Stress Related Takotsubo Cardiomyopathy: A Case Report

Transcription

1 Journal of Pharmacy and Pharmacology 6 (2018) doi: / / D DAVID PUBLISHING Stress Related Takotsubo Cardiomyopathy: A Case Report Ana Beatriz Boamorte Cortela 1, Franciele Silva Bernardo 2, Marcos Tadao Kavanishi 1, Vilmar Queiroz de Menezes 3 and Nivaldo Cortela 3 1. Faculty of Medicine, Centro Universitário de Várzea Grande, Várzea Grande , Brazil 2. Faculty of Medicine, Universidade do Estado de Mato Grosso, Cáceres , Brazil 3. Hospital Regional de Cáceres Dr. Antônio Fontes, Universidade do Estado de Mato Grosso, Cáceres , Brazil Abstract: First described in Hiroshima City Hospital in 1990, Takotsubo Cardiomyopathy emerged as an important differential diagnosis for acute coronary syndrome, since this disease mimics some commemoratives presentations of acute coronary syndrome such as chest symptoms, electrocardiographic changes and cardiac injury biomarker alteration. Also, it s important to emphasize that, although it commonly occurs among woman, TCC can happen in males, as demonstrated in other studies which 10% of the cases occurred in male sex. In this way, this study shows the importance of Takotsubo Cardiomyopathy as a differential diagnosis for acute coronary syndrome. Key words: Takotsubo cardiomyopathy, apical ballooning, broken-heart syndrome. 1. Introduction The broken-heart syndrome, also known as TTC (Takotsubo Cardiomyopathy), is a stress-induced condition with emotional or physical triggers depending on the patient clinical history. It was first described in the 1990 s and since then was best studied and described as a transient left ventricular apical ballooning, associated with chest pain, high levels of catecholamines and electrocardiographic waves abnormalities in the absence of coronary stenosis [1, 2] Despite the TTC was extremely rare in male population, recently they constitute over 10% of the cases and are mostly related to physical stress triggers [3]. On the other side, the female population corresponds to 80%-100% of the reported cases [4-7] especially in the postmenopausal years and commonly related to emotional stress triggers. Actually, there are an amount of stress causes such as: loss of a beloved one, financial problems, personal Corresponding author: Ana Beatriz Boamorte Cortela, medicine student, research fields: cardiology. experiences of anger, frustration, anxiety, panic, or fear, major surgical procedures, acute respiratory failure, orthopedic trauma, and many others [8]. 2. Case Report A 73-years-old male patient sought cardiac care for evaluation due to an episode of precordial pain, characterized as a strong retrosternal pain, which happened 2 days ago and lasted 3 hours. During these symptoms, the BP (blood pressure) was 70/40 mmhg. At the moment of the medical appointment, the patient was asymptomatic and denied medical history of chest pain, acute myocardial infarction, diabetes and other comorbidities. In addition he was not using any medications. The physical examination presented BP of 130/80 mmhg and normal auscultation. The laboratorial tests, including blood count, blood glucose, lipidogram, renal and hepatic function, uric acid and thyroid stimulating hormone showed normal results. The ECG (electrocardiography) demonstrated sinus rhythm with ventricular repolarization changes

2 Stress Related Takotsubo Cardiomyopathy: A Case Report 249 observed in the D1, avl and V1 to V6 leads, suggesting an extensive lateral and antero-lateral walls ischemia (Fig. 1). The echocardiography showed apical left ventricle hypokinesis. With a diagnostic hypothesis of acute myocardial infarction (AMI), the following procedure was adopted: request of Cardiac Catheterism (CAT) and treatment with propranolol, acetylsalicylic acid, clopidogrel and simvastatin. These medications were taken for six days only, until the return with the CAT images. After 4 days the patient underwent CAT, which revealed very tortuous coronaries, but without obstructions and left ventricle with increased systolic and diastolic volumes, exhibiting hypocontractility in all anterior and apical segments, suggesting TTC (Fig. 2). Two days after the CAT, the patient returned to medical appointment and stated that in the last few days he was nervous because of problems with his son and that the pain has started since then. Thus, TTC was confirmed. The previous treatment was suspended and the new prescription was Somalgin, Sustrate and Simvastatin. The patient evolved with no hemodynamic complication and the return was scheduled to six months later. After this period, patient returns without complaints and only using Simvastatin. At the physic evaluation, Fig. 1 ECG abnormalities observed in the first clinical appointment.

