Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Takotsubo Cardiomyopathy: Broken Heart Syndrome Shweta Bhatnagar, OMS-III, MPH. Ira Gordon Early, MD, MPH, FACOEM Edward Via College of Osteopathic Medicine – Carolinas Campus Spartanburg, SC Spartanburg Regional Healthcare System Spartanburg SC

Introduction/Background

Conclusions

Case Presentation Discussion

Impact of Chronic Stressors: The presence of an emotional or physical trigger is frequent, but not diagnostic of Takotsubo cardiomyopathy. 4 Physical and emotional triggers are not a standard component of history taking for patient’s presenting with ACS features, but can be helpful in developing a differential diagnosis inclusive of Takotsubo cardiomyopathy. Management of chronic stressors as a lifestyle intervention may warrant further investigation as well. Management of Takotsubo: Optimal medical regimens for Takotsubo cardiomyopathy have not been studied, and management often depends on the hemodynamic status of the patient in question. 4 Hemodynamically stable patients are often treated with standard medications for HFrEF, and anti coagulation to prevent thromboembolism is administered similar to patients who are post myocardial infarction. 4 In this case, patient was treated with beta blocker therapy (metoprolol-succinate), and antiplatelet therapy (clopidogrel and aspirin) on discharge, as her blood pressure dropped with treatment of ACE-inhibitor during her hospital stay.

Figure 1: EKG of Patient on Initial Presentation to ED

Stress cardiomyopathy (also called Takotsubo cardiomyopathy) is a syndrome characterized by transient regional systolic dysfunction, principally, of the left ventricle (LV), mimicking myocardial infarction (MI), but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. 1 The disease tends to affect older, post-menopausal women most frequently, though the etiology of this is not well elucidated. 1 Diagnosis of stress cardiomyopathy is seen as left ventricular dysfunction, made by echocardiography or left ventriculography, which reveals regional wall motion abnormalities (hypokinesis, akinesis, or dyskinesis) in a characteristic pattern. 3 Stress cardiomyopathy is generally a transient disorder that is managed with supportive therapy. 2 Although most patients with stress cardiomyopathy recover, the risk of severe in-hospital complications is similar to that in patients with acute coronary syndrome. 4 Recommendations for anticoagulation to prevent thromboembolism in patients with stress cardiomyopathy with LV thrombus or severe LV systolic dysfunction are similar to those for patients post myocardial infarction. 5 Initial Presentation: Patient is a 57 year old female with history of hyperlipidemia and hypertension, who presented to the ED with symptoms of midsternal chest pain while preparing to go to work. She also reported nausea and two episodes of vomiting. Of note, the patient reported a recent stressful event in her life. In the ED, patient was hypertensive to 166/100, but vital signs were otherwise unremarkable. Workup/Diagnosis: The patient had an EKG which suggested ST segment elevations in leads V2 and V3, suggestive of an ST segment elevation myocardial infarction (STEMI). Initial labs in the ED were significant for elevated troponin of 7014 pg/mL She was treated with heparin and nitroglycerin in the ED. Patient was taken for diagnostic cardiac catheterization and possible percutaneous intervention immediately. On catheterization, patient was not found to have any significant stenoses in the coronary arteries, but was found to have a wall motion abnormality of the anterior wall involving the mid to distal segment, consistent with either Takotsubo cardiomyopathy or spontaneous coronary artery dissection. She then received echocardiogram which demonstrated mildly reduced left ventricular systolic function (ejection fraction of 45%), with the mid-distal wall segments showing apical akinesis, consistent with Takotsubo cardiomyopathy. Treatment: Patient was initially put on IV heparin, then switched to IV metoprolol. She was discharged on aspirin 81 mg, clopidogrel 75 mg, metoprolol succinate 25 mg TID, atorvastatin, and nitroglycerin as needed (PRN). Case Presentation

Context/Impact

Key Findings: ST segment elevations in leads V2 and V3, suggestive STEMI (ST segment elevation myocardial infarction) Most common EKG findings in Takotsubo cardiomyopathy include: 7

1. ST segment elevation (43.7%) 2. ST segment depression (7.7%) 3. QT prolongation, T wave inversion Figure 2: Takotsubo Cardiomyopathy Illustration 8

Takotsubo cardiomyopathy is a finding that occurs in approximately 1-2% of individuals presenting with troponin positive acute coronary syndrome. 2 The condition presents with a wide variety of EKG changes that may mimic ACS, however, ST segment elevation is only seen in 43.7% of patients. 7 Levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP are elevated in 82.9% of patients with Takotsubo cardiomyopathy. 7 However, patient’s BNP levels collected post-discharge were within normal limits (29.0 pg/mL).

Figure 2: Echo Demonstrating Takotsubo Cardiomyopathy 9

References

1. Sato, H, Taiteishi, et al. Takotsubo-type cardiomyopathy due to multivessel spasm. In: Clinical aspect of myocardial injury: From ischemia to heart failure, Kodama, K, Haze, K, Hon, M (Eds), Kagakuhyouronsha, Tokyo 1990. p.56. 2. Gianni M, Dentali F, Grandi AM, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006; 27:1523. 3. Prasad A, Dangas G, Srinivasan M, et al. Incidence and angiographic characteristics of patients with apical ballooning syndrome (takotsubo/stress cardiomyopathy) in the HORIZONS-AMI trial: an analysis from a multicenter, international study of ST-elevation myocardial infarction. Catheter Cardiovasc Interv 2014; 83:343. 4. Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004; 141:858. 5. Vallabhajosyula S, Dunlay SM, Murphree DH Jr, et al. Cardiogenic Shock in Takotsubo Cardiomyopathy VersusAcute Myocardial Infarction: An 8-Year National Perspective on Clinical Characteristics, Management, and Outcomes. JACC Heart Fail 2019; 7:469. 6. Kim H, Senecal C, Lewis B, et al. Natural history and predictors of mortality of patients with Takotsubo syndrome. Int J Cardiol 2018; 267:22. 7. Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929. 8. Cleveland Clinic. Broken Heart Syndrome 2022. 9. Wojciuk , J. An unusual ‘heart attack’ – Takotsubo cardiomyopathy. The British Journal of Cardiology 2009.

Patient’s ECG Findings: Apical akinesis of the mid -distal left ventricular wall segments. Common Echocardiogram Findings: Takotsubo cardiomyopathy demonstrates regional wall abnormalities on echocardiogram, most commonly systolic apical ballooning of the left ventricle (81.7%). Less commonly, patients demonstrate hypokinesis of the mid ventricle with apex sparing, or basal hypokinesis with sparing of the mid ventricle and apex. 7 Table 1: Diagnostic Criteria 4 1. Transient LV systolic dysfunction (hypokinesis, akinesis, or dyskinesis). Diagnostic Approach: All 4 diagnostic criteria listed in Table 1 must be met to confirm diagnosis of

Takotsubo. 4 For patients who present with acute ST segment elevations who have availability to undergo percutaneous coronary intervention (PCI), angiography should be conducted as usual to rule out coronary obstructive disease. 3 In this case, the patient underwent PCI which demonstrated no significant coronary stenosis.

2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture. 3. New electrocardiographic abnormalities (either ST-segment elevation and/or T wave inversion) or modest elevation in cardiac troponin. 4. Absence of pheochromocytoma or myocarditis.

Authorization for Medical Case Study with De-Identified Medical Information was obtained

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2024 Research Recognition Day