Accepted Manuscript Serial Classic and Inverted Pattern Takotsubo Cardiomyopathy in a Middle-aged Woman Fátima Rodriguez, M.D., M.P.H Ashwin S. Nathan, M.D Amol S. Navathe, M.D., Ph.D Nina Ghosh, M.D Pinak B. Shah, M.D PII:

S0828-282X(14)00231-1

DOI:

10.1016/j.cjca.2014.04.002

Reference:

CJCA 1177

To appear in:

Canadian Journal of Cardiology

Received Date: 7 February 2014 Revised Date:

1 April 2014

Accepted Date: 2 April 2014

Please cite this article as: Rodriguez F, Nathan AS, Navathe AS, Ghosh N, Shah PB, Serial Classic and Inverted Pattern Takotsubo Cardiomyopathy in a Middle-aged Woman, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2014.04.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Serial Classic and Inverted Pattern Takotsubo Cardiomyopathy in a Middle-aged

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Woman

Category: Case Report

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Authors: Fátima Rodriguez, M.D., M.P.H.1, Ashwin S. Nathan, M.D. 1, Amol S.

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Navathe, M.D., Ph.D 1,2, , Nina Ghosh, M.D.3, and Pinak B. Shah, M.D.2

Author Affiliations: 1 Department of Medicine, Brigham and Women’s Hospital, Boston, MA; 2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadephia, PA; 3Division of Cardiovascular Medicine, Brigham and Women’s Hospital,

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Boston, MA

Address for Correspondence:

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Fátima Rodriguez, MD, MPH Brigham and Women’s Hospital Department of Internal Medicine 75 Francis Street Boston, MA 02115. ([email protected]). Phone: 617-732-5000. Fax: 617-278-6906.

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Brief Summary: A 56 year-old woman with no significant past medical history was diagnosed with recurrent Takotsubo cardiomyopathy with variations in ventricular regional involvement.

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She presented on three separate occasions with these findings, each presentation provoked by an emotional stressor.

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Abstract:

We report the case of a 56 year-old woman with no significant past medical history who

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was diagnosed with recurrent Takotsubo cardiomyopathy with variations in ventricular regional involvement including both the classic and inverted patterns. She presented on three separate occasions with these findings; emotional stressors provoked all presentations. We present echocardiography, cardiac catheterization, and MRI images

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from her consecutive presentations. This case of emotional stress repeatedly eliciting both classic and inverted forms of Takotsubo cardiomyopathy within the same patient highlights the importance of elucidating the pathological mechanisms of regional

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ventricular dysfunction.

A 56-year-old woman with a prior history of Takotsubo cardiomyopathy presented with one hour of chest tightness in the setting of severe occupational stress. Associated symptoms included palpitations, a feeling of panic, radiation of chest tightness to the left jaw and both elbows, and nausea. She had elevated cardiac biomarkers with a peak troponin T assay of 0.95 ng/dL. Electrocardiogram revealed ST segment elevations of

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less than 1 millimeter in the lateral precordial leads. Transthoracic echocardiography (TTE) revealed akinesis and systolic ballooning of the distal left ventricular segments and the entire apex and hypercontractile basal segments (Panel A). Coronary angiography

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showed non-obstructive disease, and left ventriculography confirmed distal and apical

dyskinesis (Panel B). She was treated with a beta-blocker and an ACE-inhibitor. Repeat TTE 17 days later demonstrated normalization of left ventricular systolic function. Of

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note, she had experienced a similar episode in the setting of a stressful event seven years previously, which manifested on echocardiography and cardiac catheterization with a

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classic Takotsubo cardiomyopathy pattern.

Two months later, she presented with 45 minutes of chest pain after an emotional argument. She had elevated cardiac biomarkers with a peak troponin T assay of 0.32

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ng/dL. Electrocardiogram revealed T wave flattening in the lateral precordial leads with PR depression in leads II, III and aVF. TTE revealed left ventricular dysfunction with akinesis of basal myocardial segments and hyperkinesis of the mid- and apical segments

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(Panel C). Cardiac MRI confirmed basal segment, mid-inferior, and inferolateral segmental hypokinesis with the remaining segments noted to be hyperkinetic, and normal

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right ventricular function. A pattern of myocardial edema by T2-weighted imaging in all the basal segments (Panel D) with no late gadolinium enhancement confirmed the diagnosis of Takotsubo cardiomyopathy with an inverted pattern.1 At a follow-up visit four weeks later, the patient remained symptom-free and repeat transthoracic echocardiography demonstrated normalization of left ventricular function and no evidence of wall motion abnormalities. Her beta blocker dose was increased, and she was

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started on an antidepressant in order to prevent future episodes based on clinician experience; however, there is no evidence to support the use of long-term medical

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therapy to reduce the risk of recurrence of Takotsubo cardiomyopathy.

