SESSION TYPE: Cardiovascular Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Tako-tsubo cardiomyopathy (TCM) is a transient left ventricular apical hypokinesis/akinesis that mimics acute coronary syndrome in post menopausal women. It has been reported soon after sub-arachnoid hemorrhages (SAH) in up to 50% of cases. The relationship between SAH and cardiomyopathy is not well understood. This case illustrates a rare, delayed presentation of TCM.
CASE PRESENTATION: A 62 year old woman was transferred to our facility for sudden onset head ache, photophobia and nuchal rigidity with a documented SAH by head CT. She was completely conscious, afebrile, hemodynamically stable with normal blood tests on presentation. She underwent emergency cerebral angiography and coiling of a ruptured anterior communicating artery (ACOM) aneurysm. (Fig.1) Post procedure, the patient was placed on pressors to avoid cerebral vasospasm. An echocardiogram showed normal left ventricular function. 14 days post procedure the patient became severely hypotensive and required mechanical ventilation. Trans-thoracic echo at this time showed severely impaired LV function with an ejection fraction of 10 %, apical akinesis with ballooning and basal wall sparing (Fig.2). Cardiac enzymes were not elevated. This pattern suggested a diagnosis of TCM. A coronary angiogram could not be performed as the patient’s family desired no further intervention.
DISCUSSION: Cardiac dysfunction may occur, usually within a few days of SAH, with variants ranging from TCM to neurogenic stunned myocardium (NSM). In NSM, the apex is spared and there is basal hypokinesis. In TCM there is apical hypokinesis and basal sparing. Both cardiomyopathies are thought to be the result of a complex neuro-hormonal interaction. Mayo criteria were developed for the diagnosis of TCM, considering intra-cranial bleeds as an exclusion criteria, based on available literature at that time(1). Subsequent case reports show an association of SAH with the classical echocardiographic findings of Tako-tsubo cardiomyopathy, namely apical or mid-segment hypokinesis/akinesis with basal sparing/hyperkinesis. This case illustrates the need to consider TCM even a few weeks after an intra-cranial bleed as a possible cause of potentially life threatening cardiac dysfunction.
CONCLUSIONS: This case is reported for the very late presentation of Takotsubo Cardiomyopathy after the offending neurological event. Our literature search revealed only one other case from Japan with Tako-tsubo cardiomyopathy presenting 9 days after SAH (2).
1) Bybee KA et al; Systematic Review: Transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 141: 858-865, 2004.
2) Ryuta Saito et al; Tako-tsubo cardiomyopathy induced by dopamine infusion during hypertensive therapy for symptomatic vasospasm after sub-arachnoid hemorrhage. Neurol Med Chir (Tokyo) 50: 393-395, 2010.
DISCLOSURE: The following authors have nothing to disclose: Mohan Ashok Kumar, Peter Nakaji, Priya Radhakrishnan, Richard Sue
No Product/Research Disclosure InformationInternal Medicine, St. Joseph's Hospital, Phoenix, AZ