Today we discussed the case of an elderly woman with Parkinson Disease who presented with an UGIB, found to have interesting EKG findings of diffuse ST elevations and PR depression (raising concern for pericarditis) and echocardiogram findings concerning for Takotsubo (stress) Cardiomyopathy!
Key Pearls from today:
- Takotsubo cardiomyopathy is a diagnosis of exclusion! As it closely mimics a myocardial infarction, ACS needs to be ruled-out first (other differentials include cocaine-related ACS, myocarditis, pheochromocytoma)
- Remember the classic EKG findings of acute pericarditis: 1) widespread ST elevation, with concomitant PR depression in same leads 2) knuckle sign of acute pericarditis à PR segment in aVR is elevated like a knuckle, reflecting atrial injury.
More on Takotsubo Cardiomyopathy
- Also known as: stress cardiomyopathy, apical ballooning syndrome, broken heart syndrome, etc.
- Characterized by transient regional systolic dysfunction of the LV, mimicking an MI, but in the ABSENCE of angiographic evidence of obstructive CAD or plaque rupture.
- Epidemiology : First described in 1990 in Japan! : 1-2% of patients presenting with troponin-positive ACS or suspected ST-elevation MI : Predisposition for post-menopausal women
- Pathogenesis – Catecholamine hypothesis: stress causes catecholamine-induced microvascular spasm, and multi-vessel coronary artery spasm, resulting in myocardial stunning/toxicity
- EKG findings: 1) ST elevation is a common finding! 43.7% of patients in the International Takotsubo Registry study had ST-elevations most commonly in anterior precordial leads 2) ST depression: Less common (7.7%) 3) Other less common findings: QT prolongation, T wave inversion, non-specific changes
- Cardiac biomarkers: elevated in MOST patients
- Echo findings: Most common type is hypokinesis of apical segments, resulting in the systolic apical ballooning of the LV : Atypical variants à ventricular hypokinesis, basal hypokinesis, anterolateral segment hypokinesis
Medications and Takotsubo Cardiomyopathy
- Today, a question was raised as to whether the patient’s PD medications (such as levodopa-carbidopa) may have been the offending culprit behind Takotsubo cardiomyopathy.
- A review of the literature showed that:
- Medications CAN cause Takotsubo cardiomyopathy, but Sinemet in particular has not been associated with this syndrome.
- Previously described agents that cause Takotsubo: intraocular phenylephrine, albuterol, anti-psychotic medications, Adderall, epinephrine (see the trend?)