A 63 year old female with no significant PMH presented with a history of central crushing chest pain, present since her mother passed away the day before.
The below ECG’s were captured:
Her Troponin was 1000 and she was started on treatment for ACS.
A bedside echo was performed by the Emergency Medicine SpR:
Findings & Explanation:
LV: There is dilatation of the apex. Basal LV contractility is hyperdynamic, whilst there is mid-LV and apical akinesia.
MV M-mode: There is normal E and A movements in diastole and a suggestion of low-grade systolic anterior motion towards end-systole (SAM – see Ultrasound of the Week 035).
RV: Non-dilated. Longitudinal systolic function acceptable : TAPSE 17mm
IVC collapsing with respiration
No pericardial effusion
LV : high preload, poor contractility, basal hyperkinesia with apical akinesia. Low-grade SAM.
RV: normal preload (collapsing IVC), normal size and contractility.
This is highly suggestive of Takotsubo’s syndrome.
Takotsubo syndrome, the classic “Broken Heart syndrome”, is thought to occur due to massive catecholamine release causing ‘stunned myocardium’ through excessive ATP consumption. It is thought that LV beta-receptors are most prevalent in the apex and hence this area is most affected.
The classic presentation is post-menopausal females(90%) shortly after physical or emotional trauma presenting with chest pain, but can include arrythmias or heart failure[1,2]. Differentiating Takotsubo’s from acute MI can be difficult as symptoms, ECG changes and echo findings are similar, and Takotsubo’s is thought to represent 1-2% of patients presenting with suspected STEMI.
Investigations include ECG, bloods including Troponin and echocardiography. Troponin elevations are usually modest in the context of the extent of echo wall motion abnormalities. Angiography may be performed to assess coronary patency.
Echo findings in typical Takotsubo’s are of LV akinesia of the apex with basal hypercontractility. The anterior MV leaflet (AMVL) should be assessed for systolic anterior motion (SAM) suggesting LV outflow tract obstruction (LVOTO). This occurs as the hyperdynamic LV base cause increased velocity across the AV. For a more detailed explanation of the reasoning behind this, see Ultrasound of the Week 035. RV function is generally not affected although variants of Takotsubo’s do exist that involve the RV and carry a worse prognosis.
Management is discussed in more detail elsewhere, yet some salient learning points are:
- Takotsubo syndrome is likely more common than we think
- Diagnosis is usually a combination of clinical history and echocardiography
- Management is focused on physiological sequelae:
- Haemodynamically stable
- Cardiogenic shock
- LVOTO – “well filled, slow, sinus, reduce hypercontractility & maintain high afterload”
For an excellent article on Takotsubo syndrome by Josh Farkas, see https://emcrit.org/ibcc/takotsubo/.
Conclusion and Case Progression:
The case was discussed with the local PCI centre who agreed the history and ECG were suggestive of Takotsubo syndrome and that management should be supportive under local cardiology. She had ongoing chest pain and the medical team were keen to be started on GTN.
Given the risk of dynamic LVOTO due to SAM in Takotsubo syndrome, the ED team counselled strongly against the use of GTN and this was not given. After further discussion with cardiology she was started on an ACE-inhibitor and bisoprolol and admitted to CCU for observation. The following day her pain was considerably improved. She is due to go for a diagnostic angiogram to assess coronary patency.
- Thygesen K et al; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018 Oct 30;72(18):2231-2264. doi: 10.1016/j.jacc.2018.08.1038. Epub 2018 Aug 25. PMID: 30153967.
- Farkas, J., 2021. Takotsubo syndrome. [online] EMCrit Project. Available at: <https://emcrit.org/ibcc/takotsubo/> [Accessed 5 September 2021].