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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 102-104

Takotsubo cardiomyopathy: A hype or a hypo?


1 Department of Cardiology, Kasturba Medical College (KMC), Manipal University, Manipal, Karnataka, India
2 Department of Medicine, Kasturba Medical College (KMC), Manipal University, Manipal, Karnataka, India

Date of Web Publication20-Jun-2017

Correspondence Address:
Mugula Sudhakar Rao
Department of Cardiology, Kasturba Medical College (KMC), Manipal University, Manipal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449x.208553

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  Abstract 

A 51-year-old female was admitted with subarachnoid hemorrhage (SAH) secondary to aneurysmal rupture of the anterior communicating artery (ACoA). Initial echocardiogram was normal. She underwent aneurysmal clipping and the initial postoperative period was uneventful. On the 9th postoperative day, she developed sudden-onset hypotension. Electrocardiogram (ECG) was performed suggestive of acute anterior wall myocardial infarction. Echocardiogram revealed apical ballooning with basal hypercontractility consistent with stress cardiomyopathy. To confirm the diagnosis, coronary angiography was performed, which was normal. She was treated conservatively; however, on the 11th postoperative day she had a sudden cardiac arrest and succumbed to death.

Keywords: Broken heart syndrome, subarachnoid hemorrhage, Takotsubo cardiomyopathy


How to cite this article:
Ramachandran P, Naik N, Jayaram AA, Rao MS. Takotsubo cardiomyopathy: A hype or a hypo?. Heart India 2017;5:102-4

How to cite this URL:
Ramachandran P, Naik N, Jayaram AA, Rao MS. Takotsubo cardiomyopathy: A hype or a hypo?. Heart India [serial online] 2017 [cited 2021 Dec 2];5:102-4. Available from: https://www.heartindia.net/text.asp?2017/5/2/102/208553


  Introduction Top


The prevalence of Takotsubo cardiomyopathy is 0.02% among all hospitalized patients. Out of all cases with subarachnoid hemorrhage, stress cardiomyopathy is found in 0.8% of the cases. Subarachnoid hemorrhage (SAH), as in our case is rarely described in the literature. To our knowledge, till now less than 40 cases of SAH and stress cardiomyopathy have been reported. Though known in the literature to carry a favorable prognosis, rarely patients may have a dismal prognosis as described in our case. We focus the importance of early diagnosis of the condition as soon as the hemodynamic impairment sets in.


  Case Report Top


A 51-year-old female patient was admitted to the emergency department with vomiting, headache, and one episode of loss of consciousness. General physical examination at the time of admission was unremarkable. Neurological evaluation at the time of admission showed paraparesis and the patient is in altered sensorium. Her baseline blood investigations and electrocardiogram (ECG) were normal. Plain computed tomography of the brain showed large intraparenchymal hemorrhage with perilesional edema in the bilateral frontal lobes in the parafalcine location with interhemispheric fissure extension, intraventricular extension with obstructive hydrocephalus [Figure 1]. Left internal carotid artery angiogram was performed, which showed a saccular aneurysm measuring 7.5 × 6.6 × 7.0 mm arising from the ACoA [Figure 2]. She was stabilized and taken up for surgery. Intraoperatively aneurysm ruptured; it was controlled and clipped. The postoperative period was uneventful and the patient made good recovery. On the 9th postoperative day, she developed sudden-onset hypotension. ECG showed ST-segment elevation in Lead I, aVL, and V2-V6 [Figure 3]. Troponin T was 0.946 ng/mL. Echocardiography revealed apical ballooning and hyperkinesis of the basal segment [Figure 4]. Coronary angiogram showed normal coronary arteries [Figure 5]. A diagnosis of Takotsubo cardiomyopathy was made and she was managed conservatively. However, on the 11th postoperative day the patient had a sudden cardiac arrest and succumbed to death.
Figure 1: Computed tomography of the brain showing bilateral frontal intraparenchymal hemorrhage with interhemispheric fissure extension, intraventricular extension with obstructive hydrocephalus, and subarachnoid hemorrhage

