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takotsubo, stress cardiomyopathy, Takotsubo Cardiomyopathy, ventricular dysfunction


Cardiology | Cardiovascular Diseases | Diagnosis | Internal Medicine


Introduction: For the past 15 years, Stress Cardiomyopathy (SC) was known as Takotsubo, The Japanese word for Octopus trap. Takotsubo resembles the apical ballooning form of the left ventricle seen in an echocardiogram or ventriculogram. SC comprises different variants. SC mimics acute coronary syndrome for EKG changes and/or cardiac enzymes elevation in the setting of no coronary obstruction. The left ventricular dysfunction in this entity is completely reversible. We present the case of a female who presented with chest pain and mild cardiac enzymes elevation. The left heart catheterization revealed an interesting variant, anterior segmental ventricular ballooning.

Case: A 59-year-old woman with a past medical history notable for Type 2 Diabetes Mellitus(T2DM), hypertension, and hyperlipidemia presented with substernal chest pain which lasts 10 minutes, palpitations, and numbness of the left arm. The patient presented with the symptoms after a heated argument at work. The patient's T2DM and Hypertension were well controlled. On physical exam, the patient was mildly hypertensive. However, the rest of the exam, CBC and BMP were unremarkable. Initial troponin was 0.11ng/ml and peaked to 1.80ng/ml. Chest radiography did not show cardiomegaly or pulmonary congestion. The patient was treated as no ST-elevation myocardial infarction. A left heart catheter was obtained showing left segmental anterior ventricular ballooning with an ejection fraction of 57%, and normal coronaries. The patient recovered and was discharged with a follow-up appointment in one month when a subsequent echocardiogram showed recovering of the EF to 72%.

Discussion: Stress cardiomyopathy was observed in 0.7-2.5% of patients with the suspected acute coronary syndrome. It affected women in 90.7% of the cases, especially post-menopausal. This entity is characterized by absence of coronary obstruction, reversibility of the left ventricular dysfunction, new EKG abnormalities or modest elevation in cardiac troponin. The EKG on admission showed ST-elevation in 71.1% of cases. The classical apical ballooning variant made up 54% of the cases, postero-basal 1%, Basal and mid-ventricular 1%, diaphragmatic 2%, localized apical 2%, anterolateral 11%, and complete mid-ventricular 29%. The pathophysiology of SC is not fully understood, but several hypotheses have been postulated. Dysfunction of the microvasculature has the most acceptance following by transient vasospasm, the encircling of the left anterior descending artery, and the effect of the adrenaline. The pathological changes showed focal myocytolysis and infiltration of small mononuclear cells which makes SC likely to be an inflammatory heart disease rather than a coronary artery disease. In light of the reversibility of this entity, the treatment is supportive in addition to control of the risk coronary factors. Our case is unique for the rare localization of an anterior segmental ventricular ballooning causing left ventricular dysfunction.

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Texas Chapter of the American College of Physicians