Takotsubo Syndrome

Download : Download full-size image A 68-year-old female presented to the Emergency Department with substernal chest pain and shortness of breath after an episode of syncope. She had a past medical history of hypertension, diabetes, and anxiety. She reported significant stress and anxiety surrounding her family’s recent move to a new city away from friends of many years. Physical exam was pertinent for blood pressure 80/60 mmHg, pulse 130 beats per minute (bpm), respiratory rate 30 breaths per minute, and oxygen saturation 92% on room air. Other findings included jugular venous pressure (JVP) of 20 mmHg, bibasilar crackles, 2 + pitting edema bilaterally in the lower extremities, and cold extremities. Laboratory evaluation revealed a troponin 4.5 ng/mL, BNP (brain natriuretic peptide) of 500 ng/L, potassium 4.5 meQ/L, and creatinine of 2.0 mg/dL. Electrocardiogram (ECG) demonstrated ST segment elevation in leads V2–V6 with deep T-wave inversions and QTc of 500 ms. Chest X-ray was pertinent for cephalization of pulmonary vessels and bilateral Kerley B lines and was consistent with pulmonary edema. Given her presentation, she was suspected of having an acute coronary syndrome (ACS) and was taken to the cardiac catheterization laboratory. Coronary angiography revealed no obstruction of the coronary arteries and left ventricular end diastolic pressure of 30 mmHg with left ventriculography showing apical hypokinesis. Transthoracic echocardiogram revealed a dilated left ventricle with a depressed function of 30% with apical akinesis, and basal segments were hypercontractile. Moderate-to-severe mitral regurgitation was noted due to systolic anterior motion of the anterior leaflet of the mitral valve, with mild-to-moderate tricuspid regurgitation. Aortic valve was trileaflet with mild aortic regurgitation and a normal aortic root measurement. Right ventricular size and function were normal. What is the etiology of her presentation, and how would you manage her going forward? Over the past several decades, there has been an increasing awareness of sex differences in cardiovascular disease presentation and pathophysiology. Stress-induced cardiomyopathy or Takotsubo syndrome (TTS) is one such condition that overwhelmingly affects postmenopausal women who have recently experienced a physical or an emotional stressor. The stressor activates a neurohormonal cascade causing a catecholamine storm that provokes symptoms similar to those described in acute coronary syndrome and heart failure. There are characteristic echocardiographic features that can indicate that a Takotsubo event has occurred. Treatment focuses on management of acute heart failure and monitoring for arrhythmias, because these patients can be at high risk of adverse outcomes and complications during the acute phase. This review focuses on our contemporary understanding of pathophysiology, diagnosis, and management of this condition that differentially impacts women.