An atypical case of inverted Tako-Tsubo syndrome: case report and review of the literature

Abstract

A 69-yearold Caucasian woman was admitted to our emergency department (ED) for an acute and initial episode of substernal chest pain radiating to the left arm, which had lasted about 1 h, associated with dyspnea and diaphoresis. She had a past medical history of depression and first stage primary biliary cirrhosis. She was taking chronic low-dose sotalol therapy (80 mg PO bid) for a prior episode of supraventricular tachycardia. She had an otherwise normal heart, and was without cardiovascular risk factors.At admission, she denied any recent emotional or stressful event. The first EKG recorded 10 min after the ED admission showed mild ST-segment depression in the precordial leads V5 and V6 ( Fig. 1), without significant changes in the inferior, posterior and right precordial leads.The first blood sample analysis exhibited normal values of Troponin-I (cTn-I: 0.10 lg/L, normal range: 0-0.15 lg/L) and CK-MB (1.1 ng/ml, normal range: 0.5-3.6 ng/ml).The patient, fully asymptomatic, was admitted to our intensive observation unit.Based on our protocol, a second blood chemistry control was performed 6 h after the initial results. An elevated cTn-I value of 3.31 lg/L with normal CK-MB value (1.0 ng/ml) was observed. The EKG registered at the same time as the laboratory blood tests showed T-wave inversion in the precordial leads from V1 to V4 (Fig. 2), not present in the first tracing,and a small QT dispersion with a QT interval a bit longer than previous EKG. Trans-thoracic echocardiography showed normal left ventricular internal dimensions; the segmental wall motion analysis revealed akinesis of the basal anterior wall and the entire interventricular septum associated with hypokinesis of the inferior wall basal segments. Posterolateral basal segments and all mid-ventricular and apical segments appeared hyperkinetic. Preliminary diagnosisDr. Zanobetti, Dr. Conti, Dr. Pini: Based on the initial presentation, EKG abnormalities and a positive marker of myocardial necrosis, an acute coronary syndrome, myocarditis, or an atypical presentation of Tako-Tsubo syndrome were considered.None of the serial EKGs exhibited abnormalities characteristic of an acute coronary syndrome, and there was a mismatch between the limited extension of EKG abnormalities and the diffuse wall motion abnormalities in the echocardiographic examination. This mismatch can support the diagnosis of myocarditid, especially in the presence of limited abnormalities of myocardial specific enzymes. However, all indices of inflammation (C-Reactive Protein, leucocytes, erythrocyte sedimentation rate)

Tako-tsubo cardiomyopathy: is there a preferred time of onset?

“…In a clinical emergency setting, the importance of promptly thinking of TTC is very important, and either clinical factors (female gender, postmenopausal age, recent stressful events, typical chest pain) and instrumental examinations (electrocardiogram, transthoracic echocardiography) are essential [50]. In this context, the demonstration of temporal periods with the highest frequency risk of onset may have useful implications in terms of awareness and in the provision of a warning alert.…”

Different Characteristics between Patients with Apical and Non-Apical Subtypes of Stress-Induced Cardiomyopathy

“…Prolongation of QTc interval is another representative feature. Zanobetti et al3) analyzed 22 previously reported cases with inverted takotsubo cardiomyopathy. Although ECGs of 9 patients (40.9%) demonstrated ST elevation, more than half of patients (59.1%) showed only subtle ECG changes such as mild ST depression or QTc prolongation.…”

Uncommon type of tako-tsubo cardiomyopathy - Case report and current view

“…Tato kasuistika je zajímavá zejména pro atypickou lokalizaci hypokineze myokardu, která byla patrna v bazálních segmentech levé komory. Forma TTK s postižením bazálních segmentů a obvykle s hyperkinezí hrotu je známá jako "inverted tako-tsubo" -invertovaná nebo obrácená forma tako-tsubo kardiomyopatie a byla v literatuře popsána jen velmi vzácně [16]. V nedávné multicentrické studii, publikované v Journal of the American Medical Association, zahrnující 239 pacientů ze sedmi center v Evropě a Severní Americe byla tato forma nalezena ve dvou případech.…”