 2. The Indian Practitioner q Vol.67 No.11. November 2014 Case Report 708 She was put on ventilatory support and inotropes. Intravenous Frusemide was given alongwith crushed tablets of Aspirin, Clopidogrel and Atorvastatin via Ryle’s tube. Subcutaneous enoxaparin was given after ruling out intracerebral bleed on CT brain. ECG showed low voltage with sinus tachycardia and ST flattening in V3 to V6. Serial ECG’s showed T wave inversions from V3 to V6. Qualitative Troponin-T spot test was negative with normal cardiac enzymes (CPK 86 U/L, CPK-MB 20 U/L), total leucocyte count 20,100 cells/cu.mm (neutro- phils 30%). All other biochemical investigations were normal. X-ray chest showed bilateral diffuse haziness in bi- lateral mid and lower zones with cardiomegaly (Cardio- thoracic ratio > 60%). 2D echocardiography showed mildly dilated left ventricle with akinetic ballooned apex (Fig.1) and moderate systolic dysfunction with a left ven- tricular ejection fraction (LVEF) of 35%. Cardiac cathe- terisation showed normal coronary arteries and normal renal arteries bilaterally. Ultrasound examination of ab- domen and pelvis did not show any mass over the kid- neys. Thyroid function tests, MRI brain and EEG were normal. Cardiac MRI with contrast on day 5 showed ballooned akinetic cardiac apex (Fig.2) with fair LV systolic func- tion (LVEF = 45%). No myocardial scarring, significant valvular regurgitation, pericardial effusion or chamber enlargement was noted. Repeat 2D Echo revealed similar findings as cardiac MRI. X-ray chest showed reduction of cardiomegaly (Cardio-thoracic ratio > 50%). Thereafter patient remained relatively stable and was discharged by day 10. Cardiac MRI with contrast was repeated on fol- low up after 1 week and showed normal LV size and sys- tolic function (LVEF = 63%) with no myocardial scarring. She was asymptomatic on follow up and reported an un- eventful stay at home post-discharge. Thus, a diagnosis of takotsubo cardiomyopathy was made with evidence of reversible left ventricular dysfunction, no residual re- gional wall abnormalities, normal coronary arteries and in absence of other obvious causative pathology. Discussion Various insults whether emotional or physical, like status epilepticus,2 hypertensive crisis, scorpion sting Table 1:- Proposed Mayo criteria for the clinical diag- nosis of the transient left ventricular apical balloon- ing syndrome1 1. Transient akinesis or dyskinesis of left ventricular apical and mid-ventricular segments with regional wall-motion abnormalities extending beyond a sin- gle epicardial vascular distribution 2. Absence of obstructive coronary disease or angio- graphic evidence of acute plaque rupture 3. New electrocardiographic abnormalities (either ST-segment elevation or T-wave inversion) 4. Absence of : ● Recent significant head trauma ● Intracranial bleeding ● Phaeochromocytoma ● Obstructive epicardial coronary artery disease ● Myocarditis ● Hypertrophic cardiomyopathy Fig.1: Octopus trap or “takotsubo” shaped left ventricle (arrow) on echocardiography. Figure 2: Ballooned apex (arrow) seen on Cardiac MRI with contrast
  3. 3. The Indian Practitioner q Vol.67 No.11. November 2014 Case Report envenomation, acute ischaemic stroke or sub-arachnoid haemorrhage, thyroid storm, tachycardia induced car- diomyopathy, sepsis, multiorgan dysfunction, postcardi- ac arrest syndrome, physical stress like trauma, surgery have been established as causatives of takotsubo cardio- myopathy.3 Whatever the cause, the clinical presentation is that of acute LV dysfunction. Likely pathophysiological mechanisms are as below. Epicardial coronary vasospasm Multivessel coronary vasospasm may be responsible for myocardial infarction like picture associated with non obstructive coronary disease. However, urgent coronary angiography conducted at different centres at the time of presentation showed variability in incidence of coronary vasospasm. This inconsistency makes multivessel coro- nary vasospasm less likely a mechanism.4,5,6 Endothelial dysfunction Thrombolysis in myocardial infarction (TIMI) frame counts have demonstrated endothelial dysfunction in all 3 major epicardial coronary arteries during the acute phase. In addition, concomitant abnormalities of fatty acid metabolism have also been reported causing further endothelial damage. Microvascular ischaemia probably contributes to LV dysfunction as opposed to myocardial damage in transient apical ballooning.1,7,8 However, ad- equate data on this hypothesis is lacking. Catecholamine-induced LV dysfunction Catecholamine excess and increased cortisol secretion may cause myocardial stunning. It may also promote en- dothelial dysfunction. Nonapical regional wall motion abnormalities that do not follow a single coronary dis- tribution can be explained by this. In patients recover- ing from subarachnoid haemorrhage “cerebral T waves” might reflect the transient wall motion abnormalities in acute stress-related cardiomyopathy predominantly in- volving the ventricular apex.9,10 Management includes non-specific therapies like ni- trates for pulmonary oedema, intra-aortic balloon pump for low output, combined alpha and beta blockers rather than selective beta blockade if haemodynamically stable, and magnesium for arrhythmias related to QT prolon- gation. Anticoagulation is generally withheld due to the occasional occurrence of ventricular rupture. Coronary angiography is required to rule out acute coronary oc- clusion.11 This report is to alert the physician to consider takotsubo cardiomyopathy in apt clinical settings. References 1 Aurigemma GP. Acute Stress Cardiomyopathy and Reversible Left Ventricular Dysfunction-Cardiology rounds. 2006 December; 10(10). 2 Seow SC, Lee YP, Tao S, et al. Takotsubo cardiomyopa- thy associated with status epilepticus. Eur J Neurol. 2008 June;15(6): e46 3 Richard C. Stress-related cardiomyopathies. Annals of Intensive Care. 2011;1:39 4 Seth PS, Aurigemma GP, Krasnow JM, Tighe DA, Untereker WJ, Meyer TE. Asyndrome of transient left ventricular api- cal wall motion abnormality in the absence of coronary disease: a perspective from the United States. Cardiology. 2003;100:61-66. 5 Bybee KA, Kara T, Prasad A, et al. Systemic Review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141:858-865 6 Kurisu S, Sato KT, Ishihara M, et al. Tako-tsubo–like left ventricular dysfunction with ST segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J. 2002;143:448-455. 7 Kurisu S, Inoue I, Kawagoe T, et al. Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction. J Am Coll Cardiol. 2003;41(5): 743-8. 8 Bybee KA, Prasad A, Barsness GW, et al. Clinical charac- teristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical bal- looning syndrome. Am J Cardiol. 2004;94:343-6. 9 Ako J, Sudhir K, Farouque HM, Honda Y, Fitzgerald PJ. Transient left ventricular dysfunction under severe stress: brain-heart relationship revisited. Am J Med. 2006; 199(1):10-17. 10 Kono T, Morita H, Kuroiwa T, Onaka H, Takatsuka H, Fujiwara A. Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. J Am Coll Cardiol 1994;24:636-40. 11 Antonio D’Aloia, Claudia Fiorina, Enrico Vizzardi, Pompilio Faggiano, Livio Dei Cas. Hypertensive crisis and acute, re- versible, left ventricular systolic dysfunction: a case report. The European Journal of Heart Failure. 2002;655–660. 9 709

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