Sethwala et al. Int J Clin Cardiol 2021, 8:227 Volume 8 | Issue 3 International Journal of Clinical Cardiology Open Access Citaon: Sethwala A, Habersberger J, Sher J, Pearson M, Beer N (2021) Takotsubo Cardiomyopathy Triggered by Intervenon for a Threatened Acute Myocardial Infarcon - It is not over ll it is over!. Int J Clin Cardiol 8:227. doi.org/10.23937/2378-2951/1410227 Accepted: May 29, 2021: Published: May 31, 2021 Copyright: © 2021 Sethwala A, et al. This is an open-access arcle distributed under the terms of the Creave Commons Aribuon License, which permits unrestricted use, distribuon, and reproducon in any medium, provided the original author and source are credited. Sethwala et al. Int J Clin Cardiol 2021, 8:227 DOI: 10.23937/2378-2951/1410227 ISSN: 2378-2951 • Page 1 of 5 • Takotsubo Cardiomyopathy Triggered by Intervenon for a Threatened Acute Myocardial Infarcon - It is not over ll it is over! Anver Sethwala, MBBS (Hons) 1 , Jonathan Habersberger, FRACP 2 , Joshua Sher 2 , Michael Pearson, B.App.Sc (Med Rad) 2 and Nathan Beer, FRACP 1,2,3,4 1 Department of Cardiology, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia 2 St Francis Xavier Cabrini Hospital, Malvern, Australia 3 Department of Nuclear Medicine, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia 4 University of Melbourne, Melbourne, Australia *Corresponding author: Dr. Anver Sethwala, MBBS (Hons), Department of Cardiology, The Royal Melbourne Hospital, Melbourne Health, 300 Graan Street, Parkville, Victoria 3050, Australia, Tel: +61456537268 Abstract Takotsubo cardiomyopathy is commonly associated with a sudden psychological, emotional or physical stress such as a death of a family member. Here we present a case of Takotsubo cardiomyopathy occurring after revasculariza- tion of an acute coronary syndrome providing evidence that these two discrete, separate, but inherently inter-related events can coexist. Keywords Takotsubo cardiomyopathy, Acute coronary syndrome, Stress cardiomyopathy CASE REPORT Check for updates venon for an inferior ST segment elevaon myocardial infarcon (STEMI) occurring during a dobutamine myo- cardial perfusion scan, providing addional evidence that the somac stress of an acute coronary syndrome can also precipitate Takotsubo cardiomyopathy. Case Descripon An 89-year-old female with mulple cardiac risk fac- tors was experiencing atypical chest pain and was re- ferred for a diagnosc elecve dobutamine myocardial perfusion scan. Past history included asthma, and the test was performed off her usual medicaons. Baseli- ne electrocardiogram (ECG) showed sinus rhythm with a paral right bundle branch block paern (Figure 1A). Rest images of myocardial perfusion were performed aſter the rest injecon of 214 MBq of Tc-99m sestamibi (Figure 2). This showed normal perfusion and normal LV funcon with LVEF > 80% at rest. No regional wall moon abnormality was seen. Twelve minutes into a standard dobutamine infusion, at 40 ug/kg/min, the ECG evolved into ventricular bigeminy with inferior and lateral ST elevaon (Figure 1B). She described no chest pain, but looked “unwell”. The dobutamine infusion was immediately ceased; the stress dose of Tc-99m sestami- bi was not injected. The paent was taken for urgent coronary angiography, developing chest pain in transit Introducon Takotsubo cardiomyopathy or stress cardiomyo- pathy was first described in 1990 by Sato, et al. and is characterized as a transient cardiac syndrome with reversible leſt ventricular systolic dysfuncon precipi- tated by a sudden psychological, emoonal or physical stress [1]. Examples of such stressors are the death of a family member, a heated argument or winning a lot- tery. Takotsubo cardiomyopathy following medical pro- cedures, especially aſter coronary angiography for an acute coronary syndrome has been rarely described in the literature [2-4]. We present a case of Takotsubo car- diomyopathy following percutaneous coronary inter-
Takotsubo Cardiomyopathy Triggered by Intervention for a Threatened Acute Myocardial Infarction - It is not over till it is over!
