International Journal of Cardiology 197 (2015) 315–316
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Takotsubo cardiomyopathy precipitated by anticipation of elective coronary intervention J. Kanawati, H.C. Lowe ⁎ Cardiology Department, Concord Repatriation General Hospital and University of Sydney, Sydney, NSW, Australia
a r t i c l e
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Article history: Received 6 June 2015 Accepted 21 June 2015 Available online 27 June 2015 Keywords: Takotsubo Cardiomyopathy Coronary intervention
A case of Takotsubo cardiomyopathy (TCM) is described, precipitated by a previously unreported trigger, that of elective coronary intervention. A 67-year-old female developed symptoms of severe chest pain, dyspnea and presyncope, while preparing to present on a Monday morning to hospital for a recently booked elective coronary angiogram and possible coronary intervention. On arrival to the emergency department by ambulance, the blood pressure was 72/48 and there was clinical and radiographic evidence of pulmonary edema. ECGs suggested widespread ischemia (Fig. 1) but angiography performed urgently revealed minor coronary irregularity only, and ventriculography was characteristic of TCM (Fig. 2 A, B). The subsequent clinical course was consistent with TCM with prompt symptom improvement, rapid resolution of pulmonary edema and a return to normal LV function with standard therapy. The patient had a prior history of atrial fibrillation successfully treated with ablation, and coronary disease treated with bare metal stenting. A femoral approach coronary angiogram four years prior had been associated with deep vein thrombosis and bilateral pulmonary emboli, and on a separate occasion she had developed an allergic reaction to contrast with a generalized pruritic rash. She also reported stress related to the death of a brother 3 weeks prior due to sepsis following chemotherapy for carcinoma. Takotsubo cardiomyopathy or “stress cardiomyopathy” is well described [1,2], and though the pathogenesis remains incompletely understood [3], it is reported as occurring more commonly in postmenopausal women, with multiple triggers, both physical and emotional,
⁎ Corresponding author at: Cardiac Catheterisation Laboratories, Concord Repatriation General Hospital, Hospital Rd, Concord, Sydney, NSW 2021, Australia. E-mail address: [email protected] (H.C. Lowe).
http://dx.doi.org/10.1016/j.ijcard.2015.06.091 0167-5273/Crown Copyright © 2015 Published by Elsevier Ireland Ltd. All rights reserved.
being described [2]. Some cases also appear to occur without an obvious trigger [4]. It is conceivable that anxiety related to the planned coronary angiogram was the trigger for TCM in this case. Her previous procedure had been complicated by life-threatening pulmonary embolism and she readily stated that she was highly anxious in anticipation of the planned angiogram on the day she developed her symptoms. Contributors could also have been circadian influences and grief following unexpected death of her brother. The presentation was on a Monday morning, a previously documented peak in incidence of TCM [5], though grief-induced TCM has been documented to have a closer temporal relationship than in this case [6]. TCM has been reported during acute illness and surgical or outpatient procedures, including elective cardioversion [2,7,8], though to our knowledge anticipation of a coronary angiogram or coronary intervention has not been previously documented as a precipitant. It would appear that coronary angiography needs to be added to the increasing list of triggers for this increasingly recognized condition [2]. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] 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 (Japanese). [2] S.W. Sharkey, B.J. Maron, Epidemiology and clinical profile of Takotsubo cardiomyopathy, Circ. J. 78 (2014) 2119–2128. [3] I.S. Wittstein, D.R. Thiemann, J.A. Lima, K.L. Baughman, S.P. Schulman, G. Gerstenblith, K.C. Wu, J.J. Rade, T.J. Bivalacqua, H.C. Champion, Neurohumoral features of myocardial stunning due to sudden emotional stress, N. Engl. J. Med. 352 (2005) 539–548. [4] K.A. Bybee, A. Prasad, Stress-related cardiomyopathy syndromes, Circulation 118 (2008) 397–409. [5] S.W. Sharkey, J.R. Lesser, R.F. Garberich, V.R. Pink, M.S. Maron, B.J. Maron, Comparison of circadian rhythm patterns in Tako-tsubo cardiomyopathy versus ST-segment elevation myocardial infarction, Am. J. Cardiol. 110 (2012) 795–799. [6] S. Kurisu, Y. Kihara, Tako-tsubo cardiomyopathy: clinical presentation and underlying mechanism, J. Cardiol. 60 (2012) 429–437. [7] J.H. Park, S.J. Kang, J.K. Song, H.K. Kim, C.M. Lim, D.H. Kang, Y. Koh, Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU, Chest 128 (2005) 296–302. [8] D. Haghi, S. Fluechter, T. Suselbeck, J. Saur, O. Bheleel, M. Borggrefe, T. Papavassiliu, Takotsubo cardiomyopathy (acute left ventricular apical ballooning syndrome) occurring in the intensive care unit, Intensive Care Med. 32 (2006) 1069–1074.
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J. Kanawati, H.C. Lowe / International Journal of Cardiology 197 (2015) 315–316
V1
Fig. 1. ECG at presentation indicating widespread ST segment elevation.
Fig. 2. Left ventriculogram (right anterior oblique) view. A) At end diastole, B) at end systole, revealing contraction of basal segments only, consistent with Takotsubo cardiomyopathy.
