I Núñez-Gil, A Fernández-Ortiz, M Luaces, J García-Rubira, E Pozo, J Gonzalez, D Vivas, C Macaya
acute coronary syndrome, acute myocardial infarction, apical ballooning syndrome, inferior, tako-tsubo cardiomyopathy
I Núñez-Gil, A Fernández-Ortiz, M Luaces, J García-Rubira, E Pozo, J Gonzalez, D Vivas, C Macaya. Transient Inferior Left Ventricular Dyskinesia: A New Tako-Tsubo Variant?. The Internet Journal of Cardiology. 2007 Volume 5 Number 2.
Apical transient dyskinesia, presents features mimicking acute coronary syndrome, being their characteristics normal coronary arteries assessed by coronariography and the complete resolution of the motion alterations. We report 6 white patients who presented with inferior left ventricular wall involvement. A thorough chart review combined with a clinical and echocardiographic follow-up was performed. The inclusion criteria were Mayo criteria. Four patients (67%) were women; and the mean age was 54 years. Emotional stress situation was associated in 2 patients. Electrocardiographic changes were displayed in all of them. A complete left ventricular motion recovery was displayed in 100% by means of echocardiography. Mean follow-up was 9,5 months. One patient developed an asymptomatic myocardial infarction during the follow-up. This case series supports the idea that an inferior left ventricular involvement of this cardiomyopathy could exist. Its probable relationship with the typical form of Tako-tsubo raises further questions about the pathophysiology, prognosis and management.
Apical transient dyskinesia, also known as apical ballooning, stress cardiomyopathy, “broken heart” syndrome or Tako-tsubo cardiomyopathy is a newly recognized entity. It was first described in Japan by Sato et al1,2 in 1990, and later confirmed in other world locations and races3,4. This syndrome presents early features similar to acute coronary syndromes, including chest pain, elevation of myocardial necrosis markers, electrocardiographic alterations and segmental left ventricular dyskinesia/akinesia. The main characteristics are the presence of normal coronary arteries assessed by coronary angiography and rapid and complete resolution of segmental motion alterations1,2,3,4. Prognosis is excellent compared with classic myocardial infarction5. Frequently but not always, stress episode (emotional or physical) is associated with the development of this process. Patients are more likely women5. Its pathophysiology remains unclear, although several theories have been proposed. Its relationship with brain and cathecolamine cardiotoxicity disorders seems established6. Even more, the previously described profile has been stressed by recently published, data as other than apical left ventricular motion alteration with midventricular7,8 basal involvement9, biventricular10 alterations and previous coronary artery disease11.
This article provides, to our knowledge, the first description of this novel transient left ventricular abnormality variant.
Subjects And Methods
We report a new variant of transient left ventricular ballooning in a multicentric 6-patient-case series, presenting as inferior acute myocardial infarction. We investigated patients who met the following inclusion criteria (Mayo)12: 1) Clinical presentation mimicking acute coronary syndrome; 2) Transient hypokinesis, akinesis, or dyskinesis of the left ventricular segments with main inferior involvement as assessed by ventriculogram; 3) Absence of significantly obstructive coronary disease or angiographic evidence of acute plaque rupture or thrombus.; 4) New ECG abnormalities (either ST-segment elevation and/or T-wave inversion) or elevated cardiac troponin.; 5) Absence of: brain or intracranial disease potentially responsible, pheochromocytoma, myocarditis, hypertrophic cardiomyopathy or previous coronary artery disease. Management was decided according to the currently STEMI and NSTEMI guidelines available. Cardiovascular risk factors and triggering factors were studied from a thorough chart review combined with a clinical and echocardiographic follow-up. The inferior involvement was determined after assessment by cardiac catheterization analysed by al least two cardiologists unaware of the purpose of this study.
Total elevated cholesterol levels (>5mmol/l) was only elevated in one patient. Thyroid hormones were determined in 5 of 6 patients and all were normal.
The sixth patient underwent the angiogram 48 hours later. Coronary arteries were normal in all patients (6/6). Left ventricular segmental motion alterations were demonstrated in 100%. Data are shown in table 3.
The Takotsubo myocardiopathy could represent an special form of left ventricular stunning, including a mild form of myocardial infarction. The pathophysiology remains unclear although several theories have been proposed: anatomic coronary alterations13; left ventricular outflow tract obstruction14; coronary microvascular dysfunction; vasospasm, evanescent intracoronary thrombus, myocarditis and catecholamine excess (brain-stress related)6.
In order to standardize diagnosis, various clinical criteria have been proposed. Our cases fulfilled Mayo criteria12, even though they were proposed for the typical Takotsubo. Although the apical affectation (Takotsubo classical or typical form) remains the most frequent transient cardiomyopathy of this type15, the recent publication of new variants of transient myocardial dyskinesia arises new questions about this syndrome7,8,9,10,11,15.
Our aim presenting this case-series was to remark that other left ventricular segments could be transiently affected, in the same manner that classical acute myocardial infarction can. This inferior variant may probably be related to the classical apical ballooning. It could represent a variant properly (inferior ECG alterations support that point) or the evolution to resolution of a typical case, although the ventriculograms were performed quite early after the onset of symptoms.
In ischemic cardiomyopathy it is well known that different segmental motion can be seen, depending on the coronary artery altered. Recently, Kurowski et al. reported that Scintigraphy and PET studies showing an strong correlation between location of wall motion abnormality and myocardial metabolism defects with a significantly higher apical decrease in glucose uptake in patients with a “typical” Takotsubo pattern compared with midventricular variant8. Likewise, a relationship between Takotsubo and ischemic cardiomyopathy is being recognised11. Therefore, it is possible we can not rule out Takotsubo and its variants to be a variant itself of ischemic cardiomyopathy, with mild anatomic or transient lesion assessed by angiogram but with functional repercussion.
Takotsubo cardiomyopathy, even if it is supposed to carry a very good prognostic5 is not lacking of complications. In fact, 2 of our 6 patients suffered mild in-stay complications (33%). On the other hand, 1 patient suffered complications related to the cathetherization. Of note, is the interesting question raised by the silent myocardial infarction presented by one patient, the marathon-runner, during intense exercise, after a first transient episode. After that, It could be advisable to avoid extreme physical exercise, sometime, perhaps a month after the admission.
To conclude, further studies about this entity are needed in order to develop adequate management and preventive strategies.
Dr. Iván Javier Núñez Gil. Avda. del TALGO 83, 1ºE. 28023 Aravaca, Madrid. Spain. Europe. 913307645 Fax 913303730 firstname.lastname@example.org