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Takotsubo Cardiomyopathy Triggered by Intervention for a Threatened Acute Myocardial Infarction - It is not over till it is over!Volume 8 | Issue 3 International Journal of
Clinical Cardiology Open Access
Citation: Sethwala A, Habersberger J, Sher J, Pearson M, Better N (2021) Takotsubo Cardiomyopathy Triggered by Intervention for a Threatened Acute Myocardial Infarction - It is not over till it is over!. Int J Clin Cardiol 8:227. doi.org/10.23937/2378-2951/1410227 Accepted: May 29, 2021: Published: May 31, 2021 Copyright: © 2021 Sethwala A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Sethwala et al. Int J Clin Cardiol 2021, 8:227
DOI: 10.23937/2378-2951/1410227
ISSN: 2378-2951
• Page 1 of 5 •
Takotsubo Cardiomyopathy Triggered by Intervention for a Threatened Acute Myocardial Infarction - It is not over till it is over! Anver Sethwala, MBBS (Hons)1, Jonathan Habersberger, FRACP2, Joshua Sher2, Michael Pearson, B.App.Sc (Med Rad)2 and Nathan Better, FRACP1,2,3,4
1Department of Cardiology, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia 2St Francis Xavier Cabrini Hospital, Malvern, Australia 3Department of Nuclear Medicine, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia 4University of Melbourne, Melbourne, Australia
*Corresponding author: Dr. Anver Sethwala, MBBS (Hons), Department of Cardiology, The Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia, Tel: +61456537268
Abstract Takotsubo cardiomyopathy is commonly associated with a sudden psychological, emotional or physical stress such as a death of a family member. Here we present a case of Takotsubo cardiomyopathy occurring after revasculariza- tion of an acute coronary syndrome providing evidence that these two discrete, separate, but inherently inter-related events can coexist.
Keywords Takotsubo cardiomyopathy, Acute coronary syndrome, Stress cardiomyopathy
CASe RePoRt
Check for updates
vention for an inferior ST segment elevation myocardial infarction (STEMI) occurring during a dobutamine myo- cardial perfusion scan, providing additional evidence that the somatic stress of an acute coronary syndrome can also precipitate Takotsubo cardiomyopathy.
Case Description An 89-year-old female with multiple cardiac risk fac-
tors was experiencing atypical chest pain and was re- ferred for a diagnostic elective dobutamine myocardial perfusion scan. Past history included asthma, and the test was performed off her usual medications. Baseli- ne electrocardiogram (ECG) showed sinus rhythm with a partial right bundle branch block pattern (Figure 1A). Rest images of myocardial perfusion were performed after the rest injection of 214 MBq of Tc-99m sestamibi (Figure 2). This showed normal perfusion and normal LV function with LVEF > 80% at rest. No regional wall motion abnormality was seen. Twelve minutes into a standard dobutamine infusion, at 40 ug/kg/min, the ECG evolved into ventricular bigeminy with inferior and lateral ST elevation (Figure 1B). She described no chest pain, but looked “unwell”. The dobutamine infusion was immediately ceased; the stress dose of Tc-99m sestami- bi was not injected. The patient was taken for urgent coronary angiography, developing chest pain in transit
Introduction Takotsubo cardiomyopathy or stress cardiomyo-
pathy was first described in 1990 by Sato, et al. and is characterized as a transient cardiac syndrome with reversible left ventricular systolic dysfunction precipi- tated by a sudden psychological, emotional or physical stress [1]. Examples of such stressors are the death of a family member, a heated argument or winning a lot- tery. Takotsubo cardiomyopathy following medical pro- cedures, especially after coronary angiography for an acute coronary syndrome has been rarely described in the literature [2-4]. We present a case of Takotsubo car- diomyopathy following percutaneous coronary inter-
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 2 of 5 •
Figure 1: Electrocardiograms. Panel A: Rest ECG prior to commencement showing a partial RBBB pattern; Panel B: ECG during dobutamine infusion showing frequent ventricular ectopy and the pattern of an inferior STEMI; Panel C: Repeat ECG, with chest pain 30 minutes post PCI to RCA suggesting an anterior STEMI.
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 3 of 5 •
Figure 2: Rest Tc-99m sestamibi study is seen to be normal. SPECT images are shown with short axis (top row), vertical long axis (middle row) and horizontal long axis (bottom row).
Figure 3: Coronary angiography images. Panel A: First angiogram demonstrating high grade right coronary artery stenosis; Panel B: Post insertion of a drug- eluting stent to right coronary artery; Panel C: Second angiogram demonstrating minor left coronary disease, unchanged from the first angiogram. No significant stenosis is seen, suggesting physiology of a Takotsubo syndrome; Panel D: Left ventriculogram in end systole showing the classical pattern of Takotsubo cardiomyopathy with apical ballooning.
