Takotsubo Cardiomyopathy an ST-Elevation Myocardial Infarction Mimic Kristina A

Advanced Emergency Nursing Journal Vol. 43, No. 1, pp. 48–52 Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. EKG COLUMN Column Editor: Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN

Takotsubo Cardiomyopathy An ST-Elevation Myocardial Infarction Mimic Kristina A. Davis, DNP,ENP-C, FNP-C, AGACNP-BC

Abstract Takotsubo cardiomyopathy (TC), a rare syndrome often preceded by an emotional or physical trigger, which earned the nickname broken heart syndrome, was first diagnosed in 1990. Takotsubo cardiomyopathy can mimic an ST-elevation myocardial infarction (STEMI). Originally, TC was thought to be self-limiting and benign. However, there is a 4%–5% mortality rate, which is associated with serious complications. The majority of people diagnosed with TC are postmenopausal women, but it can affect all ages. Patients will often present to the emergency department with chest pain and dyspnea. An electrocardiogram (ECG) often demonstrates ST elevation. There is no definitive way to differentiate between TC and STEMI on an ECG. Therefore, all patients need to have emergent coronary angiography with left ventriculography. Key words: apical ballooning syndrome, broken heart syndrome, electrocardiogram, infarction, ST-elevation myocardial, stress-induced cardiomyopathy, Takotsubo cardiomyopathy

AKOTSUBO CARDIOMYOPATHY (TC), catecholamine surge. A catecholamine surge otherwise known as broken heart syn- affects B-adrenergic receptors, which have a T drome, apical ballooning syndrome, high density in the left ventricle (LV) apical or stress-induced cardiomyopathy, resembles myocardium (Akashi, Nef, & Lyon, 2014). a myocardial infarction without obstructive First discovered in 1990, TC is named after coronary artery disease (Amin, Amin, & the octopus trap used in Japan that resembles Ptadipta, 2020). Takotsubo cardiomyopa- the apical ballooning shape seen in most thy is a temporary and reversible systolic cases (Sato & Tateishi, 1990). Ballooning abnormality of the left ventricular apical of the LV typically occurs in the apex 75%– area, akinesis, that is typically preceded by 80% of the time, in the mid-LV 10%–15% of a physical or emotional trigger that causes a the time, and base of the ventricle less than 5% of the time (Lyon et al., 2016). When Author Afﬁliation: College of Nursing, Rocky Moun- the mid or basal LV segments are involved tain University of Health Professions, Provo, Utah. and without apical involvement, it can be Disclosure: The author reports no conﬂicts of interest. called inverted TC (ITC) or atypical TC Corresponding Author: Kristina A. Davis, DNP, ENP- (Manzanal, Ruiz, Madrazo, Makan, & Perez, C, FNP-C, AGACNP-BC, College of Nursing, Rocky Mountain University of Health Professions, 122 East 2013). 1700 South, Provo, UT 84606 ([email protected]). Initially, TC was thought to be self-limiting DOI: 10.1097/TME.0000000000000338 and therefore a benign condition. However,

