So what about that troponin?
Continuing our case from a few days ago…A cardiac cath was done, which showed completely clean coronary arteries. However, there was apical hypokinesis of the left ventricle with an EF of 30%. The answer: Takotsubo Cardiomyopathy, or “Broken Heart Syndrome.”
This is a stress-induced transient cardiomyopathy wherein there is stunning of the myocardium leading to ballooning of the apex of the left ventricle. The left ventricular base is intact and functioning correctly, leading to the classic ballooning appearance of the left ventricle, as shown above. Classically, patients with this present as new onset heart failure, and many times will have EKG changes consistent with an anterior myocardial infarction. They therefore are frequently sent to the cath lab, where they are found to have acute heart failure with clean coronary arteries, and preserved systolic function at the base of the LV.
This is thought to be related to elevated levels of circulating catecholamines, although the exact mechanism is unclear. Studies have found that it is more frequent in older women. Symptoms at presentation include chest pain, shortness of breath, heart failure, and cardiogenic shock. Think about this possibility when your history elicits a recent tragic or stressful event in the patient’s life.
Treatment is the same as you would for any other patient with the above symptoms. The incidence has been reported as about 1.7% of patients with acute coronary syndrome, and is therefore somewhat rare. Treat your patient as if they are having an MI. Treat heart failure and cardiogenic shock in the standard fashion.
Patients typically do very well, as long as they survive the initial presentation, even when they present severely in cardiogenic shock. Mild cases with minimal troponin elevation as in our patient typically regain systolic function within the first week, and most regain normal function within the first 6 months after presentation. Rarely do these patients have any in hospital morbidity or mortality.
Remember, your patient can die of a broken heart!
Eshtehardi P et al. Transient apical ballooning syndrome - clinical characteristics, ballooning pattern, and long term follow up in a Swiss population. Int J of Cardiology, 135 (3): 370-5. 2009.
Image obtained from : http://www.nature.com/nrcardio/journal/v3/n1/fig_tab/ncpcardio0414_F2.html