Stress Cardiomyopathy in the Setting of COPD Exacerbation

Abstract

Introduction. Stress cardiomyopathy, or takotsubo cardiomyopathy, is an acute, reversible left ventricular dysfunction usually initiated by a psychological or physical stress. We report this case of stress cardiomyopathy following a chronic obstructive pulmonary disease exacerbation and the subsequent treatment. Case Description. A 49-year-old white female with a history of chronic obstructive pulmonary disease presented to the emergency room via emergency medical services with worsening severe shortness of breath and productive cough for 2 weeks but denied any chest pain on arrival. On presentation, she was noted to be tachypneic, using her accessory muscles and with bilateral coarse expiratory wheezing on lung auscultation. Initial electrocardiogram demonstrated sinus tachycardia. She was treated with multiple albuterol treatments. Soon afterwards, the course was complicated by hypoxic respiratory failure eventually requiring intubation. Her repeat electrocardiogram showed acute changes consistent with myocardial infarction, and an echocardiograph demonstrated apical akinesia with an ejection fraction of 25% to 30%. The patient was urgently taken for cardiac catheterization, which showed no angiographic evidence of coronary artery disease. Three days after initial presentation, a repeat transthoracic echocardiogram showed overall left ventricular systolic function improvement. Discussion. This case provided a unique look at the difficulty of balancing catecholamines in a patient with bronchospasm and stress cardiomyopathy.

An uncommon cause for grade 3 primary graft dysfunction after lung transplantation: Takotsubo cardiomyopathy

“…[1][2][3][4] The dynamic ST/T alterations on ECG in the inferior and lateral leads without reciprocal ST depression in the other leads are the typical feature of TTC, in the absence of epicardial coronary artery disease, pheochromocytoma, or myocarditis. [1,2] Although the exact pathophysiological pathway of TTC still remains unclear, catecholamine-mediated myocardial stunning including an acute multi-vessel coronary spasm and coronary microcirculation dysfunction has been suggested to play a key role.…”

“…[2] Exposure to emotional or physical stress and exaggerated sympathetic activity leads to secretion of excessive catecholamine production and, therefore, it has been suggested that those catecholamine molecules are directly related with myocardium injury. [4] Elevated catecholamine levels decrease the viability of myocytes through cyclic-AMP mediated calcium overload, resulting in contraction band necrosis which is a histological pattern of myocardium injury seen in stress cardiomyopathy. [4] On the other hand, hypoxia and hypercarbia may play an important role in the pathophysiology of TTC using both peripheral and central chemoreceptors.…”

“…[4] Elevated catecholamine levels decrease the viability of myocytes through cyclic-AMP mediated calcium overload, resulting in contraction band necrosis which is a histological pattern of myocardium injury seen in stress cardiomyopathy. [4] On the other hand, hypoxia and hypercarbia may play an important role in the pathophysiology of TTC using both peripheral and central chemoreceptors. The suggested mechanism for hypoxia may be through peripheral chemoreceptors.…”

“…[4,5] In a review by Manfredini et al, [3] TTC was more likely to exist in patients with severe respiratory disease, and patients who needed invasive procedures. This syndrome occurred primarily in females (81.6%) with an age of approximately 65 years.…”

“…[3] Also, COPD, asthma, pulmonary embolism, pulmonary hypertension, pneumonia, lung malignancies, and surgery of the lungs, as well as invasive procedures of the lungs, such as rigid bronchoscopy and bronchoalveolar lavage, are considered major pulmonary etiological factors for TTC. [3,4,6] Not only diseases causing respiratory insufficiency or interventions to the lungs, but also emotional or physical stressful conditions may pose a risk for the development of TTC. Organ transplantation is at the top of the conditions in which physical and emotional stress is at the highest level.…”