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Shortness of Breath, Chest Pain

Kaplan, Bonnie MD

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doi: 10.1097/01.EEM.0000476276.02356.34
    Supraventricular tachycardia with premature supraventricular complexes, left posterior fascicular block, marked ST abnormality, and possible lateral subendocardial injury.

    A 73-year-old woman with a past medical history of insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, and renal transplant presented with shortness of breath and chest pain. She does not use oxygen at home, and only speaks Thai.

    Her oxygen saturation was 59% on arrival, and she had a heart rate of 120 bpm and a blood pressure of 123/56 mm Hg, and was afebrile. She was pale, with crackles on her lung exam. Her heart sounds are not muffled.

    This was her initial ECG and chest x-ray. What else could this be if it is not ST-elevation MI? What causes this syndrome?

    Find the diagnosis and case discussion on p. 18.

    Diagnosis: Takotsubo Cardiomyopathy

    A plain single-view AP chest x-ray. Findings: Multifocal airspace disease, which could represent pulmonary edema or infection, grossly enlarged cardiac silhouette.

    Takotsubo is also known as stress-induced cardiomyopathy, broken heart syndrome, or apical ballooning syndrome (ABS). This syndrome is unique because it is a reversible cardiomyopathy. A stressful event often precedes the event. This can include emotional stress, illness, or procedures. About one to two percent of patients who present with signs of an acute myocardial infarction will instead have ABS. The pathophysiology of this syndrome is not completely known. The current perspective is that it is a catecholamine-mediated myocardial stunning. (Am Heart J 2008;155[3]:408.)

    The majority of these patients are women. Physical triggers are more common in these patients than emotional stressors. (N Engl J Med 2015;373[10]:929.) The mean age of presentation is 62 years old. (Heart 2003;89[9]:1027.) One series noted that patients often present in cardiogenic shock, just as our patient did. All of these patients showed significant apical akinesia that was often seen on echocardiogram. They often had elevated troponins, low ejection fractures, and electrocardiograms concerning for STEMI. (N Engl J Med 2005;352[6]:539.) These features appear even though the patient does not have obstructive coronary disease on angiography; wall-motion abnormalities are transient. (Ann Intern Med 2004;141[11]:858.)

    The most common presenting symptoms are chest pain, dyspnea, and syncope. (N Engl J Med 2015;373[10]:929.) These patients can also present with heart failure or various arrhythmias (tachyarrhythmias or bradyarrhythmias).

    One should consider this diagnosis in adult postmenopausal women with concern for ST-elevation MI who have an echocardiogram where the akinesis extends beyond a single coronary artery distribution and who don't have angiographic evidence of acute plaque rupture. Our patient had concerns for ST-elevation MI in the inferior leads, an elevated troponin of 1.58, and an echocardiogram that had systolic apical balloon of the left ventricle. This presentation is the most common type. Her initial ejection fraction was 20%; two weeks later, it was 50%.

    Managing these patients who present in cardiogenic shock depends on whether they have significant left ventricular outflow track obstruction (LVOT). If they do not and are hypotensive, one could consider dobutamine or dopamine along with cautious fluid resuscitation. Consider beta blockers and increasing preload with IV fluids if the patient does have significant LVOT. This might help relieve the obstruction. (Mayo Clin Proc 2001;76[1]79.)

    Most of these patients recover. They are, however, at the same risk for in-hospital complications as patients who presented with ST-elevation MI. (N Engl J Med 2015;373[10]:929.)

    This patient had echocardiograms concerning for Takostubo's cardiomyopathy in the ED and in the cardiac ICU. The patient was stabilized, and then had percutaneous catheterization, during which coronary artery disease was found. She was managed medically, and her most recent ejection fracture was 50%. Her initial stressor was thought to be pneumonia.

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