Dobutamine stress echocardiography-induced broken heart syndrome (Takotsubo Syndrome)

Abstracts

Relatamos um caso de síndrome de Takotsubo induzida por ecocardiograma de estresse com dobutamina em uma paciente de 76 anos, hipertensa com queixas clínicas de dor precordial, em consulta cardiológica eletiva. Para exclusão de dor torácica de etiologia coronariana foi solicitado ecocardiograma de estresse com dobutamina. O exame foi realizado e, no pico do esforço máximo, o ecocardiograma mostrou acinesia apical com o eletrocardiograma mostrando supradesnivelamento do segmento ST em D1, AVL e V2. A paciente foi internada e submetida a coronariografia, que mostrou coronárias normais e VE com balonamento apical. A paciente evoluiu estável com reversão do quadro 21 dias após o quadro inicial.

Sindrome de Takotsubo; ecocardiografia sob estresse; dobutamina

Relatamos un caso de síndrome de Tako-Tsubo inducido por ecocardiograma de esfuerzo con dobutamina en una paciente de 76 años, hipertensa con quejas clínicas de dolor precordial, en consulta cardiológica electiva. Para exclusión de dolor torácico de etiología coronaria se solicitó ecocardiograma de esfuerzo con dobutamina. El examen fue realizado, y en el pico de esfuerzo máximo, el ecocardiograma mostró acinesia apical con el electrocardiograma mostrando supradesnivel del segmento ST en D1, AVL y V2. La paciente fue internada y sometida a coronariografía, que mostró coronarias normales y VI con abombamiento apical. La paciente evolucionó estable con reversión del cuadro 21 días después del cuadro inicial.

Síndrome de Tako-Tsubo; Ecocardiografía de Esfuerzo; Dobutamina

CASE REPORT

Hospital Regional da Unimed, Fortaleza, CE - Brazil

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ABSTRACT

We report a case of dobutamine stress echocardiography-induced Takotsubo syndrome in a 76-year-old hypertensive patient with clinical complaints of chest pain in an elective visit to the cardiologist. Dobutamine-stress-echocardiography was requested to rule out chest pain of coronary origin. During the test, at peak exercise, echocardiogram showed apical akinesia and electrocardiogram showed ST-segment elevation in D1, AVL, and V2. The patient was hospitalized and underwent coronary angiography, which showed normal coronary arteries and left ventricular apical ballooning. During follow-up, the patient's condition remained stable, with regression of the manifestations 21 days after the initial presentation.

Key Words: Takotsubo Syndrome; echocardiography, stress; dobutamine.

Case Report

A long-term hypertensive 76-year-old female patient regularly taking enalapril 20 mg/day plus hydrochlorothiazide 25 mg/day presented with history of atypical chest pain for three months. She denied other risk factors for coronary artery disease. She sought medical assistance, and dobutamine-stress echocardiography was requested to rule out coronary insufficiency. Other tests previously performed were: chest radiography, Doppler echocardiography, biochemical tests and electrocardiography, all with normal results. Physical examination was also normal. Dobutamine-stress echocardiography was initiated with no signs of complications. However, at the final phase of the test (peak exercise), electrocardiogram showed ST-segment elevation in D1, AV, and V2. Also, there was left ventricular mid-apical segment akinesia, which persisted in the recovery phase (Figure 1). The patient did not present chest pain or any other symptom, and the electrocardiogram performed after the test had reverted to the initial pattern. She was referred for cardiac catheterization, which did not show significant obstruction; left ventriculography demonstrated apical ballooning with basal segment hyperkinesia consistent with Takotsubo syndrome (Figure 2). The enzyme profile showed elevated cardiac enzymes: CK-MB mass: 12.64 ng/mL (normal < 5.1 ng/mL); troponin: 0.800 ¼g/L (normal < 0.01 ¼g/L). The patient remained clinically stable; however, she received intravenous infusion of dobutamine at 10¼g/kg/min for 48 hours. She was discharged on the fifth day of hospitalization using furosemide 40 mg/day + carvedilol 3.125 mg bid + enalapril 5 mg bid + aldactone 25 mg/day. Echocardiography performed 20 days after discharge showed normal LV segmental motion.

Discussion

The first report by a Japanese group (Satoh et al¹), in the early 1990's, described that, after severe stress, middle-aged patients, especially women, presented symptoms similar to those of acute myocardial infarction (chest pain, abnormal cardiac enzymes, left ventricular segmental impairment), however with normal coronary arteries. The syndrome was called "broken heart syndrome" or Takotsubo syndrome^1,2, because, during ventricular systole, left ventriculography showed that the heart presented the shape of an octopus trap used in Japan.

The etiology and clinical characteristics of this syndrome remain not fully understood³. Several factors have been cited as triggering factors: psychological conditions, exacerbation of systemic, neurogenic, pulmonary, gastrointestinal, and renal diseases, as well as other unspecific conditions.

Despite the unknown etiology, excessive sympathetic stimulation has been proposed as a key factor in its pathophysiology. Patients with this syndrome have higher catecholamine levels than those with myocardial infarction of the same Killip class.

A variant of transient left ventricular ballooning has been recently described, in which only the mid ventricle is affected, with hypercontractility of the basal and apical segments, named reverse Takotsubo syndrome⁴.

Although its real prevalence has not been defined, retrospective surveys suggest that 2% of the cases treated as acute coronary syndrome are actually Takotsubo syndrome⁵.

In the case reported, we present an uncommon case of dobutamine stress echocardiography-induced Takotsubo syndrome which had a favorable clinical outcome and recovery of the left ventricular function, as demonstrated by the echocardiographic control performed in the 20th day of follow-up. In the medical literature, no more than three cases of dobutamine-induced Takotsubo syndrome are described.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any post-graduation program.

References

• 1. Satho H, Takeishi H, Uchida T,Dote K, Ishihara M. Takotsubo type cardiomyopathy due to multivessel spasm. In:Kodama k, Haze K, Hon M. (eds). Clinical aspects of myocardial injury: from ischemia to heart failure. Tokyo:Kagakuhyouronsya Co; 1990.p.56-64.
• 2. Sousa JMA, Knobel M, Buchelle G, Sousa JAM, Fisher CH, Born D, et al. Síndrome da disfunção apical reversível. Arq Bras Cardiol. 2005; 84 (4): 340-2.
• 3. Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, et al. Transient left ventricular apical ballooning without coronary stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol. 2001; 38 (1): 11-8.
• 4. Lemos AET, Araujo ALJ, Lemos MT, Belém LS, Vasconcelos Filho FJC, Barros RB. Síndrome do coração partido (Síndrome de Takotsubo). Arq Bras Cardiol. 2008; 90 (1): e1-e3.
• 5. Simões MV, Marin-Neto JA, Romano MMD, O'Connell JL, de Santi GL, Maciel BC. Disfunção ventricular esquerda transitória por cardiomiopatia induzida por estresse. Arq Bras Cardiol. 2007; 89 (4): e79-e83.

Dobutamine stress echocardiography-induced broken heart syndrome (Takotsubo syndrome)

Francisco Juarez Cruz de Vasconcelos Filho; Cezario Antonio Martins Gomes; Oscar Aires de Queiroz; José Erirtonio Façanha Barreto

Publication Dates

• Publication in this collection
  13 Oct 2009
• Date of issue
  July 2009

History

• Accepted
  29 Oct 2008
• Reviewed
  29 Oct 2008
• Received
  01 Aug 2008