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Takotsubo Cardiomyopathy Triggered by Severe Vomiting
CLINICAL COMMUNICATION TO THE EDITOR
Takotsubo Cardiomyopathy Triggered by Severe Vomiting To the Editor: Takotsubo cardiomyopathy is characterized by ST-segment elevation myocardial infarction and transient myocardial stunning with left ventricular dysfunction, typically precipitated by sudden emotional stress.1 Although the initial clinical presentation mimics acute myocardial infarction, takotsubo cardiomyopathy is distinguished by the absence of coronary atherosclerotic disease. Preserved basal myocardial contractility with systolic ballooning of the left ventricular apex is characteristically seen on echocardiographic imaging in a pattern resembling a Japanese octopus trap. Presumed mechanisms include catecholamine-mediated myocardial stunning, sympathetic stimulation leading to epicardial coronary arterial spasm and ischemia, or microvascular spasm.2,3 We describe the case of a patient presenting with takotsubo cardiomyopathy in the setting of high-intensity vomiting.
Figure 1 Echocardiographic images on acute presentation (top; [A], diastole; [B], systole) and 4-week follow-up (bottom; [C], diastole; [D], systole). Left ventricular apical ballooning (arrowheads).
CASE REPORT A 49-year-old woman with a history of gastroesophageal reflux disease, hiatal hernia, Nissen fundoplication, esophagectomy, and subsequent chronic vomiting presented to the emergency department with an acute exacerbation of a several month history of nausea and vomiting, and a new symptom of severe left-sided chest pressure radiating to the left arm for several hours. During the 2 days leading up to emergency department presentation, the patient had been vomiting nearly every hour. In the emergency department a chest radiograph showed a normal mediastinum and cardiac silhouette without acute cardiopulmonary process. Electrocardiogram revealed 2 mm ST-segment elevation in leads V2 and V3, with T-wave inversion in leads V2 to V4. Sublingual nitroglycerin was administered without resolution of chest pain or change in the electrocardiogram. The patient was taken to the Funding: No external funding was provided for this report. Conflict of interest: All authors declare no conflict of interest with regard to this work. Authorship: All authors had access to the material published and a role in writing the article. Requests for reprints should be addressed to Mazen Awais, MD, 3110 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5368. E-mail address: [email protected].
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
interventional cardiology laboratory; emergency coronary arteriography revealed normal coronary anatomy with no evidence of significant coronary artery disease. An echocardiogram (Figure 1) revealed decreased left ventricular systolic function with an ejection fraction of 35% to 40%, and an anteroapical wall motion abnormality with hypercontractile basal left ventricular segments and ballooning of the apex. There were no valvular abnormalities. Chest pain and electrocardiogram changes resolved with conservative management. Repeat echocardiography 8 hours after the initial study revealed a persistent wall motion abnormality limited to the apical segments with improved mid-left ventricular regional systolic function and normalization of overall left ventricular systolic function. Follow-up echocardiographic imaging 4 weeks after presentation revealed complete normalization of left ventricular wall motion. The clinical course was typical for “broken heart syndrome,” precipitated by intractable vomiting.
DISCUSSION This patient’s presentation suggests an unusual case of takotsubo cardiomyopathy. Thought to be precipitated by a period of sudden emotional stress, this transient cardiomy-
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The American Journal of Medicine, Vol 121, No 12, December 2008
opathy is not commonly associated with severe nausea and vomiting. The majority of patients with takotsubo cardiomyopathy are older women who present with chest pain and dyspnea; however, there are few reported cases of patients presenting with nausea and vomiting. One notable case describes an elderly woman in Japan who presented with severe vomiting and subsequently died of worsening heart failure.4 In the currently described clinical scenario, the patient presented with severe acute-on-chronic vomiting and chest pain. The extreme physiologic stress produced by high-intensity vomiting may have resulted in a surge in sympathetic activity that led to myocardial stunning and the associated transient cardiomyopathy. Alternatively, highintensity vomiting could have been a marker for increased sympathetic activity of an independent but unknown cause. It is fortunate that, as is the case with the majority of patients with takotsubo cardiomyopathy, this patient experienced dramatic improvement of left ventricular dysfunction soon after presentation.
Mazen Awais, MD Roland A. Hernandez David S. Bach, MD The Department of Internal Medicine Division of Cardiovascular Medicine The University of Michigan Ann Arbor, Michigan
doi:10.1016/j.amjmed.2008.07.019
References 1. Brenner Z, Powers J. Takotsubo cardiomyopathy. Heart Lung. 2008; 37:1-7. 2. Wittstein I, Thiemann D, Lima J, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539-548. 3. Pilgrim T, Wyss T. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol. 2008;124:283-292. 4. Sakai K, Ochiai H, Katyama N, et al. A serious clinical course of a very elderly patient with takotsubo cardiomyopathy. Heart Vessels. 2005;20: 77-781.