Classically Takotsubo cardiomyopathy or “apical ballooning syndrome,” presents with anteroapical akinesis and compensatory hypercontractility of the basal segments.2 A rare

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variant of Takotsubo cardiomyopathy presents with hypokinesis of the base of the heart with preserved apical function, known as “inverted Takotsubo”.3 Inverted pattern

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Takotsubo cardiomyopathy has been described in patients with pheochromocytoma,4 alcohol-induced pancreatitis, and amphetamine or cannibis use.5 There are limited published reports of both typical and inverted patterns of stress-induced cardiomyopathy occurring in the same patient exclusively from an emotional stressor. The

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pathophysiology of Takotsubo has not been clearly elucidated; catecholamine surge and β1 adrenoreceptor involvement is hypothesized as the mechanism in the classical pattern.2 However, multiple episodes of Takotsubo cardiomyopathy with varying

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ventricular regional involvement within the same patients have been suggested to invoke additional mechanisms, such as endocanniboids via direct and cannabinoid receptor type

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1 (CB1)-mediated effects.5 This patient demonstrated both patterns over just two months, with normalization of left ventricular function in the interval, suggesting that emotional stress may act through multiple mechanisms to give rise to varying patterns of ventricular involvement.

Funding Sources:

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None

Disclosures:

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The authors of this paper do not have any relevant financial disclosures related to the

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findings presented in this paper.

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References: 1. Eitel I, von Knobelsorff-Brenkenhoff F, Bernhardt P, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA 2011;306:277-86.

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2. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. American Heart Journal 2007;155:408-17.

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3. Van de Walle SO, Gevaert SA, Gheeraert PJ, De Pauw M, Gillebert TC. Transient stress-induced cardiomyopathy with an “inverted Takotsubo” contractile pattern. Mayo Clin Proceed 2006;81:1499-502.

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4. Sanchez-Recalde A, Costero O, Oliver JM, Iborra C, Ruiz E, Sobrino JA. Images in cardiovascular medicine. Pheochromocytoma-related cardiomyopathy: inverted Takotsubo contractile pattern. Circulation 2006;113:e738-9.

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5. Kaushik M, Alla VM, Madan R, Arouni AJ, Mohiuddin SM. Images in cardiovascular medicine. Recurrent stress cardiomyopathy with variable regional involvement. Insights into etiopathogenetic mechanisms. Circulation 2011;124:e556-7.

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Figure Legends:

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Figure 1: Multimodality imaging of stress induced cardiomyopathy presenting as both classic (Panel A and Panel B) and “inverted” (Panel C and Panel D) patterns.

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A. Echocardiographic apical 4-chamber view showing apical ballooning and basal

hyperkinesis in diastole and systole. B. Left ventriculography showing dyskinesis with

classic Takosubo pattern at end-diastole and end-systole. C. Echocardiographic apical 4-

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chamber view showing akinesis of basal myocardial segments and hyperkinesis of the

mid- and apical segments at end diastole and end systole. D. Cardiac magnetic resonance

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images of the heart demonstrating the “inverted” Takotsubo pattern. Steady-state free precession 4-chamber images show akinesis of basal myocardial segments and hyperkinesis of the mid- and apical segments in diastole and systole. Small panels at the bottom show T2 weighted images with fat saturation show relative T2 hyperintensity in a

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graded fashion from base to apex.

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Video Legends: Video Clip 1: Transthoracic echocardiogram showing classical Takotsubo pattern with akinesis and ballooning of the apex and hypercontractily of the basal segments.

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Video Clip 2: Transthoracic echocardiogram showing inverted Takotsubo pattern with akinesis of basal myocardial segments and hyperkinesis of the mid- and apical segments. Video Clip 3: Transthoracic echocardiogram showing resolution of Takotsubo

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previously seen wall motion abnormalities.

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cardiomyopathy in follow-up with normalization of left ventricular function and

Serial classic and inverted pattern Takotsubo cardiomyopathy in a middle-aged woman.

We report the case of a 56-year-old woman with no significant medical history who was diagnosed with recurrent Takotsubo cardiomyopathy with variation...
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