Recurrent Takotsubo cardiomyopathy in a postmenopausal Indian lady: Is there a pattern?

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Date: April-June 2019
From: Journal of Postgraduate Medicine(Vol. 65, Issue 2)
Publisher: Medknow Publications and Media Pvt. Ltd.
Document Type: Case study
Length: 1,808 words
Lexile Measure: 1430L

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Byline: N. Sharath Babu, S. Chacko, B. Chacko, A. Irodi

Takotsubo cardiomyopathy (TTC) is a syndrome of acute left ventricular dysfunction with a clinical presentation often mimicking acute coronary syndrome. Without a high index of suspicion, this clinical entity often goes unrecognized. Although initially categorized as a benign completely reversible condition, it is no longer considered to be so. Recurrence of this condition, though rare, has been reported in a non-Indian population. We present a case of recurrent TTC in a postmenopausal Indian lady who had a similar clinical presentation both at the index event and at recurrence.

Introduction

Takotsubo cardiomyopathy (TTC) is an increasingly recognized entity of acute clinical heart failure, with significant morbidity and an in-hospital mortality of 2-5%.[1] Although described more commonly in postmenopausal women of Caucasian and Asian ethnicity, no race may be exempt. Recurrence, although rare, often adds to the morbidity of the disease. However, a second episode has been reported occurring from 3 months to even 10 years after the index event. Here, we describe Takotsubo syndrome in a postmenopausal Indian lady, who 8 months after the index event, presented with a similar clinical presentation as at the first episode, despite being on optimal medical therapy.

Case Report

A 59-year-old postmenopausal Indian lady with no diabetes, hypertension, and prior cardiac or renal disease presented to the emergency room with episodes of giddiness and dyspnea of 4 hours duration. She reported no other symptoms. Couple of days prior to the presentation, she acknowledged a definite stressful event at home while preparing for her youngest daughter's marriage which was to be held in a few days. Clinical examination showed mild tachycardia and no features of overt heart failure.

Electrocardiogram at admission showed sinus tachycardia, J-point elevation and concave upward ST elevation in V2-V6, T wave inversion in aVL, and a QTc of 402 ms [Figure 1]a. Troponin T was elevated at 493 pg/mL (normal up to 14 pg/ml), and subsequent values showed a downward trend. NT Pro-BNP was 1348 pg/ml (normal up to 125 pg/ml). Screening for pheochromocytoma was negative (urinary metanephrines of 60 [micro]g/24 h and normetanephrines of 311 [micro]g/24 h). Chest radiography was noncontributory.{Figure 1}

Echocardiography performed at admission showed moderate LV systolic dysfunction, regional wall motion abnormality involving the distal LV segments in a circumferential pattern-LV segments 13-17 (hypokinesia in apical inferior, apical lateral, apical anterior, apical septal areas and apex), but not corresponding to a single coronary arterial distribution [Figure 2], and preserved contractility of basal and mid LV segments. LV ejection fraction (EF) was measured as 37%, and there were no valvular abnormalities.{Figure 2}

Her coronary angiography done 8 months ago was normal and hence not repeated. Considering a working diagnosis of TTC...

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Gale Document Number: GALE|A584164888