International Journal of Cardiology 177 (2014) e161–e162
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letters to the Editor
Adrift: Takotsubo cardiomyopathy in an old woman in distress while taking a swim off coast Luisa De Gennaro a, Natale Daniele Brunetti b,⁎, Massimo Ruggiero a, David Rutigliano a, Cosimo Campanella a, Francesco Santoro b, Andrea Guaricci b, Matteo Di Biase b, Pasquale Caldarola a a b
Ospedale San Paolo, Bari, Italy Cardiology Department, University of Foggia, Italy
a r t i c l e
i n f o
Article history: Received 20 August 2014 Accepted 26 August 2014 Available online 30 August 2014 Keywords: Takotsubo cardiomyopathy Swimming Drifting
Takotsubo cardiomyopathy (TTC) is a form of acute and reversible heart failure presumably triggered by either emotional or physical stressors, which mainly involves the left ventricle with a typical echocardiographic pattern (apical ballooning and basal hyperkinesis) [1]. Even though the underlying mechanism is still not completely known [2,3], catecholamine toxicity has been proposed as the main pathophysiologic driver [4]. A 79-year-old woman, with a history of breast cancer, was referred to the emergency room for acute dyspnea and chest pain. The woman had been rescued by a life-guard while taking a swim off the coast. Dragged by the stream during a warm Italian sunny day on the seaside, the woman was not able to come back to shore. The life-guard noticed the woman in distress and rescued immediately. Back to shore, the woman began to have shortness of breath and chest pain. At admission to acute cardiac care unit ECG revealed sinus rhythm, QT-prolongation, left ventricular (LV) hypertrophy, incomplete right bundle branch block, left anterior hemi-block and negative T-waves (Fig. 1), while arterial blood pressure was 85/60 mm Hg. Physical examination showed rales while chest radiography confirmed the presence of pulmonary edema. Blood test revealed increased troponin-I level (5.6 ng/ml, normal values b0.10). At echocardiographic examination, a severe systolic dysfunction (LV ejection fraction (LVEF) = 25%) with apical dyskinesis and basal hyperkinesis, resembling apical ballooning typical of TTC, was unexpectedly found. Coronary angiography, immediately performed, did not ⁎ Corresponding author at: Viale Pinto 1 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 881745424. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2014.08.148 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
show any sign of significant coronary atherosclerosis. The patient was treated with fluid therapy and diuretics and gradually improved: the woman was discharged two weeks later with a complete recovery of LV systolic function. We report a case of TTC probably triggered by an unusual stressing situation; a woman dragged adrift by the stream while taking a swim off coast. The woman was in distress trying to come back to shore: the condition, characteristically joining both an emotional and a physical stressor, may have led to the onset of TTC. Cases of TTC induced by near-drowning have been previously reported [5,6]. Also diving was linked with TTC [7]. However, our woman, a very skilled swimmer despite her older age, was never really at risk of drowning. In spite of this, the acute distress associated with drifting and the sustained ineffective effort to swim back to shore were presumably responsible for the onset of TTC. Moreover, the situation may have been precipitated by the dehydration expectable in a warm sunny Italian day on seaside. Conflict of interest The authors report no relationships that could be construed as a conflict of interest References [1] Tsuchihashi K, Ueshima K, Uchida T, et al. Angina pectoris-myocardial infarction investigations in Japan. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 2001;38:11–8. [2] Brunetti ND, Ieva R, Rossi G, et al. Ventricular outflow tract obstruction, systolic anterior motion and acute mitral regurgitation in Tako-Tsubo syndrome. Int J Cardiol 2008;127:e152–7. [3] Ieva R, Santoro F, Ferraretti A, et al. Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: in the beginning was basal hyperkinesis? Int J Cardiol 2013;167:e55–7. [4] Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. [5] Citro R, Patella MM, Bossone E, Maione A, Provenza G, Gregorio G. Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy. J Cardiovasc Med 2008;9:501–5. [6] Citro R, Previtali M, Bossone E. Tako-tsubo cardiomyopathy and drowning syndrome: is there a link? Chest 2008;134:469. [7] Chenaitia H, Coullange M, Benhamou L, Gerbeaux P. Takotsubo cardiomyopathy associated with diving. Eur J Emerg Med 2010;17:103–6.
