Takotsubo Cardiomyopathy Triggered by Acute Pancreatitis: A Case Report

Takotsubo cardiomyopathy is a heart condition that is widely known to be caused by stress. It presents with symptoms that are similar to a myocardial infarction even though the coronary arteries are clear. This case report details the clinical characteristics, diagnostic assessment, and management plan of a 55-year-old male patient with a past medical history of alcoholism who arrived at the emergency department with the typical symptoms of acute pancreatitis. The case demonstrates the progression of Takotsubo cardiomyopathy, which was triggered by acute pancreatitis in the context of alcoholism, and underlines the significance of early detection and management to enhance the patient’s outcomes.

Takotsubo cardiomyopathy following envenomation:An updated review

BACKGROUND Takotsubo cardiomyopathy(TTC)can be diagnosed in patients presenting with clinical features of acute coronary syndrome(ACS)by using Mayo clinic criteria.Multiple precipitators have been attributed to causing TTC.Rarely it has been reported to occur following an acute envenomation.AIM This review describes the various patterns,mechanisms,and outcomes of envenomation induced TTC.METHODS In this review,we included all studies on“TTC”and“envenomation”published in the various databases before June 2022.To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation RESULTS A total of 20 patients with envenomation induced TTC were identified.Most episodes of envenomation induced TTC were reported following a bee sting,scorpion sting,and snake envenomation.Fear and anxiety related to the sting,direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients.95%of these patients presented with a clinical picture of ACS.Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC.Echocardiographic evidence of Apical TTC was noted in 72%of patients.94%of these patients had clinical improvement following optimal management and 35%of these patients were treated with guideline directed medications for heart failure.CONCLUSION Envenomation following multiple insect stings and reptile bites can precipitate TTC.Most reported envenomation related TTC has been due to bee stings and scorpion bites.Common mechanisms causing TTC were fear,anxiety,and stress of envenomation.Most of these patients present with clinical presentation of ACS,ST elevation,and elevated troponin.The most common type of TTC in these patients is Apical,which improved following medical management.

Case of takotsubo cardiomyopathy after surgical treatment of liver hydatid cyst: A case report

BACKGROUND Takotsubo cardiomyopathy,also called apical ballooning syndrome,is a disease that is often triggered by stress factors in postmenopausal women and mimics acute coronary syndrome.The aim of this article is to draw attention to takotsubo cardiomyopathy after surgical treatment of liver hydatid cyst.CASE SUMMARY A 50-year-old diabetic and hypertensive female patient was evaluated preoperatively before general surgery for liver hydatid cyst,and no cardiac problems were found.The patient was discharged on the 3rd postoperative day without any postoperative complications.On postoperative day 5,the patient presented to the emergency department with fever,shortness of breath,chills,and shivering and was hospitalized with the diagnosis of pneumonia.The troponin levels remained high during follow-up.Echocardiography was performed on postoperative day 7,after which the patient was referred to a tertiary center with the diagnosis of non-ST-elevation myocardial infarction due to akinesia in the apical region.Coronary angiography performed at the tertiary center showed normal coronary anatomy,and the patient was diagnosed with takotsubo cardiomyopathy.CONCLUSION Takotsubo cardiomyopathy mimicking myocardial infarction without ST segment elevation may develop after surgical treatment of liver hydatid cyst.

Takotsubo cardiomyopathy misdiagnosed as acute myocardial infarction under the Chest Pain Center model:A case report

BACKGROUND With the spread and establishment of the Chest Pain Center in China,adhering to the idea that“time is myocardial cell and time is life”,many hospitals have set up a standardized process that ensures that patients with acute myocardial infarction(AMI)who meet emergency percutaneous coronary intervention(PCI)guidelines are sent directly to the DSA room by the prehospital emergency doctor,saving the time spent on queuing,registration,payment,re-examination by the emergency doctor,and obtaining consent for surgery after arriving at the hospital.Takotsubo cardiomyopathy is an acute disease that is triggered by intense emotional or physical stress and must be promptly differentiated from AMI for its appropriate management.CASE SUMMARY A 52-year-old female patient was taken directly to the catheterization room to perform PCI due to 4 h of continuous thoracalgia and elevation of the ST segment in the V3–V5 lead,without being transferred to the emergency department according to the Chest Pain Center model.Loading doses of aspirin,clopidogrel and statins were administered and informed consent for PCI was signed in the ambulance.On first look,the patient looked nervous in the DSA room.Coronary angiography showed no obvious stenosis.Left ventricular angiography showed that the contraction of the left ventricular apex was weakened,and the systolic period was ballooning out,showing a typical“octopus trap”change.The patient was diagnosed with Takotsubo cardiomyopathy.Five days later,the patient had no symptoms of thoracalgia,and the serological indicators returned to normal.She was discharged with a prescription of medication.CONCLUSION Under the Chest Pain Center model for the treatment of patients with chest pain showing ST segment elevation,despite the urgency of time,Takotsubo cardiomy-opathy must be promptly differentiated from AMI for its appropriate management.