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 4 of 5 •
negative ionotropic effect, with a predominance in the apical myocardial regions that contain the highest con- centration of β2-adrenoceptors, giving rise to the classi- cal wall motion abnormalities seen in this condition [5]. Takotsubo cardiomyopathy can mimic clinical features of an acute coronary syndrome with chest pain, dyspno- ea and ST elevation as seen in our case. A confirmatory diagnosis requires exclusion of coronary artery disease, particularly the left anterior descending artery. Takotsu- bo cardiomyopathy has rarely been described in asso- ciation with coronary syndromes [2,3,6]. In all of these cases, left ventriculography demonstrated the segmen- tal wall motion abnormality of Takotsubo cardiomyo- pathy that could not have been caused by the non-LAD occluded vessel causing the STEMI. In our case, the de- velopment of Takotsubo occurred within 30 minutes of revascularization of an acute STEMI from one vessel and presented with an infarct pattern of potential STEMI in another vessel that showed no significant stenosis both immediately before and immediately after the chest pain event. This case adds to the evidence that Takot- subo cardiomyopathy and acute coronary syndromes can co-exist with two discrete, separate, but inherently inter-related events occurring within a very short period of time. It may not be over until it is over!
Disclosures The authors have no conflicts of interest to disclose.
All authors contributed equally for the preparation of the manuscript.
No funding was received for the preparation of the manuscript.
that revealed a subtotal occlusion of the right coronary artery with minor disease in the left coronary arteries (Figure 3A). A single drug eluting stent was inserted into the right coronary artery with no complications (Figu- re 3B). Following percutaneous coronary intervention, she was transferred to the recovery bay feeling well with normalisation of her ECG. Thirty minutes after the end of the procedure upon learning she had suffered a myocardial infarction the patient developed severe cen- tral chest pain and dyspnoea. ECG now showed sinus rhythm with anterolateral ST segment elevation (Figu- re 1C). A repeat urgent coronary angiogram was per- formed which showed unchanged minor left coronary artery disease and a patent right coronary artery stent (Figure 3C). Left ventriculography demonstrated the classical apical ballooning of Takotsubo cardiomyopa- thy (Figure 3D). This was confirmed on subsequent tran- sthoracic echocardiography the next day, which showed apical akinesis with hyperkinetic basal segments (Figure 4). High sensitivity troponin after her second angiogram was elevated at 399 ng/L (normal < 15 ng/L). She was managed with dual antiplatelet therapy for stent pro- tection, a beta blocker and ace-inhibitor for her left ven- tricular dysfunction and was discharged 22 days later after inpatient rehabilitation. At 6 week follow-up, she was asymptomatic with normalization of left ventricular function on echocardiography.
Discussion Takotsubo cardiomyopathy in most cases has an
identifiable stressor which leads to a hypersympathetic response with a sudden surge of catecholamines such as noradrenaline and adrenaline [4]. At supraphysio- logic concentrations these catecholamines result in a
Figure 4: Transthoracic echocardiogram images. End diastolic and end systolic images one day post event showing a classical pattern of Takotsubo cardiomyopathy with akinetic apical segments and hypercontractile basal segments.
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 5 of 5 •
4. Gurlek C, van Es J, van der Burgh PH, Galjee MA, van Birgelen C (2007) Full pattern of transient apical ballooning of the left ventricle triggered by minor myocardial infarction. Neth Heart J 15: 310-311.
5. Lyon AR, Rees PSC, Prasad S, Poole-Wilson PA, Harding SE (2008) Stress (Takotsubo) cardiomyopathy--a novel pa- thophysiological hypothesis to explain catecholamine-indu- ced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 5: 22-29.
6. Ezad S, McGee M, Boyle AJ (2019) Takotsubo syndrome associated with ST elevation myocardial infarction. Case Rep Cardiol 2019: 1010243.
References 1. Sato H, Tateishi H, Uchida T (1990) Takotsubo type car-
diomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, Clinical Aspect of Myocardial Injury: From ischemia to heart failure. Kagakuhyoronsha, Tokyo, 56-64.
2. Hurtado Rendón IS, Alcivar D, Rodriguez-Escudero JP, Silver K (2018) Acute myocardial infarction and stress car- diomyopathy are not mutually exclusive. Am J Med 131: 202-205.
3. Sakatani A, Kume K, Nishio M, Hirooka K, Hayashi T (2020) Takotsubo syndrome triggered by coronary artery embolism in a patient with chronic atrial fibrillation. J Cardiol Cases 22: 45-47.
