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Medycyna rodzinna 1/2019
O P I S Y P R Z Y P A D K Ó W
C A S E R E P O R T S
© Borgis Med Rodz 2019; 22(1): 15-18 DOI: https://doi.org/10.25121/MR.2019.22.1.15
Wojciech Kosowski, Maciej Kabaj, Magdalena Bastek, Andrzej Mysiak, Marta Negrusz-Kawecka
Takotsubo cardiomyopathy – a case report of a 62-year-old female
with several severe comorbidities
Kardiomiopatia takotsubo – opis przypadku 62-letniej kobiety z wieloma poważnymi
chorobami współistniejącymi
Cardiology Department, Wroclaw Medical University Streszczenie
Kardiomiopatia takotsubo jest ostrym, odwracalnym stanem kardiologicznym charakteryzującym się objawami imitującymi ostry zespół wieńcowy (OZW). W większości przypadków kardiomiopatia takotsubo występuje na skutek stresotwórczego bodźca emocjonalnego lub fizycznego i dotyczy przede wszystkim starszych kobiet.
Prezentujemy opis przypadku 62-letniej kobiety z historią nadciśnienia tętniczego stopnia 2, hipercholesterolemii, miastenii, nowotworu nerki prawej, zespołu paranowotworowego i osteoporozy, u której rozpoznano kardiomiopatię takotsubo. Z powodu prezentowania przy przyjęciu objawów imitujących OZW, postępowanie diagnostyczne i terapeutyczne było pierwotnie prowadzone w kierunku OZW, dopóki nie został on wykluczony na podstawie rzetelnych danych.
Rozróżnienie kardiomiopatii takotsubo od OZW pociąga za sobą wiele implikacji, w tym tych dotyczących farmakoterapii.
Słowa kluczowe
kardiomiopatia takotsubo, echokardiografia, bodziec stresowy
Introduction
Takotsubo cardiomyopathy, apical ballooning syndro-me, stress-induced cardiomyopathy, acute and reversible cardiomyopathy provoked by stress, broken heart syndro-me – these terms, among many others, apply to the sasyndro-me disease (1). It is takotsubo cardiomyopathy (TTC) which seems to be the most frequently used in both research and health care terminology.
TTC is an acute reversible cardiovascular disease that is characterized by symptoms which present similarly to those of an acute coronary syndrome (ACS), such as dyspnoea/ chest pain, ECG abnormalities, elevated cardiac troponin level (2). Due to the resemblance of symptoms between the diseases, TTC patients are often initially diagnosed with ACS.
The origin of the term “stress-induced cardiomyopathy” is attributed to the fact that, in most cases, TTC occurs as the response to emotional (27.7%) or physical (36%) stress
triggers (2). Most of them are negative, yet cases of TTC occurred after positive emotional triggers (such as birthday party, son’s wedding, meeting friends from high school after 50 years, positive job interview, becoming grandmother, winning several jackpots at the casino, celebration of nor-mal PET-CT scan, seeing an opera performance for families) were reported as well (3). What is important, in 28.5% of TTC patients’ cases, there has been no obvious stress trigger perceived as an obvious stimulus (2).
The disease, which is the subject of the study, affects mainly elderly females. In the International Takotsubo Registry, 89.8% of 1750 patients diagnosed with TTC were women (2).Less than 3% of TTC patients were before the age of 50 (4).
The pathophysiology of TTC has not yet been fully understood. Among several proposed mechanisms of its formation, catecholamine-mediated cardiotoxicity has been considered to play an important role (5).
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left ventricular ejection fraction at the level of 60% and no apical akinesia. Follow-up ECG (fig. 5-8) showed negative T waves at leads: I, aVL, V4-V6. The patient was referred to surgery treatment due to a malignant tumor in the right kidney with no necessity of dual antiplatelet therapy (DAPT). Other follow-up hospitalization in the Cardiology Depart-ment was scheduled in six months.
Discussion
We described a clinical case of a patient who presented at admission with symptoms of an acute coronary syndro-me (dyspnoea/chest pain, ECG abnormalities, elevated cardiac troponin level) – the symptoms which are also cha-racteristic of TTC. All patients should be initially considered
as suffering from ACS, until a reliable exclusion is made. It has been estimated that 1 to 2% of patients – initially diagnosed with ACS – have TTC (4). In our case study, the
Case report
We present a case report of a 62-year-old female with the medical history of stage 2 hypertension, hyperchole-sterolemia, myasthenia, right kidney malignancy, parane-oplastic syndrome and osteoporosis, who was referred to the Cardiology Department and Clinic of Wroclaw Medical University from the Neurology Department and Clinic after being treated with myasthenia exacerbation.
