The Journal of Emergency Medicine, Vol. 48, No. 2, pp. e35–e38, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

Selected Topics: Critical Care TAKOTSUBO CARDIOMYOPATHY INDUCED BY SUICIDAL NECK HANGING Keigo Sawamoto, MD, Mamoru Hase, MD, PHD, Shuji Uemura, MD, PHD, Takehiko Kasai, MD, and Eichi Narimatsu, MD, PHD Department of Emergency Medicine, Sapporo Medical University, Hokkaido, Japan Reprint Address: Keigo Sawamoto, MD, Department of Emergency Medicine, Sapporo Medical University, S1W16 Chuoku Sapporo, Hokkaido 060-8543, Japan

, Abstract—Background: Takotsubo cardiomyopathy (TC) is an uncommon immune-endocrinologic cause of acute reversible heart failure, generally caused by some form of stress. Case Report: We report a case of TC after hanging for attempted suicide. Upon admission, the patient demonstrated an almost entirely normal electrocardiogram (ECG) and mild hypotension. However, on the third day after hanging, she developed chest and back pain with inverted T waves and QTc prolongation on ECG. Her coronary arteries were normal on angiogram, but the left ventricle showed apical ballooning, consistent with TC. She was treated with an intra-aortic balloon pump and fully recovered. We observed that the QTc interval seemed to be a good guide for clinical course in this case. Why Should an Emergency Physician Be Aware of This?: TC should be considered in any acute stressful presentation, and to assist in the diagnosis as TC, we suggest following the QTc on ECG. TC should be taken into consideration in patients after suicide attempt with low blood pressure or an abnormal ECG, including ST segment elevation, T wave inversion, and QTc prolongation. Ó 2015 Elsevier Inc.

graphic appearance of which is known as apical ballooning. It mimics the symptoms and electrocardiographic appearance of acute myocardial infarction, generally with ST segment elevation but without any significant signs of coronary lesions on angiography. Its pathogenesis is probably secondary to damage to the myocytes mediated by the catecholamines and microvascular dysfunction. In recent years, increasing numbers of cases, arising in various circumstances of physical or mental stress, have been described in the literature. Only four reported cases after suicide attempt have been documented, two of them after hanging. We present a case of TC as a delayed complication with neck hanging in a suicide attempt. CASE REPORT A 54-year-old woman was brought to our emergency department after neck hanging for suicide attempt. She had hooked an electric cord on the doorknob to hang herself and was sitting on the floor when she was found. She had been diagnosed with schizophrenia and medicated with benzodiazepine, biperiden, and valproic acid. On admission she was unconscious (Glasgow Coma Scale score 4), with a blood pressure of 86/58 mm Hg, heart rate of 86 beats/min, and respiratory rate of 19 breaths/ min. Her pupils were 6 mm each, with no reaction to light. Arterial blood gas analysis after intubation demonstrated a metabolic acidosis with high lactate (pH 7.35; PCO2

, Keywords—takotsubo cardiomyopathy; apical balloon syndrome; neck hanging; suicide

INTRODUCTION Takotsubo cardiomyopathy (TC) manifests as a transient dysfunction of the left ventricle, the characteristic angio-

RECEIVED: 10 July 2014; FINAL SUBMISSION RECEIVED: 5 October 2014; ACCEPTED: 9 October 2014 e35


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Figure 1. Electrocardiogram on admission showing 0.44 ms in QTc interval.

30.0 mm Hg; PO2 525 mm Hg; HCO3 16.2 mmol/L; base excess 8.3 mmol/L; lactate 5.9 mmol/L). A head computed tomography (CT) showed no signs of anoxic brain injury. Neck CT showed no signs of cervical spine injury. A 12-lead electrocardiogram (ECG) showed sinus rhythm of 71 beats/min, normal axis, normal ST-segment, and normal QTc interval of 440 ms (Figure 1). ECG also showed a slight ST-T elevation in leads V3-V6, II, III, and aVF. Echocardiography performed within 1 h of her arrival showed diffuse hypokinesis without segmental asynergy. After intubation, she was admitted to the intensive care unit, where she underwent therapeutic hypothermia for prolonged unconsciousness. Dopamine was infused to maintain a blood pressure > 80 mm Hg in systolic and hemodynamic status was stable (Figure 2). On

