Quick Reference: Symptoms: Syncope and Chest Pressure : Emergency Medicine News
A 70-year-old woman with a history of hypertension, hyperlipidemia and gastric adenocarcinoma in remission presented to the emergency room with near-syncope and chest pain immediately after learning of the death of a family member due to COVID-19.
Chest pain was described as nonradiating retrosternal, pressure-like, nonpositional, and nonpleuritic. The pain was not relieved by rest and was not associated with dyspnea, orthopnea, palpitations, lower extremity swelling, or calf pain. She had no fever, cough or hemoptysis.
She was afebrile and her vital signs were within normal limits. A cardiopulmonary examination was notable for bilateral clear lung sounds and heart sounds that were regular and without murmurs, rubs or gallops. No lower limb edema or jugular venous distension was noted.
An ECG demonstrated normal sinus rhythm with flattening of the T wave in the precordial leads, but no evidence of ST-segment elevation myocardial infarction. A chest X-ray showed no signs of acute cardiopulmonary pathology. Initial lab tests were significant for a mildly elevated troponin-T of 0.15 ng/ml. A point-of-care echocardiogram was notable for apical ballooning with marked hypokinesia in multiple coronary regions.
What is the presumed diagnosis and how would you manage this patient?
Find the case discussion on the next page.
Diagnosis: Takotsubo cardiomyopathy
Takotsubo cardiomyopathy is a form of stress-induced cardiomyopathy that is characterized by left ventricular systolic dysfunction in the absence of coronary artery disease or acute plaque rupture. The term Takotsubo comes from a Japanese word meaning octopus pot, which describes the unique aspect of apical bloating of the left ventricle found in this syndrome. (Eur Heart J. 2006;27:1523)
Stress-induced cardiomyopathy occurs in about one to two percent of patients with elevated cardiac biomarkers and is more common in the elderly, especially postmenopausal women. (Eur Heart J. 2006;27:1523)
The pathogenesis of Takotsubo is not well understood, but the prevailing theory suggests myocardial damage precipitated by excess catecholamines following acute stress. Symptoms include chest pain, dyspnea, or syncope, often after an intense emotional or physical trigger such as the death of a parent, financial loss, or physical injury, hence the term broken heart syndrome. (N English J med. 2015;373:929.)
Patients may present with signs of acute heart failure – bilateral lower extremity edema, altered mental status, respiratory distress, hypotension, or arrhythmia. Given the broad differential diagnosis including acute coronary syndrome, pulmonary embolism, arrhythmias, and exacerbation of heart failure, the diagnosis is usually confirmed after a thorough evaluation in the emergency department. Diagnosis requires troponin elevation or ECG abnormalities (in the absence of acute coronary syndrome, pheochromocytoma, myocarditis, or drug-induced cardiac injury), negative coronary angiography, and left ventricular dysfunction by echocardiogram or cardiac MRI. (Ann Medical Intern. 2004;141:858.)
Left ventricular dysfunction and apical ballooning may be noted on point-of-care ultrasound, classically demonstrating regional abnormalities of wall motion at the apex crossing more than one coronary artery distribution. (N English J med. 2015;373:929.)
Treatment for Takotsubo cardiomyopathy is usually symptomatic and based on the degree of left ventricular dysfunction or subsequent complications of cardiogenic shock. Basic treatments include anticoagulation and intra-aortic balloon pump for refractory cases.
There is some debate about the usefulness of beta-blockers. Inotropic catecholamine drugs should be avoided and, as with hypertrophic cardiomyopathy, volume depletion and vasodilator therapy may be detrimental. (N English J med. 2015;373:929) Most patients recover left ventricular systolic function within one to four weeks, but some patients have persistent heart failure complications requiring prolonged treatment. Takotsubo’s death is rare but has been documented. (N English J med. 2005;352:539.)
The patient was given aspirin and sublingual nitroglycerin on arrival at the emergency room with progressive resolution of chest pain. She was admitted to the cardiology department and underwent left heart catheterization – with no evidence of coronary artery disease – and transthoracic echocardiography, again demonstrating severe apical hypokinesia with an overall left ventricular ejection fraction of 45%. His chest pain was gone and his troponin levels tended to drop on discharge. She was discharged on oral metoprolol with plans to repeat the echocardiogram in three months.
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Dr Desaiis a second-year resident physician in emergency medicine at LAC+ USC Medical Center. Dr Burkholderis assistant professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California. Follow him on Twitter@tayburkholder. Read the quick reference columns athttp://bit.ly/EMN-QuickConsult.