On admission, she presented with dyspnoea, mild chest pain, and feeling of sternum pressure. There was also an episode of collapse without loss of consciousness. Patient’s blood pressure was 145/90. Admission ECG (fig. 1-4) showed negative T waves at leads: I, II, aVL, aVF, V2-V6. Laboratory results revealed elevated troponin I (3143 pg/ml, reference values: 0-15.6 pg/ml). The remaining laboratory results have been summarized in table 1.
Coronary angiography was performed and revealed co-ronary stenosis which was hemodynamically insignificant. Echocardiography showed left ventricular ejection fraction of 30-35% and apical akinesia. There weren’t any relevant conduction abnormalities and arrhythmias at 24-hour Hol-ter ECG monitoring.
Following all symptoms and examination results, TTC was diagnosed. Follow-up hospitalization in the Cardiology
Clinic was scheduled in two months.
During second hospitalization in the Clinic of Cardiology, echocardiography was performed and revealed an improved
Fig. 1. ECG on admission (leads I, II, III)
Fig. 2. ECG on admission (leads aVR, aVL, aVF)
Fig. 3. ECG on admission (leads V1, V2, V3)
Takotsubo cardiomyopathy – a case report of a 62-year-old female with several severe comorbidities
17 Medycyna rodzinna 1/2019
exclusion principle was based on negative coronary an-giography which was urgently performed. Apical akinesia, which was diagnosed in this case, is the most frequent va-riant concerning 82% takotsubo cardiomyopathy patients. Other possibility variants are: basal, midventicular or focal type (6)According to International Takotsubo Registry, an emotional trigger of Takotsubo cardiomyopathy occurs in almost 28% of patients (2). We can assume that both myasthenia exacerbation with consecutive neurological hospitalization and the necessity of surgical treatment, due to kidney malignancy, could have provided emotional factors leading to the development of takotsubo cardio-myopathy.
Conclusions
A clear distinction to be drawn between an acute coro-nary syndrome and TTC is significantly important, also in terms of post-hospitalization treatment. Patients after an
Tab. 1. Laboratory tests’ results
Variable Value Reference value
haemoglobin [g/dl] 14.7 12-16 haematocrit [%] 43.6 37-47 red blood cells [106/µl] 4.72 4-5
white blood cells [103/µl] 5.74 4-10
platelets [1/µl] 195 000 140 000-400 000 potassium [mmol/l] 4.69 3.5-5.1 sodium [mmol/l] 142 136-146 magnesium [mg/dl] 2.2 1.9-2.5 total cholesterol [mg/dl] 162 130-200 LDL-cholesterol [mg/dl] 97 0-135 HDL-cholesterol [mg/dl] 44 ≥ 40 triglyceride [mg/dl] 106 0-150 ALAT [U/l] 32 0-35 ASPAT [U/l] 40 0-31 serum creatinine [mg/dl] 0.71 0.7-1.1
Fig. 8. Follow-up ECG (leads V4, V5, V6) Fig. 5. Follow-up ECG (leads I, II, III)
Fig. 6. Follow-up ECG (leads aVR, aVL, aVF)
Fig 7. Follow-up ECG (leads V1, V2, V3)
episode of stress-induced cardiomyopathy do not require DAPT, which is further crucial in avoiding a higher risk of perioperative bleeding in surgically treated patients.
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References
Sharkey SW, Lesser JR, Maron MS et al.: Why not just call it tako-tsubo cardiomyopa-1.
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Templin C, Ghadri JR, Diekmann J et al.: Clinical features and outcomes of Takotsu-2.
bo (stress) cardiomyopathy. NEJM 2015; 373(10): 929-938.
Ghadri JR, Sarcon A, Diekmann J et al.: Happy heart syndrome: role of positive emo-3.
tional stress in takotsubo syndrome. EHJ 2016; 37(37): 2823-2829.
Prasad A, Lerman A, Rihal CS: Apical ballooning syndrome (Tako-Tsubo or stress car-4.
diomyopathy): a mimic of acute myocardial infarction. AHJ 2008; 155(3): 408-417. Gianni M, Dentali F, Grandi AM et al.: Apical ballooning syndrome or takotsubo 5.
cardiomyopathy: a systematic review. EHJ 2006; 27(13): 1523-1529.
Barbaryan A, Bailuc SL, Patel K et al.: An emotional stress as a trigger for reverse 6.
Takotsubo cardiomyopathy: A case report and literature review. Am J Case Rep 2016; 17: 137.
Konflikt interesów Conflict of interest
Brak konfliktu interesów None
Adres do korespondencji
Wojciech Kosowski Klinika Kardiologii
Uniwersytecki Szpital Kliniczny we Wrocławiu
ul. Borowska 213, budynek A, 50-556 Wrocław tel.: +48 (71) 736-42-42 wojciech.kosowski@student.umed.wroc.pl kosowskiw@gmail.com nadesłano: 21.01.2019 zaakceptowano do druku: 11.02.2019
