Cardiomiopatia de Takotsubo: uma causa rara de choque cardiogênico simulando infarto agudo do miocárdio

Abstract

We report a case of cardiogenic shock caused by an acute left ventricular aneurysm, similar to Takotsubo or Dumbbell, in a patient without obstructive coronary lesion. The case fulfills all criteria for Takotsubo cardiomiopathy, a pathology most frequent in Japan and that can simulate acute myocardial infarction. Case ReportA 70-year-old, female patient, with precordial discomfort under constriction for 6 hours, without irradiation, followed by difficulty to breathe, with stressed worsening in the last 3 hours. In the morning before the beginning of the symptoms, the family informed and intense emotion motivated by family discussion. There was no report of morbid history or use of medications.A patient showing stressed respiratory discomfort, pale, with abounding sudoresis. Tachycardic rhythmic sounds without other noises, bullous rales of medium and thin bubbles up to pulmonary apexes. Blood pressure was 90x60 mmHg, heart rate was 135 b.p.m, respiratory rate was 35 i.p.m., axillary temperature was 37°C. During the exam in the emergency room, the patient showed stressed worsening of respiratory discomfort, needing an urgent orotracheal intubation and mechanical ventilation. Dopamine IV was started. Electrocardiogram (ECG) of 12 derivations showed sinus tachycardia with non-specific changes of ventricular repolarization. Dosage of CKMB -mass collected at the admission was 22 u.The patient was transferred to this service with the diagnostic hypothesis of non-Q infarction and cardiogenic shock.She was under mechanical ventilation, tachycardic with rhythmic sounds, heart rate of 145 b.p.m, bullous rales up to the upper third of both pulmonary fields, blood pressure was 80x50 mmHg. The thoracic radiography showed right pneumothorax, of moderate size and signs of pulmonary congestion ( fig. 1). The ECG showed changes in ventricular repolarization and sinus tachycardia ( fig. 2). The CKMB-mass was 29 u, creatinine of 1,2 mg% and glycemia 140 mg%. The pneumothorax was immediately drained. An echocardiogram performed by the bed, showed left ventricular aneurysm of anterior wall, compromising the middle and apical regions ( fig. 3). After a fast hemodynamic stabilization with careful infusion of fluids, guided by the echocardiogram, institution of dobutamine at 12 mcg/kg/min and noradrenaline at 8 mcg/min, the patient was sent to hemodynamics laboratory, where the coronary angiography showed coronary arteries without obstructive lesions ( fig. 4) and the left ventriculography showed anterior wall aneurysm in a shape similar to Takotsubo or Dumbbell (fig. 5). The patient was kept under mechanical ventilation, with vasoactive drugs. Successive measurements of CKMB revealed a peak of 45 u in approximately 40 hours of evolution. After 48 hours there was an improvement of the features, with possibility of removal of mechanical ventilation and progressive discontinuity of vasoactive drugs. A new echocardiogram, by the bed, performed 72 hours after admission, did not show abnormalities of segmental contraction ( fig. 6). The pat...

Cardiomiopatia de Takotsubo como causa de infarto agudo do miocárdio em paciente em uso de anti-histamínico associado a pseudo-efedrina

“…Embora cada vez mais freqüentes, ainda são escassas as publicações a respeito da ST na literatura ocidental e, em particular, no Brasil. Vasconcelos et al 8 relataram um caso de uma paciente com ST que evoluiu com choque cardiogênico. Mais recentemente, Meyer Neto et al 9 publicaram um caso da associação da ST com obesidade mórbida e lúpus eritematoso sistêmico.…”