Rare cases of stress cardiomyopathy triggered by pulmonary embolism and reverse Takotsubo
Main Article Content
Keywords
Takotsubo Cardiomyopathy, Pulmonary Embolism, Acute Coronary Syndrome
Abstract
Background: Takotsubo syndrome is a potentially fatal cardiomyopathy, characterized by systolic dysfunction with apical hypokinesia and basal hypercontractility in the absence of coronary lesions. It is triggered by physical or emotional stress and accounts for 2% of acute coronary syndromes; it is more common in older women. Its pathophysiology is not entirely clear, although the adrenergic hypothesis is the most accepted: a cardiotoxic effect is proposed due to beta-adrenergic stimulation, with an imbalance in oxygen supply and demand and dysregulation of calcium-dependent proteins. However, certain comorbidities can mask the condition. The objective was to describe anomalous presentations of Takotsubo syndrome and briefly review its variants to familiarize cardiologists with unusual patterns.
Clinical cases: The first case was about a 68-year-old man with angina, hemodynamic instability, and prominent T waves in V2-V4, with no coronary lesions. A ventriculogram showed systolic dysfunction and basal hypokinesia. Second case was about an 81-year-old woman with pulmonary embolism presented with systolic dysfunction with apical hypokinesia after thrombectomy.
Conclusion: Stress cardiomyopathy can have atypical presentations, which is why it should be suspected in the presence of a ventricular dysfunction with no apparent cause.
References
1. Singh T, Khan H, Gamble DT, et al, Dawson D. Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications. Circulation. 2022;145(13):1002-19.
2. Sato TH, Uchida T, Dote KMI. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. En: Kodama K, Haze K, Hori M, editors. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Tokyo: Kagakuhyoronsha Publishing Co.; 1990. pp: 56-64.
3. Cortes BLD, Manzo PE, Gómez CEJ, et al. Síndrome de tako-tsubo en adulto mayor. Acta Med GA. 2024;22(5):429-31. doi: 10.35366/11882
4. López Tristán S. Abordaje del paciente con miocardiopatía de Takotsubo. Rev Medica Sinerg. 2023;8(1):e936.
5. O’Keefe EL, Torres-Acosta N, O’Keefe JH, et al. Takotsubo Syndrome: Cardiotoxic Stress in the COVID Era. Mayo Clin Proc Innov Qual Outcomes. 2020;4(6):775-85. doi: 10.1016/j.mayocpiqo.2020.08.008
6. Nef HM, Möllmann H, Troidl C, et al. Abnormalities in intracellular Ca2+ regulation contribute to the pathomechanism of Tako-Tsubo cardiomyopathy. Eur Heart J. 2009;30:2155-64.
7. Schweiger V, Gilhofer T, Fang R, et al. Coronary microvascular dysfunction in Takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance. Clin Res Cardiol. 2024;113(12):1629-37. doi: 10.1007/s00392-023-02329-7
8. Dong F, Yin L, Sisakian H, et al. Takotsubo syndrome is a coronary microvascular disease: experimental evidence. Eur Heart J. 2023;44(24):2244-53. doi: 10.1093/eurheartj/ehad274
9. González-Jasso JG, Montero-Pola YL, Toledo-Salinas O, et al. Miocardiopatía de Takotsubo asociada al nacimiento anómalo de las arterias coronarias. Rev Med Inst Mex Seguro Soc. 2023;61(6):882-7. doi: 10.5281/zenodo.10064743
10. Pimentel-Esparza JA, Rios-Gomez M, Cervantes-Nieto JA, et al. Massive Pulmonary Embolism Related to a Patient With Heart Failure Secondary to Stress Cardiomyopathy: A Case Report. Cureus. 2024;16(1):e52985. doi: 10.7759/cureus.52985
11. Madias JE. Inverse Takotsubo syndrome resulting from a fall, malleolar fracture, anesthesia, surgery, or complicating pulmonary embolism? Korean Circ J. 2014;44(5):358. doi: 10.4070/kcj.2014.44.5.358
12. Jin Q, Luo Q, Zhao Z, et al. Takotsubo syndrome with pulmonary embolism: a case report and literature review. BMC Cardiovasc Disord. 2018;18(1):229. doi: 10.1186/s12872‑018‑0953‑7
13. Sakul NFN, Balabbigari N, Purewal J, et al. Reverse Takotsubo pattern in the setting of undiagnosed pheochromocytoma and pulmonary embolism: a rare presentation. Am J Case Rep. 2020;21:e920231. doi: 10.12659/AJCR.920231
14. Challa S, Ganji JL, Raizada A, et al. Takotsubo cardiomyopathy in a patient with pulmonary embolism. Eur J Echocardiogr. 2011;12(10):E39. doi: 10.1093/ejechocard/jer151
15. Harutyunyan H, Achuthanandan S, Tamazyan V, Oo A, Khachatryan A, Batikyan A, Shetty M, Shetty V. Pulmonary Embolism as a Potential Trigger for Takotsubo Cardiomyopathy. Cureus. 2024;16(6):e62342. doi: 10.7759/cureus.62342
16. Naji W. Acute pulmonary embolism with takotsubo cardiomyopathy: Managing a double whammy. Chest. 2017;152(4):A419. doi: 10.1016/j.chest.2017.08.445
17. Jessen N, Andersen JA, Tayal B, et al. Takotsubo syndrome and stroke risk: a nationwide register‑based study. Int J Cardiol. 2023;392:131283.
18. Redfors B, Jha S, Thorleifsson S, et al. Short- and long-term clinical outcomes for patients with takotsubo syndrome and patients with myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry. J Am Heart Assoc. 2021;10:e017290.
19. Shahid R, Yousaf H, Islam S, et al. Unraveling the enigma: A case report of reverse takotsubo cardiomyopathy. Chest. 2024;166(4):A730-1.
20. Assad J, Femia G, Pender P, et al. Takotsubo Syndrome: A Review of Presentation, Diagnosis and Management. Clin Med Insights Cardiol. 2022;16:11795468211065782. doi: 10.1177/11795468211065782
21. Hayashi T. Editorial: Reviews in takotsubo syndrome. Front Cardiovasc Med. 2024;11:1446689. doi: 10.3389/fcvm.2024.1446689
22. Ramaraj R, Movahed MR. Reverse or inverted takotsubo cardiomyopathy (reverse left ventricular apical ballooning syndrome) presents at a younger age compared with the mid or apical variant and is always associated with triggering stress. Congest Heart Fail. 2010;16:284-6.
Article Sidebar
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Authors retain their copyright and grant the Revista Médica del IMSS the right of first publication. Articles are distributed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which allows sharing as long as the author and the original source are properly credited.