The Octopus’ Trap

Today Dr. Anu Madhavan presented a very interesting case of a middle-aged woman with no cardiac risk factors and no cardiac history who presented with substernal chest pain after experiencing a fire at her workplace. Her troponin was elevated and EKG showed left anterior fascicular block and lateral T wave inversions. She was initially treated with aspirin, high-intensity statin, and heparin drip, but transthoracic echo soon revealed pronounced apical ballooning suggestive of Takotsubo’s cardiomyopathy.

Takotsubo presents very similarly to acute coronary syndrome with substernal chest pain, dyspnea, and rarely syncope in the setting of elevated troponin and ischemic EKG changes (about 44% have ST elevations, some have ST depressions or T wave inversions, and others have additional nonspecific EKG abnormalities). It is often preceded by a stressful (physical or emotional stress), but can present without a trigger as well. Echo typically shows apical ballooning and the wall motion abnormalities extend beyond the typical distribution of any one coronary artery. The name Takotsubo comes from the Japanese word for octopus trap, which is shaped like the LV with apical balloning.

It is diagnosed with the Mayo Clinic criteria, which include transient echo findings (hypokinesis, akinesis, or dyskinesis of the LV mid segments with or without apical involvement that extend beyond a single epicardial vascular distribution), absence of obstructive CAD on angiographic evidence of acute plaque rupture, new EKG abnormalities or modest elevation in cardiac troponin, and absence of pheochromocytoma or myocarditis.

Because our patient did not present with ST elevations and had typical apical ballooning, obstructive CAD was able to be ruled out with coronary CTA instead of cardiac catheterization. The apical ballooning seen on her echo would have required a large, mid or proximal LAD obstructive lesion. Coronary CTA can visualize proximal/mid left sided CAD well, but is very insensitive for distal vessels, RCA, or any pathology when the HR is extremely high.

The treatment of Takotsubo’s cardiomyopathy is not well-supported by randomized clinical trials, but there are suggestions that beta blockers and anticoagulation to prevent LV thrombus should be considered in this population.

Takotsubo’s Illness Script:

Epidemiology: Postmenopausal females most common, psychiatric or neurological disorders may be a risk factor

Pathophysiology: Multiple theories, but likely has something to do with catecholamine excess +/- microvascular spasm

Symptoms/signs: presents like ACS (substernal chest pain +/- dyspnea +/- syncope) with a trigger (emotional or physical stress). However, the trigger is not always present.

Labs: Elevated troponin +/- CK and BNP

EKG: ST elevations most common, ST depressions, other nonspecific findings (QT prolongation, TWI, Q waves)

Echo: Apical ballooning, regional all motion abnormality that extends beyond the territory perfused by a single epicardial coronary artery

Complications: tachyarrhythmias, heart failure, cardiogenic shock, stroke from apical thrombus

Treatment: supportive +/- beta blocker +/- anticoagulation (controversial)

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