Takotsubo cardiomyopathy is a unique acute cardiac syndrome characterized by typical chest symptoms,elevated ST segment on electrocardiograms,elevated cardiac markers and is usually misdiagnosed as acute myocardial infarction. Coronary angiography usually reveals no evidence of obstructive atherosclerotic coronary disease. Left ventriculography reveals a peculiar regional systolic dysfunction with hyperkinesis of the basal ventricular segment and akinesis of the mid-ventricle and apex.The syndrome was initially recognized in Japanese patients and has been named so after the fishing pot with a round bottom and narrow neck that is used for trapping octopus in Japan (octopus is “tako,” and pot is “tsubo” in Japanese).We report a case of this rare syndrome in our critical care setting and discuss the the pathophysiology involved .
Patient is a 67 year old female with history of end stage renal disease on hemodialysis who was admitted to intensive care unit with 1 day complaint of fever(102’F),altered mental status and hypoxic respiratory failure for which she required intubation. Her examination was unremarkable except for fever and crackles on right side of chest and confusion. Laboratory demonstrated a white blood cell count of 16,000 The serum cardiac markers and electrocardiography were unremarkable EKG. Chest radiograph demonstrated a right lower lobe infiltrate and fluid overload. Blood cultures subsequently grew Streptococcus Bovis and the urinary streptococcal antigen was positive. She was successfully extubated but then she developed sinus tachycardia with rate of 122 beats/min and electrocardiography demosntrated 3mm of elevation in Leads V1 to V5 and 1 and avL with an acute anteroseptal and lateral injury pattern. The troponin I increased to 64,CK 763, MB 54 and index of 7.1.Bedside echocardiogram showed akinesis of the mid distal anteroseptum and apex.Because of the concern of an acute coronary event, she was taken to the cardiac catherization laboratory. Coronary angiogram showed normal coronary arteries and a left ventriculogram revealed anteroseptal akinesis and basal hyperkinesis. The patient was treated with beta blockers and ACE inhibitors and remained stable without any further complications.
Reversible left ventricular asynergy,known as “Takotsubo” cardiomyopathy is rare and most often affects postmenopausal women with a mean age between 62 to 75 years of age and mimics an acute coronary syndrome in presentation despite the absence of obstructive coronary disease. An episode of emotional or physiologic stress frequently has been reported prior to the presentation. We believe that pneumonia and streptococcal bacteremia was the precipitating event in our patient. It has been described in patients with pneumothorax,alcohol withdrawl and head trauma,intracranial or subarachnoid bleed,pheochromocytoma,myocarditis,hpertrophic cardiomyopathy can also present with similar regional wall motion abnormalities. The exact cause of this apical balloning is not known but multivessel coronary artery spasm, catecholamine induced cardiomyopathy, adrenoceptor-hyperactive cardiomyopathy and neurogenically mediated myocardial stunning have all been proposed as a possible mechanism. The overall prognosis is good with a low mortality and a low risk of recurrence. There has been a case report of cardiac rupture and sudden cardiac death. Other potential complications include left heart failure, ventricular arrhythmia, mural thrombus formation, mitral regurgitation, and dynamic intraventricular obstruction. Treatment is mainly supportive with beta blockers and angiotensin converting enzyme inhibitors. Anticoagulation is often used in the setting of significant left ventricular systolic dysfunction.
Takotsubo is a rare syndrome with a relative lack of publised data and dignostic criteria. It should be considered in the differential diagnosis of acute myocardial infarction. Additional information is needed to determine the precise pathophysiology of this disease.
Nikhat Salamat, None.