Broken Heart Syndrome, stress induced cardiomyopathy, left ventricular wall ballooning, that resembles a traditional Japanese ceramic octopus trap…Takotsubo; all of these yes. Japanese motorcycle…unfortunately not.
Often spoken about it like the mythical unicorn, rarely do we have the opportunity to discover one in our daily clinical investigation. This month at Right Seat Medicine, the Erin Baker brings to us a presentation of Takotsubo (Stress) Cardiomyopathy.
Broken Heart Syndrome, otherwise known as apical ballooning syndrome, which is characterized by transient systolic dysfunction of mid segment or apex of the left ventricle, can mimic an acute myocardial infarction, without the presence of obstructive coronary artery disease.
The pathogenesis is not well understood, but is often triggered by medical illness or emotional stress.
So what does it look like when you actually find one of these patients. Invariably most are post menopausal females who have suffered some variance of emotional distress and present with atypical or vague histories of malaise or discomfort. Not typically the population we would always perform a 12 lead echocardiogram upon, but todays case will again highlight the (differential and) diagnostic value of the 12 lead ECG.
In the case presented today, Erin Baker responds to a GP’s office for a 76 year old female patient with a 2 day history of feeling “like something was not right”. Patient complained of chest pain 2 days prior but none today or on arrival. Prior to arrival, the patient presented to the GP’s office with the above vague symptoms and was subsequently sent (a short walk) to an outpatient ECG clinic which revealed an Anterior STEMI. EMS was called and the patient was administered 180mg ASA prior to EMS arrival.
Physical findings include warm, pink and dry skin with no delay in capillary refill. No JVD, equal breath sounds with fine inspiratory crackles bilaterally at the bases, amidst scattered wheezes. S1 and S2 clearly audible, with no obvious S3 or S4, murmurs, or rubs. Abdomen is soft x4; no palpable masses. No abnormalities noted on the back. Equal grips & leg strength with mild pedal edema noted. Normotensive, non tachypnic, non tachycardic with no aberrancy or ectopy on the 4 lead ECG, although subsequent 12 lead reveals the following;
The patients medical history includes: NIDDM that is well controlled. Chronic HTN (Rx Carbetalol & Coversyl), No previous cardiac investigation nor respiratory illness. Social history reveals chronic ETOH use, smoker 1 x ppd. Seemingly a well adjusted elderly female who lives alone in her own home. Patients mother passed 2 years previously and has brought emotional distress into her life after the event.
Due to the absence of any associated symptomology you consider Silent MI in the elder diabetic female patient yet notice the absence of any reciprocal changes in the limb leads and ponder a STEMI mimic. Yet as the monitor flags STEMI you begin the STEMI transmission and consult with the receiving EP at St Pauls, who subsequently accepts the patient. The short (14min) transport time sees no further evolution or changes on serial 12 lead ECG’s.
On arrival at St Pauls you are diverted to the PCI lab where the patient undergoes emergent angiography. Results that reveal no (aka none) occlusions nor narrowing of the coronary vasculature yet left ventricular wall abnormality (ballooning) is clearly evident.
The interventional cardiologist confirm your initial diagnosis of stress induced (Takotsubo’s) cardiomyopathy. The patient is admitted for observation to St Pauls Hospital.
Again, thank you to Erin Baker for presenting this case to us at RightSeatMedicine.
Once again reminding us to;
1. perform 12 lead investigation as an easy, cheap and non invasive test that can change the clinical course of action and outcome for your patient,
2. Ensure to telephone consult with the receiving EP regarding the clinical findings of your interesting STEMI after transmission is completed enroute,
3. Continuing education surrounding those STEMI mimics and their clinical sequelae, and
4. Takotsubo is not a Japanese motorcycle.