517359 research-article2013
ACC0010.1177/2048872613517359European Heart Journal: Acute Cardiovascular CareDesmet et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original scientific paper
The apical nipple sign: a useful tool for discriminating between anterior infarction and transient left ventricular ballooning syndrome
European Heart Journal: Acute Cardiovascular Care 2014, Vol. 3(3) 264–267 © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2048872613517359 acc.sagepub.com
Walter Desmet1,2, Johan Bennett1, Bert Ferdinande1, Dries De Cock1, Tom Adriaenssens1, Mark Coosemans1, Peter Sinnaeve1,2, Peter Kayaert1 and Christophe Dubois1,2
Abstract Aims: Even after coronary angiography, transient left ventricular ballooning syndrome (TLVBS) can be misdiagnosed as ST-elevation myocardial infarction (STEMI) caused by transient thrombotic occlusion of the left anterior descending artery, as the appearance of the left ventricular angiograms is often very similar. As prognosis and antithrombotic treatment of these two conditions differ widely, it is desirable to make a correct diagnosis as early as possible. Methods: Between January 1998 and August 2012, we identified 145 patients diagnosed with TLVBS in a single tertiary hospital, based on the Mayo criteria and (near) normalization of left ventricular function over weeks. For 119 of these patients, coronary and left ventricular angiograms were available for detailed study. Results: In 27 (22.7%) patients, mid-ventricular ballooning was observed, with preserved contractility of the apex, while in 92 (77.3%) typical apical ballooning was seen, with extensive akinesis of the apex. In 28 of the patients with typical apical ballooning (30.4%), we observed the presence of a very small zone with preserved contractility in the most apical portion of the left ventricle. We coined this phenomenon ‘apical nipple sign’. For comparison, we reviewed the left ventricular angiograms of 405 patients who had been treated for anterior STEMI by emergency percutaneous intervention on the left anterior descending artery in our hospital between February 2007 and October 2012. On careful review, the apical nipple sign was not seen in any of these. Conclusion: While discrimination between TLVBS and anterior STEMI is warranted as early as possible after admission, this is very difficult, especially in the majority of cases presenting with the classical apical ballooning phenotype. By observing the herein-described apical nipple sign, the attending physician can make the diagnosis of TLVBS with virtual certainty in almost one-third of cases. Keywords Anterior infarction, apical ballooning, apical nipple sign, Takotsubo cardiomyopathy, transient left ventricular ballooning syndrome Date received: 30 September 2013; accepted: 28 November 2013
Introduction Transient left ventricular ballooning syndrome (TLVBS) has been described under many names, among which Takotsubo or stress-induced cardiomyopathy, apical ballooning syndrome, broken heart syndrome, ampulla cardiomyopathy, and neurogenic stunned myocardium. It is a syndrome characterized by acute and often very severe transient left ventricular dysfunction, frequently occurring
1University 2KU
Hospitals Leuven, Leuven, Belgium. Leuven, Leuven, Belgium.
Corresponding author: Walter Desmet, Department of Cardiovascular Medicine, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium. Email: [email protected]
Downloaded from acc.sagepub.com at UNIV OF NORTH DAKOTA on June 14, 2015
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Desmet et al. after significant emotional or physical stress. It was first described in Japan over two decades ago1 and the first series of TLVBS patients outside of Japan was reported by our group in 2003.2 It is estimated to represent almost 2% of all suspected acute coronary syndromes, with 90% of cases being in postmenopausal women.3 Most patients present with symptoms suggestive of acute myocardial infarction, such as chest pain (67.8%), and dyspnoea (17.8%), and hence many are misdiagnosed as anterior STEMI. Many aspects of its pathogenesis still remain poorly understood. Prognosis was generally considered to be good, but has in more recent studies been reported as comparable to the prognosis of myocardial infarction.4 In 2008, Mayo Clinic diagnostic criteria were proposed, consisting of the following: (1) transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid segments with or without apical involvement, extending beyond a single epicardial vascular distribution; (2) absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; (3) new electrocardiographic abnormalities or modest elevation in cardiac troponin in the (4) absence of phaeochromocytoma and myocarditis.5 The authors acknowledged, however, the possibility that TLVBS can develop in a patient with obstructive coronary atherosclerosis, but that such cases were rare in the published literature, perhaps because such cases are misdiagnosed as an acute coronary syndrome. While most clinicians do not support the theory that TLVBS is an unusual variant of acute coronary syndrome, and most of the patients have no significant coronary artery disease (CAD), a substantial proportion (up to 63%) have evidence of some CAD, with up to 10% presenting with stenoses >75%.6 Hence, in many cases it is very difficult to differentiate between anterior STEMI and TLVBS in the acute phase, even after coronary angiography and left ventriculography. Indeed, interventional cardiologists are regularly confronted with a patient with symptoms and ECG findings suggestive of anterior STEMI, an extensive akinesis of the apex, and a minor or moderate stenosis of the left anterior descending artery (LAD), leaving them with the question whether the LAD should be stented or not. Over the years, it struck us on several occasions that some patients with the apical variant of TLVBS showed limited preserved contractility of a very small (