3 250 Stress Related Takotsubo Cardiomyopathy: A Case Report Fig. 2 From the left to the right: CAT during diastole, CAT during systole, CAT showing left coronary with no obstructions. Fig. 3 ECG after 6 months.

4 Stress Related Takotsubo Cardiomyopathy: A Case Report 251 BP of 120/80 mmhg, normal heart auscultation, ECG within normal limits (Fig. 3) and echocardiogram: discrete aortic insufficiency and normal cardiac contractility. With TTC resolved, the Somalgin and Sustrate were discontinued, but the Simvastatin was maintained. The return was oriented to happen within one year. 3. Discussion The Takotsubo Syndrome is a reversible situation, characterized by a transient dysfunction of the left ventricle, which mimics the acute coronary syndrome (ACS). TTC occurs after a physic or emotional stress event, especially in postmenopausal woman as many studies have showed as Refs. [4-7, 9]. The present description shows a TTC in male patient, situation that occurs in nearly 10% of the reported cases [3, 9, 10]. Also, studies have shown that the majority of cases in man happened due to a physical stress, for instance, acute respiratory failure, AMI, and others [3, 10-13]. Other physical stress includes surgery procedures, subarachnoid hemorrhage, hypertensive crisis, cancer, etc. [8]. However, our patient presented an emotional stress triggering the syndrome, more specifically, an interpersonal problem between him and his son. The possible association is the adrenergic discharge stress-provoked [5]. Many etiologies and pathophysiology mechanisms where proposed such acute myocarditis, diffuse coronary spasm, non-occlusive plaque rupture followed by spontaneous thrombolysis, and others [5]. New hypothesis has been accepted as cardio toxicity catecholamine-mediated, which causes an overload of calcium to the cardiac myocytes, unleashing a ventricular contraction and ventricular function disturb [14]. It is possible that the endothelial dysfunction is related to the menopausal decrease of estrogen [15]. The mental stress may have a direct effect over the endothelial function on account of the endothelin receptor type A activation. Nevertheless, the pathophysiology remains undetermined and it s likely to be multifactorial, involving the vascular, endocrine and nervous systems. The symptoms of TTC include chest pain or dyspnea but they do not present the same severity as the ACS [17]. Clinical state is associated to electrocardiographic alterations such ST-segment elevation and T-wave inversion respecting the leads of a single coronary territory. Our patient had a left anterior descending coronary pattern, which is similar in patients with this artery obstruction. Ref. [16] made a comparison between those two conditions and found that the only difference was the ST-segment amplitude, which is lower in TTC. While the etiology of the ECG alterations is not defined, it s important to treat AMI and request an imaging exam. Echocardiography, cardiac magnetic tomography or even resonance is useful in this case, and they consist in non-invasive methods of evaluation. With them it s possible to analyze the segments with abnormal contraction, reveal presence of apical thrombosis, cardiac rupture and other conditions that evolve to cardiogenic shock [1]. It is essential to require CAT in the acute phase of ST-segment elevation, due to the possibility of coronary obstruction [1]. In TCC, the coronary angiography reveals totally normal blood vessels in most cases, but non-critical luminal stenosis can be found. In fact, the presence of coronary artery disease does not exclude the possibility of TTC involvement, since it was found to participate on the TCC development [17, 18]. On the other side, patients under hemodynamic risks or in which the CAT s harm exceeds its benefits must undergo echocardiography first [1]. Essentially, the treatment basis is support and observation as the spontaneous and complete reversion of the cardiac dysfunction occurs in days or weeks. The prognostic of the illness itself is benign, but the previous condition and the presence of comorbidities are the most important predictors of complications and adverse outcomes [19]. Possible complications are

