International Journal of Cardiology 184 (2015) 278–279
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Takotsubo cardiomyopathy in a young woman with coronary hypoplasia detected at CT-scan Francesco Santoro a, Domenico Gianfrancesco b, Giovanni De Luca b, Roberto Stanzione c, Luigi Di Martino a, Matteo Di Biase a, Natale Daniele Brunetti a,⁎ a b c
University of Foggia, Foggia, Italy Ospedale Vittorio Emanuele II, Bisceglie, Italy Ospedale San Paolo, Bari, Italy
a r t i c l e
i n f o
Article history: Received 10 January 2015 Accepted 21 February 2015 Available online 24 February 2015 Keywords: Takotsubo cardiomyopathy Coronary hypoplasia Young woman CT coronary angiography
Takotsubo cardiomyopathy (TTC) is an acute and reversible form of heart failure [1], [2]. It is featured by a fully reversible acute deterioration of left-ventricular (LV) function, which is mainly found in postmenopausal women after an episode of emotional or physical stress. A 24-year-old woman, without cardiovascular risk factors, was referred for acute chest pain after an emotional stress (her grandfather death). Blood pressure at admission was 110/70 mm Hg and electrocardiogram showed sinus rhythm at 64 bpm. Laboratory parameters were normal except for troponin-I (1.5 ng/mL, n.v. b 0.1) and NTproBNP (2502 pg/mL, n.v. b 125). Unexpectedly, echocardiogram showed typical signs of apical ballooning (LV ejection fraction [EF] 35%). Diuretics and esmolol infusion was started for hemodynamic support. A coronary CT-scan was performed, without any evidence of coronary stenosis. Right coronary artery was slightly hypoplastic with an additional small artery arising from the aorta just beside the right artery. Left coronary angiography showed coronary hypoplasia of both circumflex artery and left anterior descending artery (Fig. 1). The patient gradually improved, and was discharged 5 days later, after a full recovery of LV function (LVEF at discharge N 55%). To the best of our knowledge, we report one of the first cases of TTC in a young female with coronary hypoplasia. Although high levels of catecholamines have been recognized as the main factor responsible for ⁎ Corresponding author at: Department of Medical & Surgical Sciences, University of Foggia, Viale Pinto 1 71100 Foggia, Italy. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2015.02.066 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
TTC [3], the exact mechanism leading to apical ballooning and its therapy are not well known [4], [5]. The role of the coronary artery anatomy and function in TTC has been addressed in several studies. Coronary vasospasm has been reported as one of the main mechanisms leading to TTC [6]. However, coronary hypoplasia was found by Cocco et al. [7] in 40% (16/40) of patients with TTC; several patients presented underdeveloped coronary arteries (with hypoplastic branching) in the LV apex. In this series all women, however, were in postmenopausal age. Stiermaier et al., evaluating the anatomical features of the left anterior descending coronary artery (LAD) among patients with TTC, found an increased prevalence of recurrent LAD if compared to a control group (55.6% vs 35.4%, p b 0.001) [8]. Therefore, apical LV hypoperfusion could be hypothesized as one of the possible driving mechanisms of TTC. In young patients with TTC, an accurate study of coronary artery anatomy should be performed.
Fig. 1. a–b) Additional small artery arising from the aorta next to the origin of the right artery. c) Right coronary artery (arrow a) and additional artery (arrow b). d) Diffuse hypoplasia of both circumflex artery and left anterior descending coronary.
F. Santoro et al. / International Journal of Cardiology 184 (2015) 278–279
Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] P. Elliott, B. Andersson, E. Arbustini, Z. Bilinska, F. Cecchi, P. Charron, O. Dubourg, U. Kühl, B. Maisch, W.J. McKenna, L. Monserrat, S. Pankuweit, C. Rapezzi, P. Seferovic, L. Tavazzi, A. Keren, Classification of the cardiomyopathies: a position statement from the European Society Of Cardiology Working Group on myocardial and pericardial diseases, Eur. Heart J. 29 (2008) 270–276. [2] R. Ieva, F. Santoro, A. Ferraretti, G. Spennati, L. De Gennaro, M. Di Biase, N.D. Brunetti, Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: in the beginning was basal hyperkinesis? Int. J. Cardiol. 167 (2013) e55–e57. [3] H. Paur, P.T. Wright, M.B. Sikkel, M.H. Tranter, C. Mansfield, P. O'Gara, D.J. Stuckey, V.O. Nikolaev, I. Diakonov, L. Pannell, H. Gong, H. Sun, N.S. Peters, M. Petrou, Z.
