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Persisting myocardial sympathetic dysfunction in takotsubo cardiomyopathy.

Verberne HJ, van der Heijden DJ, van Eck-Smit BL, Somsen GA - J Nucl Cardiol (2009)

View Article: PubMed Central - PubMed

Affiliation: Department of Nuclear Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, Amsterdam, 1100 DE, The Netherlands. h.j.verberne@amc.uva.nl

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The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1)... Acute coronary angiography was performed but no significant coronary artery disease was found... Shortly after treatment with intravenous inotropics, and ACE inhibition the patient became hemodynamically stable and metoprolol was added... Cardiac MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability... The diagnosis of a stress-induced cardiomyopathy, apical ballooning syndrome or TC was based on the presence of the typical symptoms and signs of an anterior wall infarction after a highly stressful moment (a lifetime crisis), combined with normal coronary angiography, LV apical ballooning, no signs of late contrast enhancement on MRI scanning, and rapid recovery of LV function... However, in the case report of Moreo et al I-MIBG myocardial uptake increased, after a 2-month treatment with carvedilol... Moreover, in patients with heart failure β-adrenoreceptor-blockers and ACE inhibitors are associated with an increase in I-MIBG uptake and reduced washout., In our patient ACE inhibition was discontinued after the acute phase and the β-adrenoreceptor-blocker was continued... Another possible confounding factor of persisting abnormal I-MIBG scintigraphic findings is denervation due to a previous myocardial infarction... In our patient, myocardial sympathetic activity was increased in the early phase of TC... Normalization of myocardial I-MIBG uptake has been described in several case reports., This is the first report showing persisting sympathetic dysfunction in a patient with TC after complete normalization of the LV function and no signs of late enhancement on MRI... In the present case, the patient experienced the same symptoms after an emotional event several years earlier which may have been an earlier episode of TC... Predictors of TC recurrence are not known... As TC is associated with a hyperadrenergic state, the persisting increased myocardial sympathetic activity may have prognostic implications... Therefore, myocardial I-MIBG scintigraphy may identify patients at risk for the recurrence of TC.

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ECG at admission suggestive for an acute anterior wall infarction: sinus-rhythm with 58 beats per minute, 1st degree AV block, ST segment elevation in leads V1-V4, and pathological Q waves in V2 and V3
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Fig1: ECG at admission suggestive for an acute anterior wall infarction: sinus-rhythm with 58 beats per minute, 1st degree AV block, ST segment elevation in leads V1-V4, and pathological Q waves in V2 and V3

Mentions: On admission the patient was in cardiogenic shock. Auscultation of the heart revealed a grade 3/6 systolic murmur radiating to the left axilla. The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1). Acute coronary angiography was performed but no significant coronary artery disease was found. Left ventricular (LV) angiography showed severe mitral regurgitation and apical ballooning (Figure 2). An intraventricular gradient of 100 mmHg was measured. Echocardiography showed apical akinesia and basal hyperkinesia resulting in severe mitral regurgitation due to systolic anterior movement of the anterior mitral valve leaflet. Troponin T (1.73 ng/L) and CK-MB (22 μg/L) were slightly increased. Based on these findings, the diagnosis of a takotsubo cardiomyopathy (TC) was made. Shortly after treatment with intravenous inotropics, and ACE inhibition the patient became hemodynamically stable and metoprolol was added.Figure 1


Persisting myocardial sympathetic dysfunction in takotsubo cardiomyopathy.

Verberne HJ, van der Heijden DJ, van Eck-Smit BL, Somsen GA - J Nucl Cardiol (2009)

ECG at admission suggestive for an acute anterior wall infarction: sinus-rhythm with 58 beats per minute, 1st degree AV block, ST segment elevation in leads V1-V4, and pathological Q waves in V2 and V3
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2697369&req=5

Fig1: ECG at admission suggestive for an acute anterior wall infarction: sinus-rhythm with 58 beats per minute, 1st degree AV block, ST segment elevation in leads V1-V4, and pathological Q waves in V2 and V3
Mentions: On admission the patient was in cardiogenic shock. Auscultation of the heart revealed a grade 3/6 systolic murmur radiating to the left axilla. The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1). Acute coronary angiography was performed but no significant coronary artery disease was found. Left ventricular (LV) angiography showed severe mitral regurgitation and apical ballooning (Figure 2). An intraventricular gradient of 100 mmHg was measured. Echocardiography showed apical akinesia and basal hyperkinesia resulting in severe mitral regurgitation due to systolic anterior movement of the anterior mitral valve leaflet. Troponin T (1.73 ng/L) and CK-MB (22 μg/L) were slightly increased. Based on these findings, the diagnosis of a takotsubo cardiomyopathy (TC) was made. Shortly after treatment with intravenous inotropics, and ACE inhibition the patient became hemodynamically stable and metoprolol was added.Figure 1

View Article: PubMed Central - PubMed

Affiliation: Department of Nuclear Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, Amsterdam, 1100 DE, The Netherlands. h.j.verberne@amc.uva.nl

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1)... Acute coronary angiography was performed but no significant coronary artery disease was found... Shortly after treatment with intravenous inotropics, and ACE inhibition the patient became hemodynamically stable and metoprolol was added... Cardiac MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability... The diagnosis of a stress-induced cardiomyopathy, apical ballooning syndrome or TC was based on the presence of the typical symptoms and signs of an anterior wall infarction after a highly stressful moment (a lifetime crisis), combined with normal coronary angiography, LV apical ballooning, no signs of late contrast enhancement on MRI scanning, and rapid recovery of LV function... However, in the case report of Moreo et al I-MIBG myocardial uptake increased, after a 2-month treatment with carvedilol... Moreover, in patients with heart failure β-adrenoreceptor-blockers and ACE inhibitors are associated with an increase in I-MIBG uptake and reduced washout., In our patient ACE inhibition was discontinued after the acute phase and the β-adrenoreceptor-blocker was continued... Another possible confounding factor of persisting abnormal I-MIBG scintigraphic findings is denervation due to a previous myocardial infarction... In our patient, myocardial sympathetic activity was increased in the early phase of TC... Normalization of myocardial I-MIBG uptake has been described in several case reports., This is the first report showing persisting sympathetic dysfunction in a patient with TC after complete normalization of the LV function and no signs of late enhancement on MRI... In the present case, the patient experienced the same symptoms after an emotional event several years earlier which may have been an earlier episode of TC... Predictors of TC recurrence are not known... As TC is associated with a hyperadrenergic state, the persisting increased myocardial sympathetic activity may have prognostic implications... Therefore, myocardial I-MIBG scintigraphy may identify patients at risk for the recurrence of TC.

Show MeSH
Related in: MedlinePlus