A 70‐year‐old woman developed sudden‐onset right upper quadrant pain that woke her up from sleep. She lost consciousness and was found to be pulseless by EMS. Cardiopulmonary resuscitation was performed, and she was intubated in the field and rushed to the hospital after successful resuscitation. EKG showed ST elevations in inferior leads and T‐wave inversions in anterior leads, which ruled her in for ST elevation myocardial infarction. She was found to have elevated troponins, with a maximum troponin of 3.13. Physical examination and elevated pancreatic enzymes were diagnostic of acute pancreatitis. She was treated with hydration and pain medications for acute pancreatitis and urgently transferred to a tertiary‐care hospital for emergent cardiac catheterization. Cardiac catheterization revealed normal coronaries with no obstructive atherosclerotic disease and decreased LV systolic function. Echocardiogram showed severely decreased ejection fraction of 30%. The patient was Treated with beta‐blockers and ACE‐inhibitors and supporlively managed. She recovered uneventfully and was discharged with a life vest with instructions to follow up at cardiac clinic as an outpatient. Echocardiogram repeated 6 weeks after the event showed a normal ejection fraction. A diagnosis of Takotsubo cardiomyopathy caused by acute pancreatitis leading to cardiac arrest was clinched.
Takotsubo cardiomyopathy, also called stress‐induced cardiomyopathy or apical ballooning syndrome, is characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle that mimics myocardial infarction in the absence of significant obstructive coronary artery disease. Postulated causes include microvascular spasm, myocarditis, or dysfunction due to catecholamine excess, leading to myocardial stunning. In a majority of cases, cardiac enzymes are elevated. There is a female preponderance. In patients with EKG suggestive of ST elevation Ml, urgent coronary revascularization should be sought regardless of suspicion of Takotsubo cardiomyopathy. Management comprises aspirin, beta‐blockers, ACE inhibitors, and diuretics; however, the mainstay of management is treatment of the inciting event or stressor that led to the development of Takotsubo cardiomyopathy.
In our patient, EKG changes including ST elevations and T‐wave inversions and elevated cardiac enzymes occurred after the onset of symptoms of pancreatitis. The deterioration of ejection fraction after the episode in the absence of obstructive coronary artery disease, and normalization of the ejection fraction 6 weeks after the event further substantiates the diagnosis of Takotsubo cardiomyopathy triggered by pancreatitis. Takotsubo cardiomyopathy causing cardiac arrest is exceedingly rare, which makes this case unique.
M. Pednekar, Maimonides Medical Center, Brooklyn, New York, employment; P. Chandra, Maimonides Medical Center, Brooklyn, New York, employment.