Figure 2. Clinical course. BNP = brain natriuretic peptide; CK = creatine phosphokinase; IABP = intra-aortic balloon pump.

the third day, after successful extubation, she complained of chest and back pain. A repeat ECG revealed T wave inversion in leads V3-V6, II, III, and aVF, and a prolonged QTc interval of 550 ms (Figure 3). Echocardiography showed apical akinesis, similar to TC. Emergency coronary angiogram revealed normal coronary arteries (Figure 4). Left ventriculography confirmed the marked apical hypokinesis (Figure 5). Brain natriuretic peptide and troponin I were significantly elevated up to 2070 pg/mL and 3.23 mg/L, respectively, but the creatine phosphokinase was normal (Figure 2). The patient was reintubated and treated with intra-aortic balloon pumping (IABP). On the fifth day, her hemodynamic

Figure 3. Transition of electrocardiogram.

Takotsubo Cardiomyopathy Induced by Hanging


Figure 4. Coronary angiogram on day 3 showing normal coronary arteries.

status was stable and the IABP was stopped. On the next day, she was successfully extubated. The QT interval normalized on day 8, and she was transferred to the psychiatric unit. DISCUSSION TC was described for the first time in 1990 in Japan (1). TC is characterized by transient systolic dysfunction of the apical segment of left ventricle (sometimes described as apical ballooning), with normal coronary arteries. Many hypotheses have been proposed to explain the pathophysiology of TC, including multivessel coronary vasospasm, abnormalities of coronary microvascular function, and catecholamine-mediated cardiotoxicity (2). There are only two cases reported in the literature of TC arising after a neck hanging, one in Japan and another in India (3,4). The onset of TC is frequently triggered by an acute medical illness or intense emotional or physical stress (5). Abnormalities on the ECG in TC are characterized

by anterior ST elevation, T-wave inversions within 24 to 48 h after presentation, with associated prolongation of the QT interval (6). The prognosis for TC is usually favorable with supportive care (6). In our case, both emotional stress with suicide attempt and physical stress with asphyxia caused by hanging were possible triggers for the TC. Forty hours after attempting suicide, our patient developed chest and back pain with clear evidence changes on the ECG, including inverse T wave and QTc prolongation. In retrospect, on admission, she showed a slight prolongation of the QTc and low blood pressure, and her psychiatric medication did not affect the QTc interval. Interestingly in this case, it seems that QTc prolongation closely mimicked her clinical course. To diagnose TC with ST-T changes on the ECG, we must exclude ST elevation myocardial infarction (STEMI) at first. In this case, we believe that the echocardiography was helpful and angiography was necessary to identify TC or STEMI.

Figure 5. Left ventriculogram on day 3 showing hypercontractile basal segment.


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WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? TC should be considered in patients after suicide attempt with low blood pressure or an abnormal ECG, including ST segment elevation, T wave inversion, and QTc prolongation. REFERENCES 1. Sato H, Tateishi H, Uchida T, et al. Tako-Tsubo like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K, Hori M, eds. Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo: Kagakuhyoronsha Publishing Company; 1990:56–64.

2. Gianni M, Dentali F, Grandi AM, et al. Apical ballooning syndrome or Takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006; 27:1523–9. 3. Nakata H, Miyamoto T, Nakamura M, et al. A case of Takotsubo cardiomyopathy caused by hanging. J Jpn Assoc Acute Med 2005;16: 587–92. 4. Gnanavelu G, Sathiakumar DB. Reversible left ventricular dysfunction in suicidal hanging. J Assoc Physicians India 2008; 56:545–6. 5. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina PectorisMyocardial Infarction Investigations in Japan. J Am Coll Cardiol 2001;38:11. 6. Bybee KA, Kara T, Prasad A, et al. Transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004;141: 858–65.

Takotsubo cardiomyopathy induced by suicidal neck hanging.

Takotsubo cardiomyopathy (TC) is an uncommon immune-endocrinologic cause of acute reversible heart failure, generally caused by some form of stress...
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