In takotsubo cardiomyopathy, the clinical appearance is that of an acute myocardial infarction T akotsubo cardiomyopathy (TC) is characterized by the clinical appearance of an acute myocardial infarction and by left ventricular (LV) apical ballooning in a patient who has no obstructive coronary artery disease.1 Patients typically present after a precipitating physical or emotional stressor. However, the mechanism by which these stimuli lead to cardiac decompensation is unclear-proposed factors include catecholamine excess and coronary vasospasm.2 We present the case of a patient whose TC was precipitated by elective direct-current (DC) cardioversion for atrial fibrillation.
Case ReportIn January 2012, a 67-year-old woman was admitted to our hospital after a syncopal episode. She had been cooking breakfast and was able to catch herself before falling. During the event, her shirt caught on fire, but she was not burned. She reported no palpitations or chest pain; however, she had experienced dizziness and diaphoresis minutes after the event.The patient's medical history included paroxysmal atrial fibrillation and hypertension, treated with spironolactone and metoprolol succinate. Two years before the patient's current presentation, a computed tomographic angiogram had revealed normal coronary arteries. Her metoprolol succinate dose had recently been increased from 12.5 mg/d to 50 mg/d, and her warfarin therapy had recently been discontinued because of hematuria in the presence of a supratherapeutic international normalized ratio.Upon the patient's presentation, examination revealed an irregular pulse of 126 beats/min and a blood pressure of 106/72 mmHg. An electrocardiogram showed atrial fibrillation and low voltage (Fig. 1A). Laboratory values, including cardiac troponin I levels, were within normal limits. Echocardiograms showed normal LV function, normal wall motion, and a mildly dilated left atrium.The decision was made to establish sinus rhythm by means of DC cardioversion. The patient was sedated with propofol, and electrical cardioversion via biphasic energy at 200 J was performed, with a resultant rhythm of sinus bradycardia at 30 beats/min. After cardioversion, the patient was hypotensive and lethargic, despite the correction of the bradycardia with atropine and epinephrine. She was intubated for respiratory Case Reports
Anticoagulation is vital for stroke and systemic embolism prevention in patients with atrial fibrillation. Current therapy with the vitamin K inhibitor warfarin has many inherent limitations in clinical practice. With the potential of broadening anticoagulation therapy to a larger population, new classes of anticoagulants have recently emerged with the potential for improved efficacy, safety and convenience. Direct thrombin inhibitor and Factor Xa inhibitor classes are showing promise for both patients and clinicians.
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