A 99-year old patient with takotsubo cardiomyopathy recovering from cardiogenic shock

Takotsubo syndrome(TTS)is a rare clinical entity commonly seen in post-menopausal women after an emotional or sometimes physical stress.[1,2]This syndrome is thought to be caused by increased circulation catecholamine levels secondary to an adrenergic stimulus resulting in transient coronary spasm and microvascular dysfunction.[3]TTS is characterized by acute and reversible left ventricular dysfunction with the typical ECG and clinical findings of an acute coronary syndrome but no significant coronary stenosis.[4]Typically,in TTS,antero-apical ballooning is observed in ventriculography,and segmentary wall motion abnormalities are observed in magnetic resonance imaging and echocardiography.Acute heart failure,left ventricular outflow tract obstruction,mitral regurgitation and cardiogenic shock may complicate this syndrome.[5]Herein,we present a case who is the oldest one in the literature with TTS and cardiogenic shock.

Atypical variants of takotsubo cardiomyopathy: mechanistic and clinical implications

Over past decades,takotsubo cardiomyopathy(TTC)has drawn a substantial interest as a unique form of acute and reversible cardiomyopathy that usually emerges in response to adrenergic hyperactivation associated with a variety of emotional and physical triggers.[1,2]Even though,this phenomenon is generally characterized by an apical balloning pattern(classical variant),it might occasionally present with atypical morphological variants including mid-ventricular,inverted and focal forms of myocardial involvement.

Atypical Takotsubo cardiomyopathy presenting as acute coronary syndrome:A case report

BACKGROUND Takotsubo cardiomyopathy(TS)is a rare acute cardiac disease with clinical features,symptoms,and electrocardiographic manifestations similar to those of acute myocardial infarction.We present the case of a patient with TS caused by a pheochromocytoma,which was confirmed by the postoperative pathology.Furthermore,we present the patient’s subsequent management,treatment,and outcome.CASE SUMMARY A 64-year-old woman was admitted to the hospital with episodic chest pain and palpitations,electrocardiogram(ECG)findings suggestive of high lateral wall myocardial infarction,echocardiogram showing left ventricular wall segmental motion abnormalities,and elevated levels of the myocardial marker troponin.The patient underwent coronary angiography,which revealed unobstructed blood flow without obvious stenosis.During their hospitalization,the patient had paroxysmal elevation of blood pressure accompanied by palpitations and profuse sweating,with elevated blood catecholamine levels during seizures.Subsequent computerized tomography of the adrenal glands revealed the presence of a nodule in the right adrenal,which was resected and determined to be an adrenal pheochromocytoma.Therefore,the diagnosis of pheochromocytoma-induced atypical TS was made.The patient had an uneventful postoperative recovery.CONCLUSION Cardiologists should consider pheochromocytoma in patients with TS.Early detection allows timely intervention,benefiting patients.

Recurrent Takotsubo cardiomyopathy triggered by emotionally stressful events: A case report

BACKGROUND Takotsubo cardiomyopathy(TCM)is characterized by reversible left ventricular dysfunction triggered by emotional or physical stress.Only 1%-2%of patients with acute coronary syndrome are diagnosed with TCM.Although obstructive coronary artery disease is frequently considered to be the cause of chest pain,TCM should be considered in some clinical settings.In this case,clinicians did not make a timely and accurate diagnosis for TCM due to a lack of knowledge until the third hospitalization with a left ventriculogram.CASE SUMMARY A 55-year-old postmenopausal woman had intermittent chest pain following emotionally stressful events three times in the past 3 years.Cardiac troponin levels increased after each instance of symptom onset.A transthoracic echocardiogram showed reversible left ventricular dysfunction.The patient underwent three coronary angiograms without evidence of coronary artery disease.A left ventriculogram was first performed at the third hospitalization and revealed apical akinesia with ballooning of the apical region and consistent hypercontractile basal segments.The diagnosis of TCM was confirmed.The patient was treated with an angiotensin-converting-enzyme inhibitor(perindopril)and aβ-blocker(metoprolol).No complications occurred during the patient’s hospitalization.The patient was told to avoid stressful events.During the 9-mo follow-up visit,the patient was asymptomatic with an ejection fraction of 55%.CONCLUSION Clinicians should be conscious of the possibility of TCM,especially in postmenopausal women presenting with clinical manifestations similar to acute coronary syndrome without coronary occlusion.

