Acute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome

Transcription

1 Acute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome N.Μoschos, A.Dimitra, E.Tsakiri, D.Stavrianakis, A.Nouli CARDIOLOGY DEPARTMENT GENERAL HOSPITAL OF RHODES

2 First Medical Contact: Case Report 72 yo male patient visits ER Symptoms: Dysuria, suprapubic discomfort, frequency, chills, fever. Medical history: diabetes, hypertension, dyslipidemia, BPH. Physical examination: moderate general condition hypothermia (35,6 0 C) HR=110 bpm RR=17 breaths/min BP=120/80 mmhg abdominal tenderness in the suprapubic area.

3 Case Report Initial laboratory results: Blood analysis: WBC count of (Poly 82%) Blood sugar 300 CRP 27,3 (NV<1.5) Urine analysis: cloudy urine positive for nitrates 30 WBC 12 RBC many bacteria 3+ protein, 3+ glucose, 2+ hemoglobin.

4 The patient was admitted in the Urology Department: Diagnosis: Acute complicated Urinary Tract Infection (UTI). Urine and two peripheral blood cultures were collected prior to initiation of antibiotics. Urine: > cfu/ml E.coli multi-susceptible, resistant to Quinolones. Blood: negative. ECG of admission Case Report RBBB SR tachycardia No ST-T abnormalities

5 Cardiology Contact: Case Report The 2 nd day of hospitalization the patient complained of an abrupt onset of chest pain and concomitant dyspnea: Critical clinical condition Signs of left-sided congestion: Orthopnoea Bilateral pulmonary rales (Killip III) Hypotension BP<90/60 HR=120bpm RR=30 breaths/min Blood gas examination Hypoxaemia Hypocapnia

6 Diagnostic Investigation New ECG with signs of ischemia RBBB SR tachycardia 3mm ST depression in all leads 2mm ST elevation in avr

7 Diagnostic Investigation TTEcho Reduction of EFLV=30% Concentric akinesia of the basal segments of the LV. No valve abnormalities BIOMARKERS Troponin=6,33 (NV<0,15) Pro-BNP =7.371 (NV<125)

8 While being asymptomatic, the patient had sudden clinical manifestations of: Acute Heart Failure Elevated biomarkers for Heart Failure Severe reduction in LV systolic function Elevated indexes of myocardial necrosis Myocardial Infarction without ST elevation (NSTEMI) Cardiogenic shock Critical clinical condition The patient was transferred to the ICCU.

9 An ACS treatment pathway was activated. He received therapy according to the Guidelines for NSTEMI and acute HF: DAPT (aspirin and clopidogrel) Anticoagulant treatment (fondaparinux) Atorvastatin Vasopressors (norepinephrine) Diuretics Hemodynamically stabilized Immediate coronarography

10 ICA LAO RAO CAU Absence of culprit CAD (occlusion, dissection, thrombosis, plaque rupture) CRA

11 LEFT VENTICULOGRAM End-Diastolic frame End-Systolic frame Unusual ventriculogram: Hypercontractility of the apex and medium segments Marked symmetrical hypokinesia of the basal segments of anterior and inferior wall. Severely reduced EFLV=25-30% Elevated LVEDP=23mmHg

12 LEFT VENTICULOGRAM

13 Outcome In the ICCU the patient s general condition gradually improved. Treatment for HF (b-blockers, ACEI, MRA), aspirin, statin and antibiotic treatment. He got discharged on the 20 th day of hospitalization. ECG: Pre-discharge Echo dramatically improved: LV systolic function recovered back to normal.

14 Follow-up Echo (20 days) Our patient s subsequent TTE demonstrated normal LV systolic function with an estimated EF=65%.

15 Differential Diagnosis Myocardial infarction: Type II MI: secondary to ischemia due to mismatch between oxygen demand-supply MINOCA Myocarditis Takotsubo syndrome

16 CARDIAC MRI LGE reflects irreversible myocardial injury (necrosis and fibrosis). The pattern of LGE can offer important information regarding the underlying etiology: MI Myocarditis Takotsubo :transmural or subendocardial :epicardial :absent or if present acutely patchy form

17 MRI (15 days after discharge) EFLV=62% Cardiac T1* Cardiac T2* (Gd) No LGE

18 Diagnosis Acute Heart Failure due to: Takotsubo syndrome

19 Discussion Takotsubo syndrome-definition: It is a form of acute and reversible Heart Failure. Possibly caused by acute catecholaminergic myocardial stunning. Absence of culprit CAD (occlusion, dissection, plaque rupture, thrombosis). The initial presentation has similar features to STEMI or NSTEMI It accounts for 1-2% of all cases with suspected ACS. European Journal of Heart Failure Volume 18, Issue 9, September 2016

20 Discussion Diagnostic criteria (2015 HFA of ESC): 1. Transient regional wall motion abnormality after a stressful trigger (emotional or physical). 2. Beyond a single epicardial vascular distribution (circumferential dysfunction). 3. Absence of culprit CAD or other pathology. 4. ECG abnormalities. 5. Elevated serum natriuretic peptides. 6. Relatively small elevation of Troponin. 7. Recovery of systolic function on cardiac imaging at follow-up (3 6 months). European Journal of Heart Failure Volume 18, Issue 9, September 2016

21 Discussion Clinical subtypes: PRIMARY Acute cardiac symptoms the primary reason for FMC. ± Stressful triggers Co-existing medical conditions (not primary cause). SECONDARY Patients being hospitalized for another condition: Medical Surgical Anesthetic Obstetric or Psychiatric European Journal of Heart Failure Volume 18, Issue 9, September 2016

22 Discussion Anatomical variants: Classical pattern 75-80%. Mid LV variant ~10-15% Reverse or basal ~5% Biventricular <0.5% Localized type Isolated RV European Journal of Heart Failure Volume 18, Issue 9, September 2016

23 Discussion Anatomical variants: Classical pattern 75-80%. Mid LV variant ~10-15% Reverse or basal ~5% Biventricular <0.5% Localized type Isolated RV European Journal of Heart Failure Volume 18, Issue 9, September 2016

24 Final Diagnosis Acute Heart Failure due to: Takotsubo syndrome Secondary clinical subtype, after an acute complicated UTI Reverse anatomical variant

25 Comparison of LVES frames in Reverse vs Classical variant Reverse Takotsubo Classic variant

26 Conclusion Takotsubo syndrome is a rare entity (1-2% of ACS). Increasingly recognized by the medical community. Reverse Takotsubo variant appears in ~5% of all cases. Extremely rare case report (0,5-1 ). Systolic HF is the most common complication (12-45%) In patients with Cardiogenic Shock the in-hospital mortality rates are high and variant (3-17%). Early recognition contributes to treatment plans and aids in the expectation of recovery and prognosis.

27 Statistical data Cardiology Department General Hospital of Rhodes The last 3 years since our Cath Lab s establishment: 1500 Coronarographies in ACS patients. 10 patients were diagnosed with Takotsubo syndrome. Men:Women 1:1 Women with Primary Takotsubo presenting as STEMI Men with Secondary Takotsubo presenting as NSTEMI 1 patient with Reverse Takotsubo variant Extremely rare case 1:1500 ( %)

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