International Journal of Cardiology 198 (2015) 49–50
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Of hearts and minds: A case of simultaneous transient global amnesia and regional left ventricular dysfunction Pankaj Jain ⁎, Jonathan Michel, Jane McCrohon St Vincent's Hospital, Sydney, Australia
a r t i c l e
i n f o
Article history: Received 15 June 2015 Accepted 26 June 2015 Available online 2 July 2015
A 73 year-old lady with hypertension and type 2 diabetes mellitus presented to the Emergency department with sudden-onset dizziness and acute confusional state. On arrival, general and cardio-respiratory examinations were unremarkable. Severe persistent antegrade and partial retrograde amnesia were evident although the neurological examination was otherwise normal. An urgent CT of the brain was normal, and a clinical diagnosis of transient global amnesia (TGA) was determined. An electrocardiogram in the Emergency department revealed a 2 mm inferior ST elevation with associated downsloping ST depression in V2 to V4, although the patient denied any symptoms consistent with cardiac ischaemia or heart failure. Treatment with oral aspirin was commenced but given the absence of cardiac symptoms and the marked persistent amnesia, immediate coronary angiography was deferred. A subsequent transthoracic echocardiogram demonstrated posterior left ventricular hypokinesis. The initial high-sensitivity troponin T assay was elevated at 36 ng/L (b14 ng/L), rising to 559 ng/L after two hours. At this time the patient began to describe persistent mild dull epigastric discomfort, although the ECG abnormalities had now resolved. She was treated for acute coronary syndrome with clopidogrel and intravenous heparin with a view to performing coronary angiography the following day. The patient's amnestic symptoms gradually improved. By day 1 of admission her antegrade memory had returned to baseline but she remained unable to recall the events of the previous day. Coronary angiography on day 1 demonstrated normal coronary arteries and mid-ventricular inferior dyskinesis on left ventriculography
⁎ Corresponding author. E-mail address: [email protected] (P. Jain).
http://dx.doi.org/10.1016/j.ijcard.2015.06.117 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
(Fig. 1). Cardiac MRI on day 3 demonstrated localised posterior mid-ventricular akinesis, but no late gadolinium enhancement to indicate myocardial scarring. The patient was managed with low-dose beta-blocker and ACEinhibitor. A subsequent MRI brain was normal and she required no specific neurological treatment. Repeat transthoracic echocardiography revealed complete resolution of the regional wall motion abnormality, confirming the diagnosis of transient regional left ventricular dysfunction (TRLVD) in the context of TGA. The observed association between acute neurological events and TRLVD (stress cardiomyopathy; Tako-tsubo cardiomyopathy) has been well described. The most commonly reported precipitating events are subarachnoid haemorrhage, ischaemic stroke and intracerebral haemorrhage [1]. By comparison TGA in association with TRLVD is rare, documented in isolated case reports and one registry [2]. Case reports have variously described TGA followed by TRLVD [3], TGA with concurrent TRLVD [4], and TGA with associated troponin elevation but no regional wall motion abnormality [5]. TGA has also been reported as a symptom of acute myocardial infarction [6]. Given this heterogeneity, the causal mechanism of the association remains unclear. In our case, the symptoms of TGA and initial investigations consistent with acute coronary syndrome manifested concurrently and in the absence of any typical symptoms of cardiac ischaemia. We propose the following hypotheses to account for this unusual presentation: first, TRLVD occurred in response to a primary neurological event manifesting as TGA; second, TGA was an atypical symptom of a primary stress cardiomyopathy; or third, an unspecified common mechanism concurrently caused TGA and TRLVD. Importantly, the combination of significant biomarker elevation but no scar on cardiac MRI essentially rules out a fourth option — a primary epicardial coronary event. This distinction has important implications for the patient's long-term management. Two factors were key to our initial decision to defer coronary angiography. First, the patient's symptom profile lessened the likelihood of an acute obstructive epicardial coronary lesion, and therefore the potential yield of coronary angiography. Second, her marked amnesia raised concerns around the immediate safety of performing an invasive procedure. The challenges presented by this unusual case highlight the need to balance the anticipated procedural risk and potential yield of invasive angiography, with the time-critical nature of myocardial ischaemia.