Clinical Cardiology Open Access
Citation: Sethwala A, Habersberger J, Sher J, Pearson M, Better N (2021) Takotsubo Cardiomyopathy Triggered by Intervention for a Threatened Acute Myocardial Infarction - It is not over till it is over!. Int J Clin Cardiol 8:227. doi.org/10.23937/2378-2951/1410227 Accepted: May 29, 2021: Published: May 31, 2021 Copyright: © 2021 Sethwala A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Sethwala et al. Int J Clin Cardiol 2021, 8:227
DOI: 10.23937/2378-2951/1410227
ISSN: 2378-2951
• Page 1 of 5 •
Takotsubo Cardiomyopathy Triggered by Intervention for a Threatened Acute Myocardial Infarction - It is not over till it is over! Anver Sethwala, MBBS (Hons)1, Jonathan Habersberger, FRACP2, Joshua Sher2, Michael Pearson, B.App.Sc (Med Rad)2 and Nathan Better, FRACP1,2,3,4
1Department of Cardiology, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia 2St Francis Xavier Cabrini Hospital, Malvern, Australia 3Department of Nuclear Medicine, The Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia 4University of Melbourne, Melbourne, Australia
*Corresponding author: Dr. Anver Sethwala, MBBS (Hons), Department of Cardiology, The Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia, Tel: +61456537268
Abstract Takotsubo cardiomyopathy is commonly associated with a sudden psychological, emotional or physical stress such as a death of a family member. Here we present a case of Takotsubo cardiomyopathy occurring after revasculariza- tion of an acute coronary syndrome providing evidence that these two discrete, separate, but inherently inter-related events can coexist.
Keywords Takotsubo cardiomyopathy, Acute coronary syndrome, Stress cardiomyopathy
CASe RePoRt
Check for updates
vention for an inferior ST segment elevation myocardial infarction (STEMI) occurring during a dobutamine myo- cardial perfusion scan, providing additional evidence that the somatic stress of an acute coronary syndrome can also precipitate Takotsubo cardiomyopathy.
Case Description An 89-year-old female with multiple cardiac risk fac-
tors was experiencing atypical chest pain and was re- ferred for a diagnostic elective dobutamine myocardial perfusion scan. Past history included asthma, and the test was performed off her usual medications. Baseli- ne electrocardiogram (ECG) showed sinus rhythm with a partial right bundle branch block pattern (Figure 1A). Rest images of myocardial perfusion were performed after the rest injection of 214 MBq of Tc-99m sestamibi (Figure 2). This showed normal perfusion and normal LV function with LVEF > 80% at rest. No regional wall motion abnormality was seen. Twelve minutes into a standard dobutamine infusion, at 40 ug/kg/min, the ECG evolved into ventricular bigeminy with inferior and lateral ST elevation (Figure 1B). She described no chest pain, but looked “unwell”. The dobutamine infusion was immediately ceased; the stress dose of Tc-99m sestami- bi was not injected. The patient was taken for urgent coronary angiography, developing chest pain in transit
Introduction Takotsubo cardiomyopathy or stress cardiomyo-
pathy was first described in 1990 by Sato, et al. and is characterized as a transient cardiac syndrome with reversible left ventricular systolic dysfunction precipi- tated by a sudden psychological, emotional or physical stress [1]. Examples of such stressors are the death of a family member, a heated argument or winning a lot- tery. Takotsubo cardiomyopathy following medical pro- cedures, especially after coronary angiography for an acute coronary syndrome has been rarely described in the literature [2-4]. We present a case of Takotsubo car- diomyopathy following percutaneous coronary inter-
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 2 of 5 •
Figure 1: Electrocardiograms. Panel A: Rest ECG prior to commencement showing a partial RBBB pattern; Panel B: ECG during dobutamine infusion showing frequent ventricular ectopy and the pattern of an inferior STEMI; Panel C: Repeat ECG, with chest pain 30 minutes post PCI to RCA suggesting an anterior STEMI.
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 3 of 5 •
Figure 2: Rest Tc-99m sestamibi study is seen to be normal. SPECT images are shown with short axis (top row), vertical long axis (middle row) and horizontal long axis (bottom row).
Figure 3: Coronary angiography images. Panel A: First angiogram demonstrating high grade right coronary artery stenosis; Panel B: Post insertion of a drug- eluting stent to right coronary artery; Panel C: Second angiogram demonstrating minor left coronary disease, unchanged from the first angiogram. No significant stenosis is seen, suggesting physiology of a Takotsubo syndrome; Panel D: Left ventriculogram in end systole showing the classical pattern of Takotsubo cardiomyopathy with apical ballooning.
