PURPOSE:Transient left ventricular apical ballooning syndrome (LVABS) or Takotsubo's cardiomyopathy is characterized by symptoms and electrocardiogram (ECG) changes similar to acute coronary syndromes in absence of significant coronary artery obstruction. The pathogenesis of the LVABS has not been elucidated clearly. We describe six patients with LVABS to illustrate the clinical features and a possible cause of this transient left ventricular systolic dysfunction. These patients developed LVABS on exposure to exogenous catecholamines.
METHODS:A total of 105 patients with symptoms and electrocardiographic changes consistent with acute coronary syndrome were admitted at our institution from March 2006 to Feb 2007. Of these 6 patients (6.3%) were subsequently diagnosed with LVABS based on Mayo criteria. All patients underwent coronary angiography and serial echocardiography for evaluation of left ventricular systolic function. This study was approved by Institutional Review Board.
RESULTS:These six cases (3 males, 3 females) exhibited characteristic transient clinical, ECG and echocardiographic changes of LVABS. They were admitted with varied presentations including chest pain, pulmonary edema and cardiogenic shock requiring intra-aortic balloon counterpulsation (1). Their median age was 62 years. Initial ECG showed normal sinus rhythm in all four but three cases had deep T-wave inversions in anterolateral leads while the other had ST elevation of 1mm in inferior leads. Median peak Troponin I was 2.3 ng/ml. On echocardiography they had similar contractile pattern, with preserved basal function and apical akinesis. Median ejection fraction of 0.20 at presentation improved to 0.55 six to ten days later with normal contractility of all segments. Angiography revealed non-obstructive coronary arteries in all patients. Notably, all six were exposed to catecholamines (× agonist inhalers and one during a dobutamine stress test) immediately prior to developing regional wall motion abnormality.
CONCLUSION:Takotsubo cardiomyopathy is an important condition impersonating acute coronary syndromes. Catecholamines (exogenous or endogenous) may be central to the cause of transient left ventricular apical ballooning syndrome.
CLINICAL IMPLICATIONS:Takotsubo cardiomyopathy mimicks acute coronary syndrome.
DISCLOSURE:Shikha Sharma, No Financial Disclosure Information; No Product/Research Disclosure Information