Takotsubo cardiomyopathy associated with bronchoscopic operation:A case report

BACKGROUND Takotsubo cardiomyopathy(TTC),a syndrome of acute left ventricular(LV)dysfunction,is characterized by transitory hypokinesis of LV apices with compensatory hyperkinesis of the LV basal region.The symptoms of TTC mimic acute myocardial infarction,without significant coronary stenoses on coronary angiography.Echocardiogram plays a key role in the diagnosis and prognosis of TTC.New indicators from echocardiograms may be helpful in disease evaluation.CASE SUMMARY A 67-year-old man with a 10-year history of non-small cell lung cancer was admitted to our hospital for emerging facial edema and dry cough.Bronchoscopic lavage,brushing,and biopsy were performed to evaluate tumor progression.During this procedure,he complained of left chest pain,nausea,and vomiting,with elevated troponin levels.Electrocardiogram showed sinus bradycardia with ST-segment elevation in I,AVL,and V4 to V6 leads.Coronary angiography revealed mild stenosis in the right coronary artery.Echocardiography showed hypokinesis of LV apices with compensatory hyperkinesis of the LV basal region.At the 7-d follow-up,echocardiographic pressure-strain analysis showed a normal LV ejection fraction,but partial recovery of LV myocardial work,which fully recovered 5 mo later.CONCLUSION This is a case of TTC caused by bronchoscopic operation.We strongly recommend noninvasive myocardial work measured by echocardiographic pressure-strain analysis as a necessary supplementary test for the long-term follow-up of TTC.

Myasthenic crisis-induced Takotsubo cardiomyopathy in an elderly man:A case report of an underestimated but deadly combination

BACKGROUND Patients with myasthenia gravis(MG)are at a higher risk of developing Takotsubo cardiomyopathy(TTC),particularly during a myasthenic crisis.Myasthenic crisis-associated TTC occurs predominantly in women.In this case report,we present a man with metastasized prostate carcinoma who developed TTC after new-onset MG.CASE SUMMARY An 81-year-old man with non-insulin dependent diabetes mellitus and metastasized prostate carcinoma presented with dyspnea.During primary assessment examination at the emergency department,there was evident blepharoptosis of his right eye.His electrocardiograms were suggestive of an acute anterior wall myocardial infarction,for which he underwent emergency coronary angiography.No obstructive coronary artery disease was found.During the coronary angiography,the patient developed respiratory failure and was admitted to the Intensive Care Unit for non-invasive respiratory support.The following day,diagnostic neostigmine test revealed a myasthenic crisis.Bedside echocardiography revealed left ventricular apical ballooning with a typical appearance of TTC.Despite the potentially reversible character of both MG and TTC,the patient and family requested an end of support in the Intensive Care Unit due to age and chronic malignancy with reduced quality of life in recent months after non-chemo-responding prostate carcinoma.The patient died soon after treatment withdrawal.CONCLUSION Elderly men should be carefully evaluated for TTC when new-onset MG is diagnosed.

Takotsubo cardiomyopathy in orthotopic liver transplant recipients: A cohort study using multi-center pooled electronic health record data

BACKGROUND Takotsubo cardiomyopathy(TCM),or stress-induced cardiomyopathy,is associated with adverse prognosis.Limited data suggest that TCM occurring in orthotopic liver transplant(OLT)recipients is associated with elevated perioperative risk.AIM To characterize the predictors of TCM in OLT recipients,using a large,multicenter pooled electronic health database.METHODS A multi-institutional database(Explorys Inc,Cleveland,OH,USA),an aggregate of de-identified electronic health record data from 26 United States healthcare systems was surveyed.A cohort of patients with a Systematized Nomenclature of Medicine-Clinical Terms of“liver transplant”between 09/2015 and 09/2020 was identified.Subsequently,individuals who developed a new diagnosis of TCM following OLT were identified.Furthermore,the risk associations with TCM among this patient population were characterized using linear regression.RESULTS Between 09/2015 and 09/2020,of 37718540 patients in the database,38740(0.10%)had a history of OLT(60.6%had an age between 18-65 years,58.1%female).A new diagnosis of TCM was identified in 0.3%of OLT recipients(45.5%had an age between 18-65 years,72.7%female),compared to 0.04%in non-OLT patients[odds ratio(OR):7.98,95%confidence intervals:6.62-9.63,(P<0.0001)].OLT recipients who developed TCM,compared to those who did not,were more likely to be greater than 65 years of age,Caucasian,and female(P<0.05).There was also a significant association with cardiac arrhythmias,especially ventricular arrhythmias(P<0.0001).CONCLUSION TCM was significantly more likely to occur in LT recipients vs non-recipients.Older age,Caucasian ethnicity,female gender,and presence of arrhythmias were significantly associated with TCM in LT recipients.