[4]
[5]
[6]
[7] [8]
279
Zheng, J. Gorelik, A.R. Lyon, S.E. Harding, High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner: a new model of takotsubo cardiomyopathy, Circulation 126 (2012) 697–706. F. Santoro, R. Ieva, A. Ferraretti, V. Ienco, G. Carpagnano, M. Lodispoto, L. Di Biase, M. Di Biase, N.D. Brunetti, Safety and feasibility of levosimendan administration in takotsubo cardiomyopathy: a case series, Cardiovasc. Ther. 31 (2013) e133–e137. F. Santoro, R. Ieva, F. Musaico, A. Ferraretti, G. Triggiani, N. Tarantino, M. Di Biase, N.D. Brunetti, Lack of efficacy of drug therapy in preventing takotsubo cardiomyopathy recurrence: a meta-analysis, Clin. Cardiol. 37 (2014) 434–439. K. Dote, H. Sato, H. Tateishi, T. Uchida, M. Ishihara, Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases, J. Cardiol. 21 (1991) 203–214. G. Cocco, D. Chu, Stress-induced cardiomyopathy: a review, Eur. J. Intern. Med. 18 (2007) 369–379. T. Stiermaier, S. Desch, S. Blazek, G. Schuler, H. Thiele, I. Eitel, Frequency and significance of myocardial bridging and recurrent segment of the left anterior descending coronary artery in patients with takotsubo cardiomyopathy, Am. J. Cardiol. 114 (2014) 1204–1209.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Takotsubo cardiomyopathy in a young woman with coronary hypoplasia detected at CT-scan Francesco Santoro a, Domenico Gianfrancesco b, Giovanni De Luca b, Roberto Stanzione c, Luigi Di Martino a, Matteo Di Biase a, Natale Daniele Brunetti a,⁎ a b c
University of Foggia, Foggia, Italy Ospedale Vittorio Emanuele II, Bisceglie, Italy Ospedale San Paolo, Bari, Italy
a r t i c l e
i n f o
Article history: Received 10 January 2015 Accepted 21 February 2015 Available online 24 February 2015 Keywords: Takotsubo cardiomyopathy Coronary hypoplasia Young woman CT coronary angiography
Takotsubo cardiomyopathy (TTC) is an acute and reversible form of heart failure [1], [2]. It is featured by a fully reversible acute deterioration of left-ventricular (LV) function, which is mainly found in postmenopausal women after an episode of emotional or physical stress. A 24-year-old woman, without cardiovascular risk factors, was referred for acute chest pain after an emotional stress (her grandfather death). Blood pressure at admission was 110/70 mm Hg and electrocardiogram showed sinus rhythm at 64 bpm. Laboratory parameters were normal except for troponin-I (1.5 ng/mL, n.v. b 0.1) and NTproBNP (2502 pg/mL, n.v. b 125). Unexpectedly, echocardiogram showed typical signs of apical ballooning (LV ejection fraction [EF] 35%). Diuretics and esmolol infusion was started for hemodynamic support. A coronary CT-scan was performed, without any evidence of coronary stenosis. Right coronary artery was slightly hypoplastic with an additional small artery arising from the aorta just beside the right artery. Left coronary angiography showed coronary hypoplasia of both circumflex artery and left anterior descending artery (Fig. 1). The patient gradually improved, and was discharged 5 days later, after a full recovery of LV function (LVEF at discharge N 55%). To the best of our knowledge, we report one of the first cases of TTC in a young female with coronary hypoplasia. Although high levels of catecholamines have been recognized as the main factor responsible for ⁎ Corresponding author at: Department of Medical & Surgical Sciences, University of Foggia, Viale Pinto 1 71100 Foggia, Italy. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2015.02.066 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
TTC [3], the exact mechanism leading to apical ballooning and its therapy are not well known [4], [5]. The role of the coronary artery anatomy and function in TTC has been addressed in several studies. Coronary vasospasm has been reported as one of the main mechanisms leading to TTC [6]. However, coronary hypoplasia was found by Cocco et al. [7] in 40% (16/40) of patients with TTC; several patients presented underdeveloped coronary arteries (with hypoplastic branching) in the LV apex. In this series all women, however, were in postmenopausal age. Stiermaier et al., evaluating the anatomical features of the left anterior descending coronary artery (LAD) among patients with TTC, found an increased prevalence of recurrent LAD if compared to a control group (55.6% vs 35.4%, p b 0.001) [8]. Therefore, apical LV hypoperfusion could be hypothesized as one of the possible driving mechanisms of TTC. In young patients with TTC, an accurate study of coronary artery anatomy should be performed.
