P026: TAKOTSUBO/ACUTE STRESS CARDIOMYOPATHY PRECEDING A ROUTINE EGD/COLONOSCOPY SCREENING
Gabriel Garcia Barrera, MD; Santiago Luis, MD; Cleveland Clinic Florida
Introduction and Case Report: Takotsubo cardiomyopathy (TC) also known as stress induced cardiomyopathy, is a rare condition characterized by transient systolic dysfunction of the apical and mid-segments of the left ventricle, in the absence of obstructive coronary artery disease (CAD) or angiographic evidence of acute plaque rupture. Postmenopausal women are typically affected and commonly presents with chest pain and dyspnea. 3
A 68-year-old female with a history of GERD, chronic gastric ulcer and former smoking history presented for diagnostic EGD and colonoscopy screening. After the administration of lidocaine and propofol, patient became tachycardic HR 103, hypertensive 159/79 and desaturated to 92-91%. She rapidly corrected with nasal airway and chin trust. ST-segment elevation appeared in lead II and PVCs with bigeminy. The procedure was aborted, and patient was transported to PACU.
In PACU, patient had no complaints of pain at the time, and hemodynamically stable (HDS). Stat ECG, CXR, laboratories were ordered, and IM/cardiology consulted. Patient developed chest pain across her chest minutes later, rated 4/10. Labs were remarkable for hemoglobin 8.4, CO2 14, Glucose of 53, calcium 7.3, magnesium 1.0. Troponin T at the time was 0.024. Chest x-ray was unremarkable. EKG showed new T wave inversions in the inferior leads, without contiguous ST changes or reciprocal ST abnormalities (Figure 1).
Patient’s chest pain resolved with sublingual nitroglycerin, and electrolyte imbalances were corrected. She continued to endorse chest pressure. In an 8-hour interval, T troponin increased from 0.02 to 0.5. A loading dose of ASA, and IV heparin was started. TTE performed showed a mildly dilated left ventricle, moderately decreased LV systolic function, grade 1 diastolic dysfunction, with severe anteroapical hypokinesis, and an estimated EF of 36% (figure 2). No significant valvular abnormalities.
Patient’s chest pain resolved, and cardiology planned for left heart catheterization (LHC). Plavix, metoprolol and atorvastatin were started. Patient remained asymptomatic and HDS, and troponin T down trended. A LHC was completed which showed no obstructive CAD, with LAD mild luminal irregularities. A diagnosis of TC was made based on consistent clinical presentation and findings. Patient’s repeat TTE about two weeks later showed a recovered EF.
Discussion: TC most commonly presents with chest pain, and dyspnea. More critical presentations include cardiogenic shock, and ventricular fibrillation. 2
While the prognosis and recovery rates are overall favorable, the mortality risk can be similar to that of acute MI. A 30-day risk of major adverse cardiac and cerebrovascular events of 5.9%, has been reported. 1 This case highlights the importance of considering TC when facing new onset EKG changes that resemble MI, acute chest pain, heart failure or ventricular arrhythmias.
1. Agarwal S, Sanghvi C, Odo N, Castresana MR. Perioperative takotsubo cardiomyopathy: Implications for anesthesiologist. Ann Card Anaesth. 2019 Jul-Sep;22(3):309-315. doi: 10.4103/aca.ACA_71_18. PMID: 31274495; PMCID: PMC6639891.
2. Amin HZ, Amin LZ, Pradipta A. Takotsubo Cardiomyopathy: A Brief Review. J Med Life. 2020 Jan-Mar;13(1):3-7. doi: 10.25122/jml-2018-0067. PMID: 32341693; PMCID: PMC7175432.
3. Scantlebury DC, Prasad A. Diagnosis of Takotsubo cardiomyopathy. Circ J. 2014;78(9):2129-39. doi: 10.1253/circj.cj-14-0859. Epub 2014 Aug 13. PMID: 25131525.