Abstract | December 19, 2022

Atypical Takotsubo Cardiomyopathy Precipitated by Gastrointestinal Bleeding: Review of Pathophysiology

Presenting Author: Aniekeme Etuk, MD, MPH, Internal Medicine Resident PGY2, NA, Thomas Hospital, Infirmary Health, Fairhope, Alabama

Coauthors: Odigwe Celestine, MD, Internal Medicine, PGY3, Thomas Hospital Infirmary Health, Fairhope, Al; Thornton Stanley, MD, Cardiologist, Thomas Hospital Infirmary Health, Fairhope, Al; Pursley Michael, MD, Cardiologist, Thomas Hospital Infirmary Health, Fairhope, Al.

Learning Objectives

  1. Identify massive gastrointestinal hemorrhage as a precipitant for the development of takotsubo cardiomyopathy.
  2. Describe the diagnostic criteria for takotsubo cardiomyopathy as well as highlighting the echocardiographic findings of the atypical variant.
  3. Discuss the pathophysiology of takotsubo cardiomyopathy

Introduction: Takotsubo cardiomyopathy is a transient dyskinesia, hypokinesia or akinesia of the left ventricle with apical ballooning in the absence of obstructive coronary artery disease with electrocardiogram changes and elevation of cardiac enzymes [1]. Although its incidence is on the rise as clinicians are more aware of the disease entity, it poses a diagnostic dilemma as it presents as a great mimicker [2]. Variants with apical sparing and mid ventricular akinesis have also been described, thus referred to as an atypical form [2]. The pathophysiology is unclear, but it is believed to be stress-induced with a varying degree of triggers [3]. We present the first case of atypical takotsubo cardiomyopathy precipitated by gastrointestinal hemorrhage.

 

Case Presentation: A 73-year-old female presented with complaint of chest pain, palpitation, and shortness of breath. She was hospitalized 48 hours prior for gastrointestinal bleeding necessitating blood transfusion. On physical examination, patient was tachycardic, with normal heart sounds.

 

An acute coronary syndrome was suspected; however, pneumonia, pulmonary embolism, and aortic dissection, could not be excluded at the time of presentation. 

 

Electrocardiogram showed ST elevation in the anterior limb leads with elevated troponin at 0.08 ng/mL. ProBNP was also elevated at 37,000 pg/mL. Chest X-ray revealed pulmonary edema. Coronary angiography showed moderate non-obstructive coronary artery stenosis with an ejection fraction of 25-30%. An echocardiogram revealed severe hypokinesis of all the mid left ventricular segments, hypokinesia of the base and apex of the left ventricle with an ejection fraction of 40%. Also, computed tomography angiography was negative for pulmonary embolism and aortic dissection.

 

Final/Working Diagnosis: A diagnosis of Acute heart failure secondary to atypical takotsubo cardiomyopathy precipitated by a recent gastrointestinal bleed was made.

 

Management/Outcome: The patient was started on dopamine infusion for cardiogenic shock which developed few hours following hospitalization. She was monitored closely in the medical intensive care unit and eventually weaned off pressor support. Goal directed medical therapy for heart failure with intravenous furosemide, losartan and metoprolol was also instituted. Patient improved clinically and was subsequently discharged home.

 

Follow-up: She was seen in outpatient service, one week and three months following discharge and was stable.

 

References:

  1. Khalid N, Ahmad S, Shlofmitz E, et.al. Pathophysiology of Takotsubo Syndrome. StatPearls Publishing; 2022 Jan.  https://www.ncbi.nlm.nih.gov/books/NBK538160/.
  2. Loong C, Firdaus M, Said M, et.al. Atypical Presentation of Takotsubo Cardiomyopathy: Stroke as a Predisposing Factor. Medeni Med J. 2020; 35:266-270. 
  3. Lyon A, Citro R, Schneider B, et.al. Pathophysiology of Takotsubo Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021; 77:902-921.
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