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P. Jain et al. / International Journal of Cardiology 198 (2015) 49–50
Fig. 1. Left ventriculogram in diastole (left) and systole (right), showing mid-ventricular inferior wall dyskinesia (white arrows).
References [1] I. Porto, R. Della Bona, A. Leo, et al., Stress cardiomyopathy (Tako-tsubo) triggered by nervous system diseases: A systematic review of the reported cases, Int. J. Cardiol. 167 (2013) 2441–2448. [2] V. Weihs, D. Szucs, B. Fellner, et al., Stress-induced cardiomyopathy (Tako-Tsubo syndrome) in Austria, Eur. Heart J. Acute Cardiovasc. Care 2 (2013) 137–146. [3] T. Bobinger, M. Kohrmann, D. Raaz-Schrauder, S. Schwab, Lost memories can break your heart: A case report of transient global amnesia followed by Takotsubo cardiomyopathy, Clin. Res. Cardiol. 102 (2013) 693–696.
[4] T. Kaida, H. Nakano, I. Watanabe, et al., A unique case of Takotsubo cardiomyopathy which might be caused by simultaneous and multiple vasospasm, J. Card. Fail. 7 (2009) S159. [5] M. Jalanko, F. Forsstrom, J. Lassus, Cardiac troponin T elevation associated with transient global amnesia: another differential diagnosis of ‘troponosis’, Eur. Heart J. Acute Cardiovasc. Care (2014) 1–4. [6] P.-Y. Courand, F. Sibellas, S. Gonidec, L. Mechtouff, G. Kirkorian, E. Bonnefoy, Acute myocardial infarction: a precipitating event for transient global amnesia, J. Cardiovasc. Med. 15 (2013) 78–79.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Of hearts and minds: A case of simultaneous transient global amnesia and regional left ventricular dysfunction Pankaj Jain ⁎, Jonathan Michel, Jane McCrohon St Vincent's Hospital, Sydney, Australia
a r t i c l e
i n f o
Article history: Received 15 June 2015 Accepted 26 June 2015 Available online 2 July 2015
A 73 year-old lady with hypertension and type 2 diabetes mellitus presented to the Emergency department with sudden-onset dizziness and acute confusional state. On arrival, general and cardio-respiratory examinations were unremarkable. Severe persistent antegrade and partial retrograde amnesia were evident although the neurological examination was otherwise normal. An urgent CT of the brain was normal, and a clinical diagnosis of transient global amnesia (TGA) was determined. An electrocardiogram in the Emergency department revealed a 2 mm inferior ST elevation with associated downsloping ST depression in V2 to V4, although the patient denied any symptoms consistent with cardiac ischaemia or heart failure. Treatment with oral aspirin was commenced but given the absence of cardiac symptoms and the marked persistent amnesia, immediate coronary angiography was deferred. A subsequent transthoracic echocardiogram demonstrated posterior left ventricular hypokinesis. The initial high-sensitivity troponin T assay was elevated at 36 ng/L (b14 ng/L), rising to 559 ng/L after two hours. At this time the patient began to describe persistent mild dull epigastric discomfort, although the ECG abnormalities had now resolved. She was treated for acute coronary syndrome with clopidogrel and intravenous heparin with a view to performing coronary angiography the following day. The patient's amnestic symptoms gradually improved. By day 1 of admission her antegrade memory had returned to baseline but she remained unable to recall the events of the previous day. Coronary angiography on day 1 demonstrated normal coronary arteries and mid-ventricular inferior dyskinesis on left ventriculography
⁎ Corresponding author. E-mail address: [email protected] (P. Jain).
