Naslov
Takotsubo cardiomyopathy mimicking NSTEMI – diagnosis confirmed by cardiac MRI

Autori
Ivanac, Irena ; Škorak, Ivan ; Hrabak, Maja ; Miličić, Davor

Vrsta, podvrsta i kategorija rada
Sažeci sa skupova, sažetak, znanstveni

Izvornik
Liječnički vjesnik 2008 ; 130 (suplement 3) / - , 2008, 58-59

Skup
7. kongres Hrvatskog kardiološkog društva s međunarodnim sudjelovanjem

Mjesto i datum
Opatija, Hrvatska, 16.10.2008. - 19.10.2008

Vrsta sudjelovanja
Poster

Vrsta recenzije
Domaća recenzija

Ključne riječi
Takotsubo cardiomyopathy; magnetic resonance imaging

Sažetak
Background: Takotsubo cardiomyopathy (TC), stress induced cardiomyopathy, „ broken heart syndrome" or transient left ventricular (LV) apical ballooning syndrome is rare and unique form of reversible cardiomyopathy. It is characterized by transient wall motion abnormalities involving LV apex and mid-ventricle in the absence of obstructive coronary artery disease. The syndrome was initially reported in Japanese population in the early 1990s and today it has been reported worldwide, most commonly in postmenopausal women after emotional or physical stress. The exact prevalence of this entity is still unknown. The symptoms (ischemic-like chest pain or dyspnea), ECG changes (ST segment elevation or T wave inversion) and mildly elevated cardiac biomarkers often mimic acute coronary syndromes. Some of the proposed patophysiologic mechanisms include transient multivessel epicardial coronary vasospasm, impaired coronary microcirculation, abnormal sympathetic innervation, myocardial damage due to excessive catecholamine excretion or neurogenically mediated myocardial stunning. Case report: A 69-year-old woman was admitted to our Coronary Care Unit because of sudden onset of chest pain, occurred after receiving information on her husband's sudden death. Patient had a history of non-significant coronary artery disease, hypertension, depression and hypothyreosis. She presented with acute onset of intermittent chest pain which lasted for five hours prior to admission. Upon admission her blood pressure was 150/100 mmHg and ECG showed sinus rhythm, 96/min, LAH and RBBB (earlier known), negative T waves in III, aVF and V1 as well as Q in inferior leads. Cardioselective biomarkers were mildly elevated as follows: CK 295, MB 23, LDH 242 and Troponin T 0, 9. She was diagnosed as NSTEMI and treated with aspirin, clopidogrel, LMWH, statin, beta-blocker and ACE-inhibitor. A transthoracic echocardiography revealed akinesis of the apex and distal 2/3 of all LV walls with hyperkinesis of the basal segments and ejection fraction of 40%. LV hypertrophy (IVS 1, 3 cm, LVPW 1, 3 cm) and mild mitral regurgitation were also presented. TC was suspected. The next day coronary angiography was performed and showed non-significant lesions of mid LAD and distal RCA (known before) with no evidence of thrombosis. LV angiography demonstrated the characteristic morphology of apical ballooning. Cardiac enzymes and Troponin T were normalized on the 5th day of hospitalization. ECG showed progression of T wave inversion in all precordial leads which didn't resolve during hospitalization period. Control echocardiography 7 days after admission showed no resolution of regional systolic function of mid and apical segments of the LV and we decided to perform a cardiac MRI (CMR). There were no early perfusion abnormalities as well as no late gadolinium enhancement on the CMR and the diagnosis of TC was confirmed. The in-hospital course was uneventful and patient was discharged on the 7th day of hospitalization. At the follow up, 6 weeks after the presentation, echocardiography showed almost full recovery of the regional systolic function in mid and apical LV segments with presence of postsystolic thickening in all affected regions and with still present mild hypokinesis of apical third of the anterior and lateral wall. The next echocardiography examination will be performed in a 1 month period. Conclusion: Some reports suggest that TC accounts for 1, 5-2, 2% of patients presenting with symptoms that initially appear to be an ACS. In cases of unclear diagnosis, especially in cases of suspected spontaneous coronary thrombolysis, cardiac MRI is of crucial diagnostic value. In TC, late gadolinium enhancement is absent, denoting the absence of detectable ischemic myocardial necrosis. Clinicians should be aware of this syndrome because of extensive distribution of wall motion abnormalities which can be accompanied by severe complications (dynamic obstruction of the LVOT, pulmonary edema, mitral regurgitation, mural thrombus formation, arrhythmias, cardiogenic shock or in rare cases even death). Still, prognosis is usually favorable with complete recovery of LV function. It can occur several days after presentation but in the vast majority of cases normalization of LV function occurs over the next 1 to 3 months. No trial data are available for treatment of this syndrome but it is reasonable to consider long-term beta-blocker therapy with the goal of preventing recurrence, as well as aspirin, ACE-inhibitors, short term anticoagulation and diuretics, as needed.

Izvorni jezik
Engleski

Znanstvena područja
Kliničke medicinske znanosti

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