Takotsubo cardiomyopathy (TC) was initially recognized in Japan in 1990. The typical patient is a postmenopausal woman with symptoms that mimic an acute coronary syndrome generally following physical or emotional stress. The EKG will typically have dynamic ST segment changes, while the angiogram will usually show normal coronary arteries. In classic TC, the left ventriculogram typically shows akinesis and ballooning of the apex with a normal or hyperdynamic base. Several variants of TC have been described. In this case report, we describe a midventricular variant of TC in a 64-year-old Hispanic female. The patient had chest pain, shortness of breath, elevated cardiac enzymes, and ST-segment elevations in leads II, aVF, and V5-V6. Coronary angiography revealed normal coronary arteries. Left ventriculogram showed hypokinesis of the midventricular segment and hyperdynamic apical and basal regions. Although the exact mechanism of TC is unknown, several theories include loss of estrogen, catecholamine or neurohumoral stimulation, coronary artery spasm, and left ventricular outflow tract (LVOT) obstruction.
Coronary computed tomographic angiography (CCTA) with prospective electrocardiographic gating reduces radiation exposure, but its prognostic power for predicting cardiovascular risk in patients with suspected CAD has not been fully validated. To determine whether prospective gating performs as well as retrospective gating in this population, we compared these scan modes in patients undergoing 64-slice CCTA.
From January 2009 through September 2011, 1,407 patients underwent CCTA; of these, 915 (mean age, 57.8 ± 13.5 yr; 54% male) had suspected coronary artery disease at the time of CCTA and were included in the study. Prospective gating was used in 195 (21%) and retrospective gating in 720 (79%). The mean follow-up duration was 2.4 ± 0.9 years.
Overall, 390 patients (42.6%) had normal results on CCTA, 382 (41.7%) had nonobstructive coronary artery disease, and 143 (15.6%) had obstructive disease. Major adverse cardiac events occurred in 32 patients (3.5%): 11 cardiac deaths, 15 late revascularizations, and 6 nonfatal myocardial infarctions. Total event occurrences were similar in both groups (retrospective, 3.8%; prospective, 2.6%; P=0.42), as were the occurrences of each type of event. On adjusted multivariate analysis, nonobstructive (P=0.015) and obstructive (P <0.001) coronary artery disease were independently associated with major adverse cardiac events. Scan mode was not a predictor of outcome. The mean effective radiation dose was 4 ± 2 mSv for prospective compared with 12 ± 4 mSv for retrospective gating (P <0.01).
The prognostic value of CCTA with prospective electrocardiographic gating compares favorably with that of retrospective gating, and it involves significantly less radiation exposure.
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