Category: Visual Diagnosis
64 year-old female presents with chest pain following an argument with her husband. Her echocardiogram (apical four-chamber view) and ECG are shown. Her initial troponin is 10. What's the diagnosis?
Answer: Takotsubo (a.k.a Stress) cardiomyopathy (TC)
TC is left ventricular dysfunction (hypokinesia, akinesia, or dyskinesia) secondary to catecholamine surge (e.g., physical / emotional stress) causing myocardial stunning; it is not due to acute coronary occlusion. TC disproportionately affects postmenopausal women, occurring in up to 90% of cases.
Patients often present with chest pain or dyspnea; 85% of patients will have an abnormal ECG (e.g., ST elevation or T wave inversions), making diagnosis difficult to differentiate between TC and acute coronary syndrome (ACS). TC has been found to be the diagnosis in 2.5% of patients initially worked up for ACS.
Diagnosis can usually be confirmed with echocardiography but cardiac catheterization (with ventriculogram) is sometimes performed if ACS is strongly suspected. Catheterization demonstrates normal coronary arteries with an abnormal ventriculogram (click for video), typically in mid-to apical portion of the left ventricle.
Treatment is symptomatic and similar to congestive heart failure (e.g., diuretics, beta-blockers, etc.); 95% of patients have full recovery within one month.
Refer to this prior PEARL by Dr. Tewelde for additional information
T Pilgrima, T Wyss, Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review, Int J Card 2008 Mar 14;124(3):283-92
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)