Pericarditis-complicated takotsubo cardiomyopathy in a patient with rheumatoid arthritis

Abstract

A 64-year-old woman with medication-controlled rheumatoid arthritis (RA) was admitted to our hospital complaining of chest pains. An electrocardiogram showed elevated ST-segments in the inferior leads, and inverted T-waves in the left precordial leads. Left ventriculography demonstrated apical ballooning, and cardiac magnetic resonance imaging demonstrated apical ballooning of the left ventricle, and moderate pericardial effusion. The patient was diagnosed with takotsubo cardiomyopathy (TTC), complicated by pericarditis. In the literature, autoimmune disorders have been associated with TTC. We suggest that this patient's pericardial effusion was caused by TTC, and that her coexisting RA might have played a role in the etiology of the significant pericardial fluid accumulation.

Pericarditis With Cardiac Tamponade Mimicking Yellow Nail Syndrome in a Patient With Rheumatoid Arthritis and a Paucity of Joint Symptoms

“…With the onset of pericarditis, rheumatoid arthritis control may have become poor in our patient. Previous studies suggest that pericarditis complication is a factor that indicates poor control of rheumatoid arthritis [11,12]. In this case, the onset of pericarditis could have been a precursor to the exacerbation of rheumatoid arthritis.…”

“…Many non-fatal complications of rheumatoid arthritis can progress chronically [5]. In contrast, pericarditis may acutely manifest and progress to fatal conditions, such as cardiac tamponade, as in this case [3,11]. Older people in rural settings tend to manage their symptoms by themselves [17][18][19][20].…”

Takotsubo Syndrome: Finally Emerging From the Shadows?

“…We have demonstrated [11] that hypotension has little or nothing to do with impaired LV systolic function, LV "outflow tract obstruction", and left ventricular end-diastolic pressure is rarely impaired to the extent which would normally result in development of pulmonary oedema via disturbance of the Starling Equation. However, patients develop myocardial oedema, together with occasional cases of pulmonary oedema [44] and pericardial [45] or pleural effusions [39]. It seems likely that both hypotension/shock and tissue oedema may reflect largely the haemodynamic impacts of vasodilator autacoids, and of transient permeabilisation of blood vessel walls with resultant fluid extravasation.…”

What triggers Takotsubo in cases without an obvious trigger?

“…We read with interest the article by Mori et al about a 64-year-old female with a history of rheumatoid arthritis starting 8 years earlier, who developed Takotsubo syndrome (TTS) 3 days prior to admission for chest pain and dyspnoea (1). No definite trigger for TTS was detected but cardiac magnetic resonance imaging (cMRI) suggested the presence of pericarditis, which was assumed not to have been causative (1).…”

“…A second point requiring discussion is the diagnosis of pericarditis (1). Pericarditis was diagnosed by cMRI but no puncture of the pericardial effusion was carried out.…”