5 252 Stress Related Takotsubo Cardiomyopathy: A Case Report cardiogenic shock, ventricular arrhythmia, ventricular fibrillation, ventricular rupture and others [19]. In our case, the patient evolved with no complications and returned to the cardiologic clinic after six months and therefore it s not possible to assume how much time took to the syndrome to reverse. TCC is characterized of resolving spontaneously in most of the cases, taking over days or few weeks to reverse. Curiously, there are cases reporting more than 3 months of abnormalities persistence [20]. 4. Conclusions As TTC is a rare disease, many things remain unknown about it, especially its etiology. On the other hand, it s always important to maintain TTC as a differential diagnosis for ACS, mainly in patients whose chest symptoms started post a stressful event, since the treatment and the prognosis of both pathologies are different. Finally, the purpose of this study is to implement the database about TTC and reinforce the importance of the diagnosis in the male gender, as demonstrated in this study. Furthermore, it s expected that more knowledge about the disease will be discovered as more searches about the theme are developed. References [1] Scantleburry, D. C., and Prasad, A Diagnosis of Takotsubo Cardiomyopathy. Circulation Journal 78: [2] Bossone, E., Savarese, G., Ferrara, F., et al Takotsubo Cardiomyopathy: Overview. Heart Failure Clin 9: [3] Kurisu, S., and Kihara, Y Tako-tsubo Cardiomyopathy: Clinical Presentation and Underlying Mechanism. Journal of Cardiology 60: [4] Tsuchihashi, K., Ueshima, K., Uchida, T., Oh-mura, N., Kimura, K., Owa, M., et al Transient Left Ventricular Apical Ballooning without Coronary Artery Stenosis: A Novel Heart Syndrome Mimicking Acute Myocardial Infarction: Angina Pectoris-Myocardial Infarction Investigations in Japan. Journal of the American College of Cardiology 38: [5] Bybee, K. A., Kara, T., Prasad, A., Lerman, A., Barsness, G. W., Wright, R. S., et al Systematic Review: Transient Left Ventricular Apical Ballooning: A Syndrome That Mimics ST-Segment Elevation Myocardial Infarction. Annals of Internal Medicine 141: [6] Brinjikji, W., El-Sayed, A. M., and Salka, S In-hospital Mortality among Patients with Takotsubo Cardiomyopathy: A Study of the National Inpatient Sample 2008 to American Heart Journal 164: [7] Leurent, G., Larralde, A., Boulmier, D., Fougerou, C., Langella, B., Ollivier, R., et al Cardiac MRI Studies of Transient Left Ventricular Apical Ballooning Syndrome (Takotsubo Cardiomyopathy): A Systematic Review. International Journal of Cardiology 135: [8] Sharkey, S. W., and Maron, B. J Epidemiology and Clinical Profile of Takotsubo Cardiomiopathy. Circulation Journal 78: [9] Pilgrim, T. M., and Wyss, T. R Takotsubo Cardiomyopathy or Transient Left Ventricular Apical Ballooning Syndrome: A Systematic Review. International Journal of Cardiology 124: [10] Manfredini, R., Manfredini, F., Fabbian, F., Salmi, R., Gallerani, M., Bossone, E., et al. Chonobiology of Takostubo Syndrome and Myocardial Infarction: Analogies and Differences. Heart Faillure Clinics 12(4): [11] Nóbrega, S., and Brito, D The Broken Heart Syndrome: State of the Art. Revista Portuguesa de Cardiologia 31 (9): [12] Taniguchi, K., Takashima, S., Iida, R., Ota, K., Nitta, M., Sakane, K., et al Takotsubo Cardiomyopathy Caused by Acute Respiratory Stress from Extubation. Medicine (Baltimore) 96 (48): e8946. Accessed January 30, [13] Christodoulidis, G., Kundoor, V., and Kaluski, E Stress Induced Cardiomyopathy Triggered by Acute Myocardial Infarction: A Case Series Challenging the Mayo Clinic Definition. The American Journal of Case Reports 18: [14] Wittstein, I. S., Thiermann, D. R., Lima, J. A. C., Baughman, K. L., Schulman, S. P. Gerstenblith, G., et al Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress. N Engl. J. Med. 352 (6): [15] Celermajer, D. S., Sorensen, K. E., Spiegelhalter, D. J., et al Aging Is Associated with Endothelial Dysfunction in Healthy Men Years Before the Age-Related Decline in Women. J. Am. Coll. Cardiol 24: [16] Sharkey, S. W., Lesser, J. R., Menon, M., Parpart, M., Maron, M. S., and Maron, B. J Spectrum and

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