The “Spiked Helmet” sign - A potential relationship to Takotsubo cardiomyopathy

Accepted Manuscript The “Spiked Helmet” sign - A potential relationship to Takotsubo cardiomyopathy

Samadov Fuad, Gasimov Emil, Aliyev Farid, Isayev Elnur PII: DOI: Reference:

S0735-6757(17)30949-X doi:10.1016/j.ajem.2017.11.041 YAJEM 57111

To appear in: Received date: Revised date: Accepted date:

3 September 2017 14 November 2017 16 November 2017

Please cite this article as: Samadov Fuad, Gasimov Emil, Aliyev Farid, Isayev Elnur , The “Spiked Helmet” sign - A potential relationship to Takotsubo cardiomyopathy. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajem(2017), doi:10.1016/j.ajem.2017.11.041

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ACCEPTED MANUSCRIPT The "Spiked Helmet" sign

- a potential relationship to Takotsubo

cardiomyopathy Running head: Spiked Helmet - a sign should not be missed

Cardiovascular Center, Azerbaijan Medical University,

Gasimov Emil, MD.

Intensive Care Unit, Azerbaijan Medical University,

Aliyev Farid, Assoc Prof.

Cardiovascular Center, Azerbaijan Medical University,

Isayev Elnur, MD.

Cardiovascular Center, Azerbaijan Medical University.

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Samadov Fuad, MD.

Corresponding author:

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Samadov Fuad, MD

Cardiovascular Center, Azerbaijan Medical University

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AZ-1078, Mardanov Gardaslari 100, Baku, Azerbaijan

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[email protected] (+994) 55 627 82 42

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Authors have nothing to disclose with regard to commercial support.

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This paper has not been previously presented or scheduled for presentation.

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Keywords: Critical illness, Electrocardiogram, Takotsubo cardiomyopathy

ACCEPTED MANUSCRIPT Abstract The "Spiked Helmet" sign (SHs), is a recently described electrocardiographic sign which is associated with critical illness and with very high risk of impending death. Here, we report the SHs in patient with sepsis and a possible diagnosis of Takotsubo cardiomyopathy (TC). Keywords

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Critical illness, Electrocardiogram, Takotsubo cardiomyopathy

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Case report

72-years-old man with a history of prostate cancer and end stage renal disease was admitted

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to intensive care unit for upper gastrointestinal bleeding. On the second day of admission, he developed fever, chills, malaise and epigastric pain. Laboratory findings were remarkable for anemia (Hb 7.1g/dl), leukocytosis (19.2*10⁹/l), elevated levels of C-reactive protein (43mg/dl,

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reference:<5mg/dl) and procalcitonin (10.4ng/m, reference:<0.05ng/ml) and antibiotics were administered for sepsis. As the ECG changes were observed during telemetry monitoring, a 12-lead

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electrocardiogram (ECG) was obtained. This ECG demonstrated widespread ST segment elevation

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in leads I, II, III, aVF, V3-V6, ST segment depression in leads V1 and aVR, QT prolongation and low QRS voltage in limb leads (figure 1). Bedside echocardiography revealed akinesis in the midand apical segments, hyperkinesis of the basal segments with depressed global left ventricular

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systolic function (30%) (unfortunately we could not store digital images). Troponin levels were

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elevated (0.683ng/ml, referance:<0.03ng/ml) and serum potassium level was in normal range. Myocardial infarction or Takotsubo cardiomyopathy (TC) were considered and due to patient's comorbidities medical treatment was preferred and we did not perform coronary angiography. The

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next day troponin level was 0.618ng/ml and this was not considered as typical rise for myocardial infarction. On the following day (3rd day of hospitalization) an ECG showed the SHs which was prominent in leads V4-V5 and resolution of ST segment changes in limb leads (figure 2). The chest X-ray taken the same day demonstrated bilateral small pneumothoraces and the conservative management was preferred. On the 4th day of hospital stay owing to progressive worsening of the clinical status he underwent intubation for mechanical ventilation. Two days later there was clinical improvement and the ECG obtained in this day showed resolution of the SHs and T wave inversions in precordial leads. A repeat echocardiography one week after the first one showed significant improvement in left ventricular wall motions and mild LV systolic dysfunction (LVEF 50%). An

ACCEPTED MANUSCRIPT ECG obtained on the 11th day of hospitalization showed T wave inversion in precordial leads without any pathologic Q waves and QRS complexes became more visible in limb leads (figure 3). On the 14th day he was extubated. Despite initial improvement the patient succumbed 7 days later. Discussion The SHs, is a recently described sign, which is associated with a very high risk of impending