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Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Takotsubo cardiomyopathy precipitated by anticipation of elective coronary intervention J. Kanawati, H.C. Lowe ⁎ Cardiology Department, Concord Repatriation General Hospital and University of Sydney, Sydney, NSW, Australia
a r t i c l e
i n f o
Article history: Received 6 June 2015 Accepted 21 June 2015 Available online 27 June 2015 Keywords: Takotsubo Cardiomyopathy Coronary intervention
A case of Takotsubo cardiomyopathy (TCM) is described, precipitated by a previously unreported trigger, that of elective coronary intervention. A 67-year-old female developed symptoms of severe chest pain, dyspnea and presyncope, while preparing to present on a Monday morning to hospital for a recently booked elective coronary angiogram and possible coronary intervention. On arrival to the emergency department by ambulance, the blood pressure was 72/48 and there was clinical and radiographic evidence of pulmonary edema. ECGs suggested widespread ischemia (Fig. 1) but angiography performed urgently revealed minor coronary irregularity only, and ventriculography was characteristic of TCM (Fig. 2 A, B). The subsequent clinical course was consistent with TCM with prompt symptom improvement, rapid resolution of pulmonary edema and a return to normal LV function with standard therapy. The patient had a prior history of atrial fibrillation successfully treated with ablation, and coronary disease treated with bare metal stenting. A femoral approach coronary angiogram four years prior had been associated with deep vein thrombosis and bilateral pulmonary emboli, and on a separate occasion she had developed an allergic reaction to contrast with a generalized pruritic rash. She also reported stress related to the death of a brother 3 weeks prior due to sepsis following chemotherapy for carcinoma. Takotsubo cardiomyopathy or “stress cardiomyopathy” is well described [1,2], and though the pathogenesis remains incompletely understood [3], it is reported as occurring more commonly in postmenopausal women, with multiple triggers, both physical and emotional,
⁎ Corresponding author at: Cardiac Catheterisation Laboratories, Concord Repatriation General Hospital, Hospital Rd, Concord, Sydney, NSW 2021, Australia. E-mail address: [email protected] (H.C. Lowe).
http://dx.doi.org/10.1016/j.ijcard.2015.06.091 0167-5273/Crown Copyright © 2015 Published by Elsevier Ireland Ltd. All rights reserved.
being described [2]. Some cases also appear to occur without an obvious trigger [4]. It is conceivable that anxiety related to the planned coronary angiogram was the trigger for TCM in this case. Her previous procedure had been complicated by life-threatening pulmonary embolism and she readily stated that she was highly anxious in anticipation of the planned angiogram on the day she developed her symptoms. Contributors could also have been circadian influences and grief following unexpected death of her brother. The presentation was on a Monday morning, a previously documented peak in incidence of TCM [5], though grief-induced TCM has been documented to have a closer temporal relationship than in this case [6]. TCM has been reported during acute illness and surgical or outpatient procedures, including elective cardioversion [2,7,8], though to our knowledge anticipation of a coronary angiogram or coronary intervention has not been previously documented as a precipitant. It would appear that coronary angiography needs to be added to the increasing list of triggers for this increasingly recognized condition [2]. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] 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 (Japanese). [2] S.W. Sharkey, B.J. Maron, Epidemiology and clinical profile of Takotsubo cardiomyopathy, Circ. J. 78 (2014) 2119–2128. [3] I.S. Wittstein, D.R. Thiemann, J.A. Lima, K.L. Baughman, S.P. Schulman, G. Gerstenblith, K.C. Wu, J.J. Rade, T.J. Bivalacqua, H.C. Champion, Neurohumoral features of myocardial stunning due to sudden emotional stress, N. Engl. J. Med. 352 (2005) 539–548. [4] K.A. Bybee, A. Prasad, Stress-related cardiomyopathy syndromes, Circulation 118 (2008) 397–409. [5] S.W. Sharkey, J.R. Lesser, R.F. Garberich, V.R. Pink, M.S. Maron, B.J. Maron, Comparison of circadian rhythm patterns in Tako-tsubo cardiomyopathy versus ST-segment elevation myocardial infarction, Am. J. Cardiol. 110 (2012) 795–799. [6] S. Kurisu, Y. Kihara, Tako-tsubo cardiomyopathy: clinical presentation and underlying mechanism, J. Cardiol. 60 (2012) 429–437. [7] J.H. Park, S.J. Kang, J.K. Song, H.K. Kim, C.M. Lim, D.H. Kang, Y. Koh, Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU, Chest 128 (2005) 296–302. [8] D. Haghi, S. Fluechter, T. Suselbeck, J. Saur, O. Bheleel, M. Borggrefe, T. Papavassiliu, Takotsubo cardiomyopathy (acute left ventricular apical ballooning syndrome) occurring in the intensive care unit, Intensive Care Med. 32 (2006) 1069–1074.
316
J. Kanawati, H.C. Lowe / International Journal of Cardiology 197 (2015) 315–316
V1
Fig. 1. ECG at presentation indicating widespread ST segment elevation.
Fig. 2. Left ventriculogram (right anterior oblique) view. A) At end diastole, B) at end systole, revealing contraction of basal segments only, consistent with Takotsubo cardiomyopathy.
V4