Fig. 1. a–b) Additional small artery arising from the aorta next to the origin of the right artery. c) Right coronary artery (arrow a) and additional artery (arrow b). d) Diffuse hypoplasia of both circumflex artery and left anterior descending coronary.
F. Santoro et al. / International Journal of Cardiology 184 (2015) 278–279
Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] P. Elliott, B. Andersson, E. Arbustini, Z. Bilinska, F. Cecchi, P. Charron, O. Dubourg, U. Kühl, B. Maisch, W.J. McKenna, L. Monserrat, S. Pankuweit, C. Rapezzi, P. Seferovic, L. Tavazzi, A. Keren, Classification of the cardiomyopathies: a position statement from the European Society Of Cardiology Working Group on myocardial and pericardial diseases, Eur. Heart J. 29 (2008) 270–276. [2] R. Ieva, F. Santoro, A. Ferraretti, G. Spennati, L. De Gennaro, M. Di Biase, N.D. Brunetti, Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: in the beginning was basal hyperkinesis? Int. J. Cardiol. 167 (2013) e55–e57. [3] H. Paur, P.T. Wright, M.B. Sikkel, M.H. Tranter, C. Mansfield, P. O'Gara, D.J. Stuckey, V.O. Nikolaev, I. Diakonov, L. Pannell, H. Gong, H. Sun, N.S. Peters, M. Petrou, Z.
[4]
[5]
[6]
[7] [8]
279
Zheng, J. Gorelik, A.R. Lyon, S.E. Harding, High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner: a new model of takotsubo cardiomyopathy, Circulation 126 (2012) 697–706. F. Santoro, R. Ieva, A. Ferraretti, V. Ienco, G. Carpagnano, M. Lodispoto, L. Di Biase, M. Di Biase, N.D. Brunetti, Safety and feasibility of levosimendan administration in takotsubo cardiomyopathy: a case series, Cardiovasc. Ther. 31 (2013) e133–e137. F. Santoro, R. Ieva, F. Musaico, A. Ferraretti, G. Triggiani, N. Tarantino, M. Di Biase, N.D. Brunetti, Lack of efficacy of drug therapy in preventing takotsubo cardiomyopathy recurrence: a meta-analysis, Clin. Cardiol. 37 (2014) 434–439. K. Dote, H. Sato, H. Tateishi, T. Uchida, M. Ishihara, Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases, J. Cardiol. 21 (1991) 203–214. G. Cocco, D. Chu, Stress-induced cardiomyopathy: a review, Eur. J. Intern. Med. 18 (2007) 369–379. T. Stiermaier, S. Desch, S. Blazek, G. Schuler, H. Thiele, I. Eitel, Frequency and significance of myocardial bridging and recurrent segment of the left anterior descending coronary artery in patients with takotsubo cardiomyopathy, Am. J. Cardiol. 114 (2014) 1204–1209.