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death (1). Characteristic feature of this sign is ST segment elevation accompanied by upward shift of

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the baseline before the onset QRS complex. ST segment morphology in this sign resembles the appearance of Pickelhaube, the German military spiked helmet introduced in 1842 by Friedrich

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Wilhelm IV, King of Prussia, from which it takes its name. Although in the first cases this ECG change was present exclusively only in the inferior leads (1), precordial lead involvement was also

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described in other reports (2-6).This sign is not yet well-known and only a limited number of cases was reported until today (1-6). But it probably does not reflect real prevalence. A lot of cases with

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the sign might go undetected due to critical illness status of the patients in which the sign generally observed and unfamiliarity of the sign. Since it is associated with increased mortality, timely

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recognition of the sign is crucial.

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Similar to the previous reports our case had critical illness status and developed pneumothorax. Distinctive feature of our case is potential relationship between the SHs and TC. Unfortunately, we were not able to supply echocardiography images and perform coronary

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angiography. But some findings support the possible diagnosis of TC in our patient: widespread ST

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segment elevation - not limited to the territory of a single coronary artery, QT prolongation, resolution of these ECG changes without any Q waves in leads with ST segment elevation, significant wall motion abnormalities (akinesis of apical and mid segments) and rapid resolution of

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these abnormalities, only slight elevation of troponin levels discordant with ECG and echocardiographic changes. In addition, the presence of ST segment depression in lead aVR supports the possible diagnosis of TC. Specificity of ST segment depression in lead aVR was 98% and 100%, if it was accompanied by inferior ST and anteroseptal ST segment elevation, respectively (7). Different mechanisms have been proposed to explain this ECG change - sudden increase in intrathoracic or intraabdominal pressure, direct stimulation of the inferior wall of left ventricle by the diaphragm, repetitive epidermal stretch that occurs in concert with the cardiac cycle (1-5). In addition to the previously described mechanisms, it is also possible that SHs is a particular stage of

ACCEPTED MANUSCRIPT the ECG changes in the course of TC, as was in our case. As was postulated by Aliyev et al, excessive sympathetic discharge may be responsible for this ECG change (6). To the best of our knowledge it is the first case with SHS in a patient with possible diagnosis of TC. We hope that our case and retrospective analysis of the serial ECGs from TC patients may shed new light on the

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possible mechanism of the sign.

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References

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1. Littmann L, Monroe MH. The “spiked helmet” sign: a new electrocardiographic marker of critical illness and high risk of death. Mayo Clin Proc 2011;86:1245-1246

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2. Tomcsányi J, Frész T, Bózsik B. ST elevation anterior "spiked helmet" sign. Mayo Clin Proc 2012;87:309

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3. Littmann L, Proctor P. Real time recognition of the electrocardiographic “spiked helmet” sign in

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a critically ill patient with pneumothorax. Int J Cardiol 2014;173:51-52 4. Agarwal A, Janz TG, Garikipati NV. Spiked helmet sign: An under-recognized electrocardiogram

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finding in critically ill patients. Indian J Crit Care Med 2014;18:238-40 5. Tomcsanyi J, Fresz T, Proctor P, Littmann L. Emergence and resolution of the

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electrocardiographic spiked helmet sign in acute noncardiac conditions. Am J Emerg Med

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2015;33:5-7

6. Aliyev F, Abdulkerimov V, Gul EE, Samedov F, Isayev E, Ferecov E. Spiked helmet sign after

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percutaneous left stellate ganglion ablation in a patient with long QT syndrome. J Electrocardiol. 2017 Jun 9. doi: 10.1016/j.jelectrocard.2017.06.016. [Epub ahead of print] 7. Frangieh AH, Obeid S, Ghadri JR, Imori Y, D'Ascenzo F, Kovac M, et al. ECG Criteria to Differentiate Between Takotsubo (Stress) Cardiomyopathy and Myocardial Infarction. J Am Heart Assoc 2016;5(6). doi: 10.1161/JAHA.116.003418.

ACCEPTED MANUSCRIPT Figure legends Figure 1: An ECG obtained on April 03, 2015 showed ST segment elevation in leads I, II, III, aVF, V3-V6, ST segment depression in leads V1 and aVR, QT prolongation and low QRS voltage in limb leads. Figure 2: An ECG obtained on April 04, 2015 showed the spiked helmet sign - in leads V4 and V5.

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Figure 3: An ECG obtained on April 14, 2015 showed T wave inversion in precordial leads without any pathologic Q waves and taller QRS complexes in limb leads compared with the previous ECGs.

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Figure 3