Is Takotsubo cardiomyopathy still looking for its own nosological identity?

Despite several efforts to provide a proper nosological framework for Takotsubo cardiomyopathy(TCM),this remains an unresolved matter in clinical practice.Several clinical,pathophysiologic and histologic findings support the conceivable hypothesis that TCM could be defined as a unique pathologic entity,rather than a distinct subset of myocardial infarction with non-obstructive coronary arteries.Further investigations are needed in order to define TCM with the most appropriate disease taxonomy.

Interventional Cardiology Management of a Cardiogenic Shock Induced by Takotsubo Cardiomyopathy at the Hospital Center of Montlucon: A Case Report

Background: Takotsubo cardiomyopathy is frequently considered as a benign disorder. We present an atypical form with cardiogenic shock that was managed by interventional cardiology measures. Case presentation: A 58 years old female patient with a past history of hypertension, obesity and multiple sclerosis was admitted at the Hospital Center of Montlucon for septic shock of urinary origin. During hospitalization in intensive care unit, the patient presented a markedly increasing of troponin levels with a diffused ST-segment elevation. Transthoracic Echocardiography showed an altered left ventricular ejection fraction at 35% with hypokinesia of apex and lateral ventricular segments in conjunction with compensatory hyperkinesis of the base;these findings were strongly suggestive of a diagnosis of Takotsubo cardiomyopathy. Despite concomitant anemia, renal failure and sepsis, all adequately treated with complete remission, the patient developed frequent episodes of ventricular tachycardia that prompted an emergency coronarography. During this procedure, the patient presented a cardiogenic shock and bradyasystole that were successfully managed by intra-aortic balloon pumping and temporary transvenous pacing. Finally, there were no coronary lesions and ventriculography confirmed a Takotsubo cardiomyopathy. Given the unstable hemodynamic status of this patient, she was addressed to the University Teaching Hospital of Clermont-Ferrand for more specialized care. Conclusion: This case alerts the physician to be more vigilant when managing all patients with Takotsubo cardiomyopathy, because some cases could be fatal. In severe cases, intra-aortic balloon pumping and temporary epicardial pacing can be life-saving.

Isolated Hyperacute T-Waves in West Nile Encephalitis Indicating Atypical Variant of Stress-Induced Cardiomyopathy

Several cardiac outcomes have been reported with West Nile-encephalitis;however, the underlying pathophysiology remains complex. We present a 42-year-old female, with multiple sclerosis, whose neurological symptoms and respiratory decline were finally explained by the diagnosis of West Nile-encephalitis. During her admission, the isolated peaked T-waves indicated the underlying stress-induced cardiomyopathy. The absence of all other causes of hyperacute T-waves, their subsequent resolution with the resolution of infection and improvement in wall motion abnormalities, further supported the association. This case highlights the importance of considering hyperacute T-waves in an approach towards the diagnosis of WNV-encephalitis related atypical variant of stress-induced cardiomyopathy.

Takotsubo syndrome:Advances in the understanding and management of an enigmatic stress cardiomyopathy

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.

Spontaneous coronary artery dissection-associated takotsubo syndrome: A systematic review of case reports

