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

12 Comments

  • Val Moczygemba says:

    Been diagnosed TWICE with this syndrome. Went straight to the cath-lab both times. It felt like what I alwasy thought a real MIA would feel like. Glad to see that it’s out there.

  • Patrick says:

    That’s amazing, I never would have guessed. I had my money on anterior wall MI.

  • VinceD says:

    Awesome case. Definitely did not know the pearl about near-drowning being a trigger. Thanks for always pushing the boundaries of our differential diagnoses.

  • RoseD says:

    Interesting case- regardless of the final diagnosis; I would have not changed any treatment regimine and would have managed patient as an acute MI. The medics correctly assumed the worse outcome and handled the patient aggressively vs. attempting to go with a field diagnosis and be wrong.

  • Tom B says:

    Val Moczygemba -

    That’s interesting! I have read that approximately 10% of patients have a recurrence within 2 years.

    I’m not aware of anything that can reliably distinguish this syndrome from acute anterior STEMI. Even if an echo shows the wall motion abnormality or apical ballooning, how do you know the coronaries are “clean” unless the patient is cathed?

    Even the history of an acute stressful stimulus is of limited help, since stress is known to trigger ACS.

    Thanks for the comment!

    Tom

  • Tom B says:

    Patrick -

    It came as a surprise to me, too! Of course, it’s at least remotely possible that the apical ballooning was secondary to coronary vasospasm or aborted MI.

    Tom

  • Tom B says:

    VinceD -

    My pleasure! One thing that’s cool about blogging is that I get to learn a lot, too.

    Tom

  • Tom B says:

    RoseD -

    I agree with you 100%! I don’t understand medics who go out of their way to not transport patients to the hospital.

    Tom

  • AKA “Broken heart syndrome” because of the prevalence of stress. From my understanding this was previously thought to be exclusively found within the Japanese male population.

  • Hillis says:

    Really amazing case !! Thanks Tom for sharing us the knowledge . I’ve learned and still learning alot from this page.

  • see www dot takotsubo dot com for some neat info

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Comments
Ivan Rios
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
Thanks for writing Tyler. They are the same thing. Strain pattern is just the result of increased pressures against the ventricles which alters the way repolarization occurs from epicardium to endocardium. Similar to stepping on a puddle of water. Your show spreads the water away from the area of pressure. The ST segment is slightly…
2014-12-17 18:44:24
Tyler
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
Can you explain how these ST segment and T wave changes can be differentiated from right strain pattern?
2014-12-17 18:18:25
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