A 67–year–old woman presented with 3 h of sharp, intermittent chest pain and palpations. The episodes lasted for several minutes at a time and were associated with shortness of breath, nausea, diaphoresis, and lightheadedness. The pain was substernal with radiation to her right neck, shoulder, and upper back. She had a history of mitral valve prolapse, and admitted to rare, prior palpations, but described her current symptoms as more severe and attributed them to drinking one glass of caffeinated tea twenty minutes before her chest pain began. She’d also admitted to being severely stress the past year. Her vital signs were normal. She had a 2/6, systolic, crescendo–decrescendo murmur on cardiac exam; her lungs were clear and there was no JVD. Cardiac enzymes, BNP, urine toxiciology, TSH, and plasma metanephrines were all within normal limits. An EKG was obtained, revealing ST elevations in leads I, II, III, aVF, V4, V5, and V6. She underwent an emergent cardiac catheterization after receiving aspirin and nitroglycerin. The left heart catheterization revealed apical dilatation and severe hypokinesis with an estimated ejection fraction of 20%. The base appeared to contract vigorously. All coronary arteries were normal without obstructive disease. A subsequent echocardiogram demonstrated apical and mid ventricular akinesis, an ejection fraction of 15–20%, left ventricular outflow tract obstruction with a gradient 60 mmHg, and a systolic anterior motion of the mitral valve, and moderate mitral regurgitation. The patient was diagnosed with Takotsubo cardiomyopathy and treated with furosemide, metoprolol, and lisinopril as tolerated by her blood pressure. Her symptoms improved after a few days, and she was discharged. Follow up echocardiogram 10 days later showed normal left ventricular wall motion, ejection fraction of 60–65%, and no abnormality of her mitral valve. She denied any recurrence of symptoms.
Takotsubo cardiomyopathy often occurs in postmenopausal women, typically after exposure to sudden emotional or physical stress, such as an unexpected death in the family, abuse, quarrel, or exhaustion. Unlike EKG artifacts such as early repolarization and left bundle–branch block that may mimick ST segement elevation, Takotsubo cardiomyopathy is a form of acute, reversible heart failure. The mechanism of disease in Takotsubo is unclear, although catecholamine toxicity appears to have an important role. Supraphysiologic concentrations of epinephrine are thought to switch beta–adrenergic receptor coupling from stimulatory G–protein signaling to inhibitory signaling with a subsequent negatively inotropic effect.
Formal treatment guidelines do not currently exist, though the use of aspirin, diuretics, beta–blockers, and ACE inhibitors are indicated in the acute phase. The long–term use of beta–blockers is controversial, as left ventricular function typically improves within a few weeks, thereby reducing the acute arrhythmogenic risk.