Friday, 17 September 2010

76 year old female CC: Chest pain - Conclusion (Tako-Tsubo Cardiomyopathy)

Here is the conclusion to the most recent case: 76 year old female CC: Chest pain.

To see Part I click HERE. To see Part II click HERE.

The patient was transported to the emergency department where she was treated for a possible acute coronary syndrome.

Serial 12-lead ECGs and cardiac biomarkers were performed.

This 12-lead ECG was captured at 1407.



This is fairly similar to the prehospital 12-lead ECGs.

The next 12-lead ECG is from 1722.



This ECG is significantly different from the prehospital 12-lead ECGs.



You will note that the hyperacute T-waves are gone, as are the ST-elevation and reciprocal changes.

Let's look at the cardiac biomarkers.

1407

CPK.............................38
CKMB........................2.56
Troponin..................< 0.01

1730

CPK............................72
CKMB.....................12.30(H)
Troponin..................0.562(H)

The patient was admitted to the hospital.

Echocardiogram showed a large anteroseptal wall motion abnormality.

0610 (the following morning)

CPK............................48
CKMB.......................7.46(H)
Troponin..................0.211(H)

It should be noted that with changes on serially obtained ECGs and a rise and fall of cardiac biomarkers, the WHO criteria for the diagnosis of acute myocardial infarction has been met.

The patient was sent to the cardiac cath lab for PTCA and stents if needed.

Results:
  1. Insignificant epicardial coronary artery narrowing in a right dominant system.
  2. Congenitally absent left main (normal variant).
  3. Severely reduced left ventricular systolic function, left ventricular ejection fraction 35% with a large anterolateral and apical area of akinesis. The apex is aneurysmal.
  4. Likely apical ballooning syndrome versus spasm in the left anterior descending coronary as a cause of the apical wall motion abnormality.
So, what is "Apical Ballooning Syndrome"?

It is also called "Tako-Tsubo Cardiomyopathy," "Stress Cardiomyopathy," or "Broken Heart Syndrome."

"Tako" is the Japanese word for octopus and "Tsubo" is the Japanese word used for pot or trap. The Japanese physician who first described this condition noted that the end-systolic ventriculogram took on the shape of an "octopus pot" and hence the name "Tako-Tsubo" or "Takotsubo".


Here's an image that shows a side-by-side of the patient's ventriculogram (end-diastole on the left and end-systole on the right).



This is a fairly obscure but well documented STEMI mimic (although one article I found from Mayo Clinic Proceedings suggests that spontaneous aborted MI is a more likely scenario).

If you would like to learn more about Tako-Tsubo Cardiomyopathy you can see the Wikipedia article HERE. The eMedicine article is HERE. The Medscape article is HERE.

From the Medscape article:
"Patients often present with chest pain, have ST-segment elevation on electrocardiogram, and elevated cardiac enzyme levels consistent with a myocardial infarction.1 However, when the patient undergoes cardiac angiography, left ventricular apical ballooning is present and there is no significant coronary artery stenosis."

"One of the more unique features of TCM is the association with a preceding emotionally or physically stressful trigger event, occurring in approximately two thirds of patients."

"Recently, TCM has been reported after near drowning episodes."
How about that, Dr. House?

See also:

76 year old female CC: Chest pain

76 year old female CC: Chest pain - The case for this being an acute anterior STEMI