Steve Mcguire, MD
82 y/o female arrives via EMS with husband after she lost control of the car, accidentally running him over in the driveway. Her husband was a trauma note and severely injured, including pelvic fractures with bladder rupture. While in the ED observing the resuscitation she complained of mid-sternal chest pain. The nurses quickly placed her in Room 11 (near the trauma bay at her request) so she can be near her ‘husband of 60years’.
PMH – HTN, HLD, remote history of Breast CA, clean cath in 2008 (episode of cp/SOB).
FMH/SocHx – non contributory
Meds – metoprolol, simvastatin, aspirin 81 mg
Vitals: HR 80 BP 140/90 RR 18 O2 99% 2L
Gen app:Mild distress, clearly agitated/concerned and weeping.
Resp: clear lungs
CV: RRR, no MRG
Troponin – 0.73 NG/mL
She was started on nitroglycerin, beta-blocker, heparin and admitted to the CCU. Her echocardiography showed an EF 30-40% with multiple wall motion abnormalities and apical akinesis. She underwent a cardiac catherization the following morning. Her catherization showed no significant coronary artery disease.
Example echo: image courtesy of google images bjcardio.co.uk
Stress (Takotsubo) cardiomyopathy, also known as “broken heart syndrome,” was described in the 1990s and often mimics an acute coronary syndrome. It is frequently found in the context of emotional, physical, or medical stress (~70%) without significant coronary atherosclerotic disease. It typically affects 80-90% women with >80% being post-menopausal. In the ED it tends to present in about 2% of suspected ACS cases.
The most common ECG changes are:
STE(42%)/STD(2%) often in precordial leads
T wave abnormalities( 38%) including deep TWI in Takotsubos
Broad upright T waves in reverse Takotsubo
In general cardiac enzymes are elevated, but tend to be lower than true ACS equivalents, and usually peak at or near ED presentation. On echocardiography LVEF is reduced <50%, especially with preservation of the base (Takotsubo or apical ballooning) but can also spare the apex and affect the base (reverse Takotsubo). In about 25 % of cases the right ventricle is affected. Typically angiography shows essentially normal coronaries (>80%) or non-critical lesions <50% occlusion.
Currently the mechanism of the pathophysiology is not entirely clear. As of now, the stress response leading to diffuse catecholamine mediated microvascular changes in perfusion, seems to best explain the constellation of findings, including the lack of correlation to coronary artery distribution for myocardial dysfunction. The resulting ischemia can also explain the ACS mimicry of the syndrome.
This mimicry also makes ED management relatively straightforward. Treat as you would for the equivalent ACS with anti-platelet therapy, anticoagulation, beta blockade, activation of the cath lab and avoid sympathomimetics. Acute congestive heart failure exacerbation can be a complication (especially RV variants) and can be treated with diuretics (on the floor).
Generally, the patients do well with supportive care, with nearly complete resolution of symptoms and signs. In the above case, follow-up ECHO was performed at 3 months, which showed LVEF of 59%.
Abraham J, Mudd JO, Kapur N, Klein K, Champion HC, Wittstein IS. Stress Cardiomyopathy After Intravenous Administration of Catecholamines and Beta-Receptor Agonists. J Am Coll Cardiol.2009;53(15):1320-1325. doi:10.1016/j.jacc.2009.02.020. PMID: 19358948
Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, Francone M, Desch S, Gutberlet M, Strohm O, Schuler G, Schulz-Menger J, Thiele H, Friedrich MG. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA. 2011 Jul 20;306(3):277-86. doi: 10.1001/jama.2011.992. PMID: 21771988
Abhiram Prasad, Amir Lerman, Charanjit S. Rihal, Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction, American Heart Journal, Volume 155, Issue 3, March 2008, Pages 408-417, http://dx.doi.org/10.1016/j.ahj.2007.11.008. PMID: 18294473
Smith, Stephen W. “COPD exacerbation, what do the ECG and bedside echo show?” Dr. Smith’s ECG Blog. HQMedEd, March 27, 2014. Web. September 28 2014. URL