BACKGROUND Spontaneous coronary artery dissection(SCAD)is underdiagnosed and requires comprehensive angiographic findings.Few SCAD occurrences have a comparable clinical appearance as takotsubo syndrome(TTS)or exist simultaneously,making it challenging for clinicians to treat and manage.Case reports lack consolidated AIM To conduct a systematic review of available case reports on SCAD in order to investigate its potential association with TTS.METHODS SCAD-associated TTS case reports were reviewed after thoroughly screening PubMed,EMBASE,Scopus,and Google Scholar databases till January 2023.Case reports described demographics,comorbidities,imaging,management,and results.RESULTS Twelve articles about 20 female patients were analyzed.30%of patients(n=6,>60 years)were elderly(mean age 56.2±9.07 years,range 36-70 years).Canada has 9 cases,United States 3,Australia 3,Sweden 2,Japan,Denmark,and France 1.Only 5 reports identified emotional stressors in these cases while 4 reports showed physical triggers for TTS.Nine had hypertension,2 had hyperlipidemia,and 1 had prediabetes.5 patients(25%)smoked.10(50%)troponin-positive myocardial infarction patients reported chest discomfort.11(55%)of 20 instances had TTS/SCAD.12(60%)of 20 patients exhibited ST elevation and 3(15%)had T wave inversion on electrocardiogram.19/20 patients had elevated troponin.9(45%)of 20 people had apical akinesis with TTS ballooning on cardiac imaging.All 20 exhibited echocardiographic wall motion abnormalities.19(95%)of 20 coronary angiography cases had SCAD.10 of 19 SCAD patients had left anterior descending,2 diagonal,and 2 left circumflex coronary artery involvement.7 of 20 patients had left ventricular ejection fraction(LVEF)data.LVEF averaged 38.78±7.35%.5(25%)of the 20 cases underwent dual antiplatelet therapy.Three(15%)of 20 cases experienced occasional ectopic ventricular complexes,Mobitz ll AV block,and paroxysmal atrial fibrillation.All 20 cases recovered and survived.CONCLUSION Given the clinical similarities and challenges in detecting TTS and SCAD,this subset needs more research to raise awareness and reduce morbidity.

Cardiovascular magnetic resonance in myocardial infarction with non-obstructive coronary arteries patients: A review

The diagnosis of myocardial infarction with non-obstructive coronary arteries(MINOCA)necessitates documentation of an acute myocardial infarction(AMI),non-obstructive coronary arteries,using invasive coronary angiography or coronary computed tomography angiography and no clinically overt cause for AMI.Historically patients with MINOCA represent a clinical dilemma with subsequent uncertain clinical management.Differential diagnosis is crucial to choose the best therapeutic option for ischemic and non-ischemic MINOCA patients.Cardiovascular magnetic resonance(CMR)is able to analyze cardiac structure and function simultaneously and provides tissue characterization.Moreover,CMR could identify the cause of MINOCA in nearly two-third of patients providing valuable information for clinical decision making.Finally,it allows stratification of patients with worse outcomes which resulted in therapeutic changes in almost half of the patients.In this review we discuss the features of CMR in MINOCA;from exam protocols to imaging findings.

Role of cardiac magnetic resonance imaging in troponinemia syndromes

Cardiac magnetic resonance imaging(MRI)is an evolving technology,proving to be a highly accurate tool for quantitative assessment.Most recently,it has been increasingly used in the diagnostic and prognostic evaluation of conditions involving an elevation in troponin or troponinemia.Although an elevation in troponin is a nonspecific marker of myocardial tissue damage,it is a frequently ordered investigation leaving many patients without a specific diagnosis.Fortunately,the advent of newer cardiac MRI protocols can provide additional information.In this review,we discuss several conditions associated with an elevation in troponin such as myocardial infarction,myocarditis,Takotsubo cardiomyopathy,coronavirus disease 2019 related cardiac dysfunction and athlete’s heart syndrome.

Transient Mid-Ventricular Ballooning Due to Bad Dream in a Postmenopausal Woman

Mid ventricular ballooning syndrome (MBS) was diagnosed in a 55-year-old woman who was admitted to emergency room due to acute chest pain. The trigger for the chest pain was reported as “bad dream” about her husband. MBS, a variant of Tako-tsubo Cardiomyopathy is more common in postmenopausal women and the triggers have been linked to stress involving the husband. Sudden catecholamine surge during nightmare augmented by estrogen deficiency in postmenopausal women may be the underlying mechanism. There are many unanswered questions related to the etiology of MBS. With supportive treatment, prognosis is excellent.

Sepsis-related cardiomyopathy:Not an easy task for ICU physicians

Sepsis-induced myocardial dysfunction is common.In addition to acute coronary syndrome,at least two types of left ventricular dysfunction can occur in septic patients:typical septic cardiomyopathy(SC)and sepsis-related takotsubo cardiomyopathy(ST).Although the definition of septic cardiomyopathy is based on left ventricular(LV)systolic dysfunction,both ventricles can be affected.In this context,it has been increasingly recognized that right ventricular(RV)systolic dysfunction is associated with long-term prognosis in septic patients.Unlike typical SC,ST patients usually displayed LV apical and circumferential mid-ventricular hypokinesia and basal hypercontractility.Timely and precise evaluation of heart dysfunction in sepsis patients is not easy but obviously mandatory.Further studies are still warranted regarding the mechanism,evaluation,and management of septic cardiomyopathy.