Takotsubo Cardiomyopathy Triggered by Severe Vomiting To the Editor: Takotsubo cardiomyopathy is characterized by ST-segment elevation myocardial infarction and transient myocardial stunning with left ventricular dysfunction, typically precipitated by sudden emotional stress.1 Although the initial clinical presentation mimics acute myocardial infarction, takotsubo cardiomyopathy is distinguished by the absence of coronary atherosclerotic disease. Preserved basal myocardial contractility with systolic ballooning of the left ventricular apex is characteristically seen on echocardiographic imaging in a pattern resembling a Japanese octopus trap. Presumed mechanisms include catecholamine-mediated myocardial stunning, sympathetic stimulation leading to epicardial coronary arterial spasm and ischemia, or microvascular spasm.2,3 We describe the case of a patient presenting with takotsubo cardiomyopathy in the setting of high-intensity vomiting.
Figure 1 Echocardiographic images on acute presentation (top; [A], diastole; [B], systole) and 4-week follow-up (bottom; [C], diastole; [D], systole). Left ventricular apical ballooning (arrowheads).
CASE REPORT A 49-year-old woman with a history of gastroesophageal reflux disease, hiatal hernia, Nissen fundoplication, esophagectomy, and subsequent chronic vomiting presented to the emergency department with an acute exacerbation of a several month history of nausea and vomiting, and a new symptom of severe left-sided chest pressure radiating to the left arm for several hours. During the 2 days leading up to emergency department presentation, the patient had been vomiting nearly every hour. In the emergency department a chest radiograph showed a normal mediastinum and cardiac silhouette without acute cardiopulmonary process. Electrocardiogram revealed 2 mm ST-segment elevation in leads V2 and V3, with T-wave inversion in leads V2 to V4. Sublingual nitroglycerin was administered without resolution of chest pain or change in the electrocardiogram. The patient was taken to the Funding: No external funding was provided for this report. Conflict of interest: All authors declare no conflict of interest with regard to this work. Authorship: All authors had access to the material published and a role in writing the article. Requests for reprints should be addressed to Mazen Awais, MD, 3110 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5368. E-mail address: [email protected].
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
interventional cardiology laboratory; emergency coronary arteriography revealed normal coronary anatomy with no evidence of significant coronary artery disease. An echocardiogram (Figure 1) revealed decreased left ventricular systolic function with an ejection fraction of 35% to 40%, and an anteroapical wall motion abnormality with hypercontractile basal left ventricular segments and ballooning of the apex. There were no valvular abnormalities. Chest pain and electrocardiogram changes resolved with conservative management. Repeat echocardiography 8 hours after the initial study revealed a persistent wall motion abnormality limited to the apical segments with improved mid-left ventricular regional systolic function and normalization of overall left ventricular systolic function. Follow-up echocardiographic imaging 4 weeks after presentation revealed complete normalization of left ventricular wall motion. The clinical course was typical for “broken heart syndrome,” precipitated by intractable vomiting.
DISCUSSION This patient’s presentation suggests an unusual case of takotsubo cardiomyopathy. Thought to be precipitated by a period of sudden emotional stress, this transient cardiomy-
e4
The American Journal of Medicine, Vol 121, No 12, December 2008
opathy is not commonly associated with severe nausea and vomiting. The majority of patients with takotsubo cardiomyopathy are older women who present with chest pain and dyspnea; however, there are few reported cases of patients presenting with nausea and vomiting. One notable case describes an elderly woman in Japan who presented with severe vomiting and subsequently died of worsening heart failure.4 In the currently described clinical scenario, the patient presented with severe acute-on-chronic vomiting and chest pain. The extreme physiologic stress produced by high-intensity vomiting may have resulted in a surge in sympathetic activity that led to myocardial stunning and the associated transient cardiomyopathy. Alternatively, highintensity vomiting could have been a marker for increased sympathetic activity of an independent but unknown cause. It is fortunate that, as is the case with the majority of patients with takotsubo cardiomyopathy, this patient experienced dramatic improvement of left ventricular dysfunction soon after presentation.
Mazen Awais, MD Roland A. Hernandez David S. Bach, MD The Department of Internal Medicine Division of Cardiovascular Medicine The University of Michigan Ann Arbor, Michigan
doi:10.1016/j.amjmed.2008.07.019
References 1. Brenner Z, Powers J. Takotsubo cardiomyopathy. Heart Lung. 2008; 37:1-7. 2. Wittstein I, Thiemann D, Lima J, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539-548. 3. Pilgrim T, Wyss T. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol. 2008;124:283-292. 4. Sakai K, Ochiai H, Katyama N, et al. A serious clinical course of a very elderly patient with takotsubo cardiomyopathy. Heart Vessels. 2005;20: 77-781.