there is a 4%–5% mortality rate, which is the ECG during the hyperacute phase of TC associated with serious complications that have increased cardiac arrhythmias and poor include systemic thromboembolism, ven- outcomes (Shimizu et al., 2014). tricular rupture, cardiogenic shock, and ventricular arrhythmias (Chazal et al., 2018; Lyon et al., 2016). Recurrence rate is in- ETIOLOGY OF ECG CHANGES conclusive, but based on different studies, The location of the myocardial injury that is data demonstrate a rate of 0%–22% (Pellicia, most often apical and LV segments correlates Kaski, Crea, & Camici, 2017). with the ST elevation (Ghadri et al., 2018). Takotsubo cardiomyopathy can affect all This closely resembles a left anterior descend- ages; however, 90% of the cases are present in ing (LAD) coronary occlusion and usually postmenopausal women. ITC is often seen in involves precordial, lateral, and apical leads. younger age and is always triggered by emo- A few small studies have been conducted to tional or physical stress, such as pheochro- determine the difference in TC ECG findings mocytoma, cerebrovascular ischemic attack, compared with a STEMI. or seizures (Ramaraj & Movahed, 2010). ST elevation is often seen in −aVR (inverse In addition, there have been cases of of aVR), which analyzes the inferolateral and ITC and TC from consumption of energy apical regions of the heart (Frangieh et al., drinks and use of antidepressants, specifi- 2016; Kosuge et al., 2010). Apex wall motion cally selective serotonin-norepinephrine re- abnormalities that extend beyond a single uptake inhibitors (SSNRIs) and selective sero- coronary artery occlusion are thought to tonin reuptake inhibitors (SSRIs) (Kaoukis, cause the diffuse ST elevation seen in TC. T- Panagopoulou, Mojibian, & Jacoby, 2012; wave inversion is often diffuse but mainly in Zvonarev, 2019). The incidence of TC diagno- lateral and anterior leads and often transient sis has increased, which is likely attributed to (Pellicia et al., 2017) education and recognition due to increased emergent coronary angiography for patients ECG DIAGNOSIS OF TAKOTSUBO with suspected ST-elevation myocardial in- CARDIOMYOPATHY farction (STEMI) (Pellicia et al., 2017). ECG changes in TC are often very similar to one another; however, the changes are ELECTROCARDIOGRAPHIC CHANGES IN very similar to an anterior STEMI. A small TAKOTSUBO retrospective study (n = 33 patients) demon- Patients will have ST elevation and/or deep strated the presence of ST elevation in aVR T-wave inversions, often in the precordial and the absence of Q waves, reciprocal leads or V leads (Selby, 2017). According changes, and no ST elevation in Lead V1 had to Kosuge et al. (2010), the most common a 96% specificity and a 91% sensitivity for TC electrocardiographic (ECG) changes are ST (Kosuge et al., 2010). According to Tamura elevation in Leads II, III, aVF, aVR, and V5– et al. (2011), measuring ST elevation at the J V6. ST elevation is found in 44% of patients, point may assist at differentiating TC from an with T-wave inversion in 41%, ST depression anterior STEMI. Tamura et al. found patients in 8%, and left bundle branch block in 5% with TC could be identified with a 74.2% sen- (Ghadri et al., 2018). sitivity and a 80.6% specificity who had no There is no definitive way to differenti- more than 1-mm ST elevation in V1 but had ate between TC and STEMI on an ECG. more than 1 mm in Leads V3–V5. Therefore, all patients need to have emergent There are several proposed diagnostic cri- coronary angiography with left ventriculogra- teria, with the last two being developed phy (Akashi et al., 2014; Ghadri et al., 2018). in 2015 from the Heart Failure Association Patients with J waves and fragmented QRS on and 2018 from the International Takotsubo

(InterTAK) Diagnostic Criteria (see Table 1). heart failure, LVOTO (left ventricular outflow Although there are studies that demonstrate tract obstruction), arrhythmias, or throm- ways to differentiate TC with an anterior bus. Discharge treatment includes treating STEMI, a definitive diagnosis of TC cannot be underlying conditions as well as considering accomplished with an ECG alone. All patients an angiotensin-converting enzyme (ACE) with ST elevation must be sent for emergent inhibitor or angiotensin II receptor blocker coronary angiography with left ventriculog- (ARB) until LV function is restored (Ghadri raphy, which is the diagnostic gold standard et al., 2018). As mentioned previously, the (Ghadri et al., 2018). Additional diagnostic recurrence rate varies. Potential precipitating studies, echocardiography, and cardiac mag- factors need to be considered and modi- netic resonance imaging (MRI) can help with fied including energy drink consumption, definitive diagnosis. The area of wall motion recreational drug use, SSRI, and SSNRI. abnormality often shows as edema in a magnetic resonance image (Bratis, 2017). CASE PRESENTATION A 24-year-old patient presented to a crit- MANAGEMENT ical access facility emergency department To date, there are no randomized studies with dyspnea, substernal chest pain radiat- to determine the best treatment modalities. ing to the left arm, and nausea. He denied Treatment is based on complications such as significant medical history or cardiac history