http://dx.doi.org/10.1016/j.ijcard.2015.06.117 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
(Fig. 1). Cardiac MRI on day 3 demonstrated localised posterior mid-ventricular akinesis, but no late gadolinium enhancement to indicate myocardial scarring. The patient was managed with low-dose beta-blocker and ACEinhibitor. A subsequent MRI brain was normal and she required no specific neurological treatment. Repeat transthoracic echocardiography revealed complete resolution of the regional wall motion abnormality, confirming the diagnosis of transient regional left ventricular dysfunction (TRLVD) in the context of TGA. The observed association between acute neurological events and TRLVD (stress cardiomyopathy; Tako-tsubo cardiomyopathy) has been well described. The most commonly reported precipitating events are subarachnoid haemorrhage, ischaemic stroke and intracerebral haemorrhage [1]. By comparison TGA in association with TRLVD is rare, documented in isolated case reports and one registry [2]. Case reports have variously described TGA followed by TRLVD [3], TGA with concurrent TRLVD [4], and TGA with associated troponin elevation but no regional wall motion abnormality [5]. TGA has also been reported as a symptom of acute myocardial infarction [6]. Given this heterogeneity, the causal mechanism of the association remains unclear. In our case, the symptoms of TGA and initial investigations consistent with acute coronary syndrome manifested concurrently and in the absence of any typical symptoms of cardiac ischaemia. We propose the following hypotheses to account for this unusual presentation: first, TRLVD occurred in response to a primary neurological event manifesting as TGA; second, TGA was an atypical symptom of a primary stress cardiomyopathy; or third, an unspecified common mechanism concurrently caused TGA and TRLVD. Importantly, the combination of significant biomarker elevation but no scar on cardiac MRI essentially rules out a fourth option — a primary epicardial coronary event. This distinction has important implications for the patient's long-term management. Two factors were key to our initial decision to defer coronary angiography. First, the patient's symptom profile lessened the likelihood of an acute obstructive epicardial coronary lesion, and therefore the potential yield of coronary angiography. Second, her marked amnesia raised concerns around the immediate safety of performing an invasive procedure. The challenges presented by this unusual case highlight the need to balance the anticipated procedural risk and potential yield of invasive angiography, with the time-critical nature of myocardial ischaemia.
50
P. Jain et al. / International Journal of Cardiology 198 (2015) 49–50
Fig. 1. Left ventriculogram in diastole (left) and systole (right), showing mid-ventricular inferior wall dyskinesia (white arrows).
References [1] I. Porto, R. Della Bona, A. Leo, et al., Stress cardiomyopathy (Tako-tsubo) triggered by nervous system diseases: A systematic review of the reported cases, Int. J. Cardiol. 167 (2013) 2441–2448. [2] V. Weihs, D. Szucs, B. Fellner, et al., Stress-induced cardiomyopathy (Tako-Tsubo syndrome) in Austria, Eur. Heart J. Acute Cardiovasc. Care 2 (2013) 137–146. [3] T. Bobinger, M. Kohrmann, D. Raaz-Schrauder, S. Schwab, Lost memories can break your heart: A case report of transient global amnesia followed by Takotsubo cardiomyopathy, Clin. Res. Cardiol. 102 (2013) 693–696.
[4] T. Kaida, H. Nakano, I. Watanabe, et al., A unique case of Takotsubo cardiomyopathy which might be caused by simultaneous and multiple vasospasm, J. Card. Fail. 7 (2009) S159. [5] M. Jalanko, F. Forsstrom, J. Lassus, Cardiac troponin T elevation associated with transient global amnesia: another differential diagnosis of ‘troponosis’, Eur. Heart J. Acute Cardiovasc. Care (2014) 1–4. [6] P.-Y. Courand, F. Sibellas, S. Gonidec, L. Mechtouff, G. Kirkorian, E. Bonnefoy, Acute myocardial infarction: a precipitating event for transient global amnesia, J. Cardiovasc. Med. 15 (2013) 78–79.