e162
L. De Gennaro et al. / International Journal of Cardiology 177 (2014) e161–e162
Fig. 1. Admission electrocardiogram showing sinus rhythm, left ventricular hypertrophy, QT-prolongation, incomplete right bundle branch block, left anterior hemi-block and negative T-waves.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letters to the Editor
Adrift: Takotsubo cardiomyopathy in an old woman in distress while taking a swim off coast Luisa De Gennaro a, Natale Daniele Brunetti b,⁎, Massimo Ruggiero a, David Rutigliano a, Cosimo Campanella a, Francesco Santoro b, Andrea Guaricci b, Matteo Di Biase b, Pasquale Caldarola a a b
Ospedale San Paolo, Bari, Italy Cardiology Department, University of Foggia, Italy
a r t i c l e
i n f o
Article history: Received 20 August 2014 Accepted 26 August 2014 Available online 30 August 2014 Keywords: Takotsubo cardiomyopathy Swimming Drifting
Takotsubo cardiomyopathy (TTC) is a form of acute and reversible heart failure presumably triggered by either emotional or physical stressors, which mainly involves the left ventricle with a typical echocardiographic pattern (apical ballooning and basal hyperkinesis) [1]. Even though the underlying mechanism is still not completely known [2,3], catecholamine toxicity has been proposed as the main pathophysiologic driver [4]. A 79-year-old woman, with a history of breast cancer, was referred to the emergency room for acute dyspnea and chest pain. The woman had been rescued by a life-guard while taking a swim off the coast. Dragged by the stream during a warm Italian sunny day on the seaside, the woman was not able to come back to shore. The life-guard noticed the woman in distress and rescued immediately. Back to shore, the woman began to have shortness of breath and chest pain. At admission to acute cardiac care unit ECG revealed sinus rhythm, QT-prolongation, left ventricular (LV) hypertrophy, incomplete right bundle branch block, left anterior hemi-block and negative T-waves (Fig. 1), while arterial blood pressure was 85/60 mm Hg. Physical examination showed rales while chest radiography confirmed the presence of pulmonary edema. Blood test revealed increased troponin-I level (5.6 ng/ml, normal values b0.10). At echocardiographic examination, a severe systolic dysfunction (LV ejection fraction (LVEF) = 25%) with apical dyskinesis and basal hyperkinesis, resembling apical ballooning typical of TTC, was unexpectedly found. Coronary angiography, immediately performed, did not ⁎ Corresponding author at: Viale Pinto 1 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 881745424. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2014.08.148 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
show any sign of significant coronary atherosclerosis. The patient was treated with fluid therapy and diuretics and gradually improved: the woman was discharged two weeks later with a complete recovery of LV systolic function. We report a case of TTC probably triggered by an unusual stressing situation; a woman dragged adrift by the stream while taking a swim off coast. The woman was in distress trying to come back to shore: the condition, characteristically joining both an emotional and a physical stressor, may have led to the onset of TTC. Cases of TTC induced by near-drowning have been previously reported [5,6]. Also diving was linked with TTC [7]. However, our woman, a very skilled swimmer despite her older age, was never really at risk of drowning. In spite of this, the acute distress associated with drifting and the sustained ineffective effort to swim back to shore were presumably responsible for the onset of TTC. Moreover, the situation may have been precipitated by the dehydration expectable in a warm sunny Italian day on seaside. Conflict of interest The authors report no relationships that could be construed as a conflict of interest References [1] Tsuchihashi K, Ueshima K, Uchida T, et al. Angina pectoris-myocardial infarction investigations in Japan. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 2001;38:11–8. [2] Brunetti ND, Ieva R, Rossi G, et al. Ventricular outflow tract obstruction, systolic anterior motion and acute mitral regurgitation in Tako-Tsubo syndrome. Int J Cardiol 2008;127:e152–7. [3] Ieva R, Santoro F, Ferraretti A, et al. Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: in the beginning was basal hyperkinesis? Int J Cardiol 2013;167:e55–7. [4] Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. [5] Citro R, Patella MM, Bossone E, Maione A, Provenza G, Gregorio G. Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy. J Cardiovasc Med 2008;9:501–5. [6] Citro R, Previtali M, Bossone E. Tako-tsubo cardiomyopathy and drowning syndrome: is there a link? Chest 2008;134:469. [7] Chenaitia H, Coullange M, Benhamou L, Gerbeaux P. Takotsubo cardiomyopathy associated with diving. Eur J Emerg Med 2010;17:103–6.
e162
L. De Gennaro et al. / International Journal of Cardiology 177 (2014) e161–e162
Fig. 1. Admission electrocardiogram showing sinus rhythm, left ventricular hypertrophy, QT-prolongation, incomplete right bundle branch block, left anterior hemi-block and negative T-waves.