ACC0010.1177/2048872613517359European Heart Journal: Acute Cardiovascular CareDesmet et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original scientific paper
The apical nipple sign: a useful tool for discriminating between anterior infarction and transient left ventricular ballooning syndrome
European Heart Journal: Acute Cardiovascular Care 2014, Vol. 3(3) 264–267 © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2048872613517359 acc.sagepub.com
Walter Desmet1,2, Johan Bennett1, Bert Ferdinande1, Dries De Cock1, Tom Adriaenssens1, Mark Coosemans1, Peter Sinnaeve1,2, Peter Kayaert1 and Christophe Dubois1,2
Abstract Aims: Even after coronary angiography, transient left ventricular ballooning syndrome (TLVBS) can be misdiagnosed as ST-elevation myocardial infarction (STEMI) caused by transient thrombotic occlusion of the left anterior descending artery, as the appearance of the left ventricular angiograms is often very similar. As prognosis and antithrombotic treatment of these two conditions differ widely, it is desirable to make a correct diagnosis as early as possible. Methods: Between January 1998 and August 2012, we identified 145 patients diagnosed with TLVBS in a single tertiary hospital, based on the Mayo criteria and (near) normalization of left ventricular function over weeks. For 119 of these patients, coronary and left ventricular angiograms were available for detailed study. Results: In 27 (22.7%) patients, mid-ventricular ballooning was observed, with preserved contractility of the apex, while in 92 (77.3%) typical apical ballooning was seen, with extensive akinesis of the apex. In 28 of the patients with typical apical ballooning (30.4%), we observed the presence of a very small zone with preserved contractility in the most apical portion of the left ventricle. We coined this phenomenon ‘apical nipple sign’. For comparison, we reviewed the left ventricular angiograms of 405 patients who had been treated for anterior STEMI by emergency percutaneous intervention on the left anterior descending artery in our hospital between February 2007 and October 2012. On careful review, the apical nipple sign was not seen in any of these. Conclusion: While discrimination between TLVBS and anterior STEMI is warranted as early as possible after admission, this is very difficult, especially in the majority of cases presenting with the classical apical ballooning phenotype. By observing the herein-described apical nipple sign, the attending physician can make the diagnosis of TLVBS with virtual certainty in almost one-third of cases. Keywords Anterior infarction, apical ballooning, apical nipple sign, Takotsubo cardiomyopathy, transient left ventricular ballooning syndrome Date received: 30 September 2013; accepted: 28 November 2013
Introduction Transient left ventricular ballooning syndrome (TLVBS) has been described under many names, among which Takotsubo or stress-induced cardiomyopathy, apical ballooning syndrome, broken heart syndrome, ampulla cardiomyopathy, and neurogenic stunned myocardium. It is a syndrome characterized by acute and often very severe transient left ventricular dysfunction, frequently occurring
1University 2KU
Hospitals Leuven, Leuven, Belgium. Leuven, Leuven, Belgium.
Corresponding author: Walter Desmet, Department of Cardiovascular Medicine, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium. Email: [email protected]
Downloaded from acc.sagepub.com at UNIV OF NORTH DAKOTA on June 14, 2015
265
Desmet et al. after significant emotional or physical stress. It was first described in Japan over two decades ago1 and the first series of TLVBS patients outside of Japan was reported by our group in 2003.2 It is estimated to represent almost 2% of all suspected acute coronary syndromes, with 90% of cases being in postmenopausal women.3 Most patients present with symptoms suggestive of acute myocardial infarction, such as chest pain (67.8%), and dyspnoea (17.8%), and hence many are misdiagnosed as anterior STEMI. Many aspects of its pathogenesis still remain poorly understood. Prognosis was generally considered to be good, but has in more recent studies been reported as comparable to the prognosis of myocardial infarction.4 In 2008, Mayo Clinic diagnostic criteria were proposed, consisting of the following: (1) transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid segments with or without apical involvement, extending beyond a single epicardial vascular distribution; (2) absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; (3) new electrocardiographic abnormalities or modest elevation in cardiac troponin in the (4) absence of phaeochromocytoma and myocarditis.5 The authors acknowledged, however, the possibility that TLVBS can develop in a patient with obstructive coronary atherosclerosis, but that such cases were rare in the published literature, perhaps because such cases are misdiagnosed as an acute coronary syndrome. While most clinicians do not support the theory that TLVBS is an unusual variant of acute coronary syndrome, and most of the patients have no significant coronary artery disease (CAD), a substantial proportion (up to 63%) have evidence of some CAD, with up to 10% presenting with stenoses >75%.6 Hence, in many cases it is very difficult to differentiate between anterior STEMI and TLVBS in the acute phase, even after coronary angiography and left ventriculography. Indeed, interventional cardiologists are regularly confronted with a patient with symptoms and ECG findings suggestive of anterior STEMI, an extensive akinesis of the apex, and a minor or moderate stenosis of the left anterior descending artery (LAD), leaving them with the question whether the LAD should be stented or not. Over the years, it struck us on several occasions that some patients with the apical variant of TLVBS showed limited preserved contractility of a very small (
