B. Stress cardiomyopathy (Takotsubo cardiomyopathy)
Discussion
The EKG shows T wave inversion in the lateral leads, which was new
for the patient compared to her EKG two months ago. The LV gram shows
apical ballooning, characteristic of stress cardiomyopathy. The patient
was treated conservatively, and on further discussion, was found to be a
victim of severe elder abuse.
Stress cardiomyopathy is characterized by transient left ventricular
systolic dysfunction (often apical ballooning), often extending beyond a
single vascular territory, with EKG findings and troponin elevation
mimicking myocardial infarction, but do not have significant coronary
artery disease. This is seen in approximately 1-2% of people presenting
with troponin-positive suspected acute coronary syndrome (ACS).1 It is more commonly seen in women in their seventh and eighth decade of life.2
The EKG findings are indistinguishable from ACS and include ST-segment
elevation in about 35 to 80%, T wave abnormalities in about 60%, and Q
waves in about 20 to 30%.3,4 Cardiac biomarkers are usually mildly elevated in most patients.3 A physical or emotional stressor is often associated with the onset of symptoms.
Stress cardiomyopathy is often a transient condition managed with
supportive therapy. However, in the presence of cardiogenic shock,
hemodynamic support via vasopressors and possibly mechanical circulatory
support are often required. Rarely, a thrombus may be found in the left
ventricle, warranting anticoagulation therapy. Similarly, if patients
present with a severely reduced ejection fraction, some authorities
recommend anticoagulation, but the evidence behind this approach is
limited. In-hospital mortality for stress cardiomyopathy varies from
0-8% in the various study populations; increasing age, physical
stressors, comorbid conditions, and shock at presentation are all
associated with poor outcome. Once patients survive the acute episode,
systolic function usually recovers within a few weeks.
References
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Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular
transient left ventricular dysfunction syndrome (tako-tsubo
cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007;132(3):809-816. doi:10.1378/chest.07-0608
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Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation. 2008;118(25):2754-2762. doi:10.1161/CIRCULATIONAHA.108.767012
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Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical
ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 2006;27(13):1523-1529. doi:10.1093/eurheartj/ehl032\
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Namgung J. (2014). Electrocardiographic Findings in Takotsubo
Cardiomyopathy: ECG Evolution and Its Difference from the ECG of Acute
Coronary Syndrome. Clinical Medicine Insights. Cardiology, 8, 29–34. https://doi.org/10.4137/CMC.S14086