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 4 of 5 •
negative ionotropic effect, with a predominance in the apical myocardial regions that contain the highest con- centration of β2-adrenoceptors, giving rise to the classi- cal wall motion abnormalities seen in this condition [5]. Takotsubo cardiomyopathy can mimic clinical features of an acute coronary syndrome with chest pain, dyspno- ea and ST elevation as seen in our case. A confirmatory diagnosis requires exclusion of coronary artery disease, particularly the left anterior descending artery. Takotsu- bo cardiomyopathy has rarely been described in asso- ciation with coronary syndromes [2,3,6]. In all of these cases, left ventriculography demonstrated the segmen- tal wall motion abnormality of Takotsubo cardiomyo- pathy that could not have been caused by the non-LAD occluded vessel causing the STEMI. In our case, the de- velopment of Takotsubo occurred within 30 minutes of revascularization of an acute STEMI from one vessel and presented with an infarct pattern of potential STEMI in another vessel that showed no significant stenosis both immediately before and immediately after the chest pain event. This case adds to the evidence that Takot- subo cardiomyopathy and acute coronary syndromes can co-exist with two discrete, separate, but inherently inter-related events occurring within a very short period of time. It may not be over until it is over!
Disclosures The authors have no conflicts of interest to disclose.
All authors contributed equally for the preparation of the manuscript.
No funding was received for the preparation of the manuscript.
that revealed a subtotal occlusion of the right coronary artery with minor disease in the left coronary arteries (Figure 3A). A single drug eluting stent was inserted into the right coronary artery with no complications (Figu- re 3B). Following percutaneous coronary intervention, she was transferred to the recovery bay feeling well with normalisation of her ECG. Thirty minutes after the end of the procedure upon learning she had suffered a myocardial infarction the patient developed severe cen- tral chest pain and dyspnoea. ECG now showed sinus rhythm with anterolateral ST segment elevation (Figu- re 1C). A repeat urgent coronary angiogram was per- formed which showed unchanged minor left coronary artery disease and a patent right coronary artery stent (Figure 3C). Left ventriculography demonstrated the classical apical ballooning of Takotsubo cardiomyopa- thy (Figure 3D). This was confirmed on subsequent tran- sthoracic echocardiography the next day, which showed apical akinesis with hyperkinetic basal segments (Figure 4). High sensitivity troponin after her second angiogram was elevated at 399 ng/L (normal < 15 ng/L). She was managed with dual antiplatelet therapy for stent pro- tection, a beta blocker and ace-inhibitor for her left ven- tricular dysfunction and was discharged 22 days later after inpatient rehabilitation. At 6 week follow-up, she was asymptomatic with normalization of left ventricular function on echocardiography.
Discussion Takotsubo cardiomyopathy in most cases has an
identifiable stressor which leads to a hypersympathetic response with a sudden surge of catecholamines such as noradrenaline and adrenaline [4]. At supraphysio- logic concentrations these catecholamines result in a
Figure 4: Transthoracic echocardiogram images. End diastolic and end systolic images one day post event showing a classical pattern of Takotsubo cardiomyopathy with akinetic apical segments and hypercontractile basal segments.
ISSN: 2378-2951DOI: 10.23937/2378-2951/1410227
Sethwala et al. Int J Clin Cardiol 2021, 8:227 • Page 5 of 5 •
4. Gurlek C, van Es J, van der Burgh PH, Galjee MA, van Birgelen C (2007) Full pattern of transient apical ballooning of the left ventricle triggered by minor myocardial infarction. Neth Heart J 15: 310-311.
5. Lyon AR, Rees PSC, Prasad S, Poole-Wilson PA, Harding SE (2008) Stress (Takotsubo) cardiomyopathy--a novel pa- thophysiological hypothesis to explain catecholamine-indu- ced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 5: 22-29.
6. Ezad S, McGee M, Boyle AJ (2019) Takotsubo syndrome associated with ST elevation myocardial infarction. Case Rep Cardiol 2019: 1010243.
References 1. Sato H, Tateishi H, Uchida T (1990) Takotsubo type car-
diomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, Clinical Aspect of Myocardial Injury: From ischemia to heart failure. Kagakuhyoronsha, Tokyo, 56-64.
2. Hurtado Rendón IS, Alcivar D, Rodriguez-Escudero JP, Silver K (2018) Acute myocardial infarction and stress car- diomyopathy are not mutually exclusive. Am J Med 131: 202-205.
3. Sakatani A, Kume K, Nishio M, Hirooka K, Hayashi T (2020) Takotsubo syndrome triggered by coronary artery embolism in a patient with chronic atrial fibrillation. J Cardiol Cases 22: 45-47.
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