Table 1. Takotsubo cardiomyopathy diagnostic criteria

InterTAK criteria Heart Failure Association criteria r r Transient ventricular dysfunction as apical LV or RV myocardium transit regional wall ballooning or midventricular, basal, or focal motion abnormalities, which are often wall motion abnormality. preceded by a physical or emotional trigger r Preceded by a physical, emotional, or a but not essential. r combined trigger, including but not Often the ventricle segments involved have obligatory. a circumferential dysfunction due to the r May be triggered by neurological disorders regional wall abnormalities frequently such as CVA, subarachnoid hemorrhage, or extending beyond a single epicardial seizures. In addition, pheochromocytoma may vascular distribution. r trigger TC. Temporary LV dysfunction not caused by r ECG changes such as ST-elevation, T-wave atherosclerotic CAD including thrombus inversion, QTc prolongation, and ST formation, coronary dissection, acute plaque depression. ECG changes may not be present formation, or other pathological conditions in rare cases. such as viral myocarditis and hypertrophic r Troponin and creatine kinase are moderately cardiomyopathy. r elevated and often brain natriuretic peptide is ST elevation, LBBB, T-wave inversion, ST signiﬁcantly elevated. depression, and/or QTc prolongation during r TC can still be diagnosed in patients with the acute phase (3 months), which are new signiﬁcant CAD. and reversible. r r No evidence of infectious myocarditis. Comparatively small elevation in troponin. r r Primarily postmenopausal women are Cardiac imaging shows return of cardiac affected. function within 3–6 months.

Note. CAD = coronary artery disease; CVA = cerebrovascular accident; ECG = electrocardiogram; InterTAK = Inter- national Takotsubo; LBBB = left bundle branch block; LV = left ventricle; QTc = corrected QT interval; RV = right ventricle; TC = Takotsubo cardiomyopathy.

Figure 1. Electrocardiogram of case study patient who was diagnosised with Takotsubo cardiomyopathy.

for himself or his family. He denied use of CONCLUSION tobacco products. He stated he had been Although the emergency provider needs under a significant amount of stress lately due to include TC as a differential diagnosis, to working two jobs. The patient stated he an ECG cannot definitively diagnose TC. drank several energy drinks a day to “help me Therefore, treatment including thrombolyt- stay awake.” ics and/or emergent cardiac catheterization An ECG was obtained (see Figure 1), which should not be delayed. A patient may have showed ST elevation in Leads I, II, aVF, V4– cardiac MRI, which will help differentiate be- V6 and deep T-wave inversion in Leads aVR, tween TC and other causes of ST elevation, V1–V2. The patient met STEMI criteria and but this typically occurs outside of the emer- was administered TNKase, which quickly al- gency setting. Complications from TC include leviated discomfort. The patient was then arrhythmias, cardiogenic shock, ventricular sent to the nearest cath lab via helicopter. rupture, and cardiogenic shock. In-hospital The patientʼscathlabstudyshowednocal- treatment modalities are focused on manag- cification or obstruction to the left main ing TC complications. There are limited data coronary artery, LAD coronary artery, left cir- to support discharge treatments; however, cumflex coronary artery, and right coronary treatment is typically focused on complica- artery. Left ventriculogram showed apical hy- tions and usually includes an ACE inhibitor or pokinesis with a pointed appearance rather ARB until LV function is restored. than a ballooning appearance, which is con- sideredanabnormalregionalwallmotion that suggests atypical stress cardiomyopathy. REFERENCES In addition, the patientʼs high-sensitivity tro- Akashi, Y. J., Nef, H. M., & Lyon, A. R. (2014). Epi- ponin peaked at 12,363. The patient was demiology and pathophysiology of Takotsubo syn- discharged on low-dose aspirin, β-blocker, drome. Nature Reviews Cardiology, 12(7), 387– and low-dose ACE inhibitor. Discharge diag- 397. doi:10.1038/nrcardio.2015.39 noses were apical hypokinesis, STEMI likely Amin, H. Z., Amin, L. Z., & Ptadipta, A. (2020). Takotsubo related to transient thrombus in the mid-LAD cardiomyopathy: A brief review. Journal of Medicine and Life, 13(1), 3–7. doi:10.25122/jml-2018-0067 related to bridging versus STEMI likely related Bratis, K. (2017). Cardiac magnetic resonance in Takot- to TC, and hypercontractile LV function from subo syndrome. European cardiology, 12(1), 58– the consumption of large amounts of red bull. 62. doi:10.15420/ecr.2017:7:2

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