Jeffrey L Anderson1,2, Benjamin D Horne3,4, Viet T Le5,6, Tami L Bair3, David B Min3, C Michael Minder3, Ritesh Dhar3, Steve Mason3, Joseph B Muhlestein3,7, Kirk U Knowlton3,7. 1. Intermountain Medical Center, Intermountain Heart Institute, 5121 So. Cottonwood Street, Building 4, 6th floor, Salt Lake City, UT, 84107, USA. JeffreyL.Anderson@imail.org. 2. University of Utah School of Medicine, 30 N Medical Dr, Salt Lake City, UT, USA. JeffreyL.Anderson@imail.org. 3. Intermountain Medical Center, Intermountain Heart Institute, 5121 So. Cottonwood Street, Building 4, 6th floor, Salt Lake City, UT, 84107, USA. 4. Stanford University School of Medicine, Stanford, CA, USA. 5. Intermountain Medical Center, Intermountain Heart Institute, 5121 So. Cottonwood Street, Building 4, 6th floor, Salt Lake City, UT, 84107, USA. viet.le@imail.org. 6. Rocky Mountain University of Health Professions, Provo, UT, USA. viet.le@imail.org. 7. University of Utah School of Medicine, 30 N Medical Dr, Salt Lake City, UT, USA.
Abstract
BACKGROUND: Takotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized. METHODS AND RESULTS: Intermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11. CONCLUSIONS: Despite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation.
BACKGROUND: Takotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized. METHODS AND RESULTS: Intermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11. CONCLUSIONS: Despite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation.
Authors: Sara Moscatelli; Fabrizio Montecucco; Federico Carbone; Alberto Valbusa; Laura Massobrio; Italo Porto; Claudio Brunelli; Gian Marco Rosa Journal: Biomed Res Int Date: 2019-10-30 Impact factor: 3.411