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Figure 2: Left internal carotid artery angiogram showing a saccular aneurysm measuring 7.5 × 6.6 × 7.0 mm arising from the anterior communicating artery

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Figure 3: Electrocardiogram showing ST-segment elevation in leads V2-V6 suggestive of anterior wall myocardial infarction

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Figure 4: Echocardiogram in apical 4-chamber view demonstrating LV cavity in systole and diastole. Apical ballooning in systole is due to hypokinesia of apex and basal hypercontractility

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Figure 5: Coronary angiogram demonstrating normal epicardial coronaries (right side of the figure showing normal left anterior descending artery in left anterior oblique view, whereas the left side of the figure showing normal right coronary artery)

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  Discussion Top


Takotsubo cardiomyopathy is a reversible stress-related cardiomyopathy precipitated by acute emotional stress and severe emotional stress in females of postmenopausal age. It is characterized by the onset of an acute coronary syndrome associated with a specific and reversible apical and mid ventricular wall motion abnormality despite the lack of coronary artery disease.[1] The name Takotsubo is a Japanese name for an octopus trap, which mimics the typical apical ballooning aspect of the left ventricle during the systole.

The clinical presentation of Takotsubo is similar to acute myocardial infarction with typical chest pain and ECG abnormalities. ST-segment elevation on ECG is the most common finding. Typically, echocardiography shows apical and mid-ventricular wall motion abnormalities and hyperkinesis of the basal myocardial segments. These wall motion abnormalities does not correspond to a single epicardial coronary distribution.

“Mayo Clinic” diagnostic criteria for Takotsubo cardiomyopathy includes:

  1. Transient left ventricular (LV) wall motion abnormalities involving the apical and/or mid-ventricular myocardial segments with wall motion abnormalities extending beyond a single epicardial coronary artery distribution
  2. Absence of obstructive epicardial coronary artery disease that could be responsible for the observed wall motion abnormality
  3. ECG abnormalities such as transient ST-segment elevation and/or diffuse T-wave inversion and QT prolongation associated with a slight troponin elevation
  4. The lack of proven pheochromocytoma and myocarditis.


SAH-induced left ventricular dysfunction is also referred to as “neurogenic stunned myocardium” or “neurogenic stress cardiomyopathy” as the cardiac dysfunction improves spontaneously with time. The prevalence of Takotsubo cardiomyopathy is 0.02% among all hospitalized patients and 0.8% among all patients of aneurysmal SAH.[2] Sudden hemodynamic dysfunction in a patient of SAH should raise the suspicion of Takotsubo cardiomyopathy, the definitive diagnosis of which can be achieved only with the help of coronary angiography.

The exact mechanism of stress cardiomyopathy is not known. However, emotional stress by stimulating the amygdala and hippocampus activates the medullary autonomic center, resulting in the release of catecholamines from the adrenal medulla. Cardiotoxicity is more with the catecholamines released neurally into the heart than those reaching the heart through blood stream. Catecholamines decrease the myocardial viability through cyclic adenosine monophosphate (AMP)-mediated free radical injury, resulting in ventricular dysfunction.[3]

Medical management includes standard heart failure medications such as angiotensin-converting-enzyme (ACE) inhibitors, beta blockers, diuretics, and vasopressors. Beta blockers can be continued on a long-term basis to prevent the recurrence by reducing the effects of adrenaline and other stress hormones. Most patients recover fully in 2 months. Rarely reported complications include arrhythmias, left ventricular thrombus formation, and left ventricular wall rupture.

Acknowledgement

We would like to thank Dr. Sumit Agarwal for his immense help during the diagnosis of the case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pernicova I, Garg S, Bourantas CV, Alamgir F, Hoye A. Takotsubo cardiomyopathy: A review of the literature. Angiology 2010;61:166-73.  Back to cited text no. 1
    
2.
Deshmukh A, Kumar G, Pant S, Rihal C, Murugiah K, Mehta JL. Prevalence of Takotsubo cardiomyopathy in the United States. Am Heart J 2012;164:66-71.e1.  Back to cited text no. 2
    
3.
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;119:10-7.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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