Original Article
Typical takotsubo cardiomyopathy in suspected ST elevation myocardial infarction patients admitted for primary percutaneous coronary intervention

https://doi.org/10.1016/j.ejim.2013.09.004Get rights and content

Highlights

  • No data available about prevalence of TCM in “real-world” PPCI admissions for STEMI.

  • 0.9% prevalence in patients admitted for PPCI in a single high volume UK centre.

  • Prevalence on 3.2% in women admitted for PPCI.

  • TCM is not a benign condition during acute presentation.

  • Good long-term survival outcome if managed appropriately.

Abstract

Aim

Takotsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography is much quicker than before. We aimed to analyse the prevalence of typical TCM in patients admitted for primary percutaneous coronary intervention (PPCI) with suspected ST elevation myocardial infarction (STEMI) to a single tertiary centre in United Kingdom.

Methods

All patients admitted to our unit with suspected STEMI from September 2009 to November 2011 were included for analysis.

Results

Of the 1875 patients admitted, 17 patients (all female) with mean age of 69 ± 11.9 yrs were identified to have clinical features of typical TCM, thus giving an overall prevalence of 0.9% in PPCI admissions (3.2% prevalence in women). The admission ECG showed ST elevation in 14 patients (82%) and 3 had LBBB (18%). In the 16 patients who had raised hs Troponin (normal range < 14), the mean level was 921 ± 668 (median 778, range 110 to 2550) ng/L. Two patients survived cardiac arrest and one had apical thrombus on presentation. Left ventricular function was severely impaired (EF ≤ 30%) in 2 patients, whilst it was moderately impaired (EF 31–50%) in others. During a mean follow-up period of 22 ± 7 months (range 8–36 months), there was no mortality or recurrence.

Conclusion

This is the first observational study to report the prevalence of typical TCM in patients admitted for PPCI in “real-world” practice. Though this condition is not benign during the acute episode, there is a good survival outcome if managed appropriately during the acute phase.

Introduction

Takotsubo cardiomyopathy (TCM) is a reversible cardiomyopathy, occurring predominantly in post-menopausal women mostly due to emotional or physical stress, but occasionally due to unknown reasons [1], [2], [3]. Typically, patients present with chest pain and ST elevation or T wave inversion on their electrocardiogram (ECG) mimicking acute coronary syndrome, but with normal coronary arteries or non-flow limiting disease. One of the cardinal features of TCM is that the LV dysfunction extends beyond a single coronary territory. The wall motion abnormalities typically involve akinesia of the apex of the left ventricle with hyperkinesia of the base of the heart. Variant forms of left ventricular dysfunction have been reported, including wall-motion abnormalities such as mid-ventricular ballooning with sparing of the basal and apical segments, or inverted Takotsubo, where the apex is spared with basal wall abnormalities [4].

The prevalence among patients with symptoms suggestive of acute coronary syndrome is 1.0–2.5%, with almost 90% of cases being in post-menopausal women [4], [5]. Overall, in patients suspected of ST elevation myocardial infarction (STEMI), the prevalence is 2%, but this included patients who were admitted for both pharmacological and mechanical reperfusion [5]. However, there is no “real-world” observational data about the prevalence of typical TCM in patients admitted for primary percutaneous coronary intervention (PPCI) for STEMI. We therefore analysed our database to identify patients with typical TCM who were admitted to our unit with suspected STEMI for PPCI and followed them up.

Section snippets

Methods

Primary PCI for STEMI in our unit started in September 2009 and we included all patients who were admitted with suspected STEMI for PPCI from September 2009 to November 2011 (inclusive). Our PPCI service is 24/7 service covering a catchment population of 1.6 million in east of England, which is predominantly a white Caucasian population. Activation of the STEMI pathway in our centre involves the PPCI team (consultant cardiologist, specialist registrar, cardiac catheter lab nurse, radiographer

Results

During the study period, 1875 patients were admitted to our unit with suspected STEMI for PPCI. Except for 20 patients, all others (n = 1855) underwent coronary angiography and 1471 patients proceeded on to have PPCI. Of those who did not undergo PPCI (n = 404), 30 patients did not have documented assessment of LV function (either by echocardiography or left ventriculography) during their index admission and they were excluded from this analysis. On reviewing the echocardiogram and/or left

Discussion

To the best of our knowledge, this is the first observational study in English literature to report the prevalence of typical TCM in patients admitted for primary PCI for STEMI in “real-world”. Our centre is a high volume cardiac unit in United Kingdom with a large catchment population of 1.6 million people. Patients with suspected STEMI are brought to our centre by 2 pathways — one, direct to our centre by the paramedics and the other by referral from emergency department from one of our 6

Limitation

The main limitation of our study to identify TCM patients is the lack of cardiac MRI (CMR) imaging for these patients. Though echocardiogram or left ventriculogram identifies the typical regional wall motion abnormalities of TCM, CMR can be extremely useful in helping differentiate TCM from different types of cardiomyopathy as well as myocarditis. Early CMR is crucial as most of the imaging findings are usually present in the first 24–48 h followed by a complete recovery within days. Late

Conclusion

This first observational study of typical TCM in STEMI patients admitted for PPCI to a single large tertiary centre showed an overall prevalence of 0.9% with 3.2% prevalence in the female population. Further reports of this condition with the early use of cardiac MRI and intravascular imaging techniques during coronary angiography in doubtful situation are needed to confirm this finding. Though TCM is not benign during the acute episode, there is a good long-term survival outcome if managed

Learning points

  • No current data available about prevalence of TCM in “real-world” PPCI admissions for STEMI.

  • 0.9% prevalence in patients admitted for PPCI in a single high volume UK centre.

  • Prevalence of 3.2% in women admitted for PPCI.

  • TCM is not a benign condition during acute presentation.

  • Good long-term survival outcome if managed appropriately.

Conflict of interests

We declare that we participated in the authoring of this paper and have seen and approved the final version. We also declare that there is no conflict of interest.

Acknowledgements

We would like to thank all the staff at cardiology department at The Essex Cardiothoracic centre and also acknowledge the help from Stewart Stent and Anita Sutton from Basildon Hospital for maintaining the database and providing data.

Cited by (16)

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    In a recent cohort study of patients admitted with suspected ST-elevation myocardial infarction who were advanced for percutaneous coronary intervention, 0.9% of patients were diagnosed with Takotsubo syndrome. Of this subset, the majority were women, with a mean age of 69 years; mean troponin elevation was 921 ng/L.4 Although ST-elevation is common at the time of presentation in patients who are diagnosed with Takotsubo syndrome, delayed ST-elevation is uncommon. As observed in this case, the two diagnoses are not mutually exclusive, and prior case reports have described ACS leading to Takotsubo syndrome, or ACS as a consequence of Takotsubo syndrome.5,6

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  • Drug treatment rates with beta-blockers and ACE-inhibitors/angiotensin receptor blockers and recurrences in takotsubo cardiomyopathy: A meta-regression analysis

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  • Soluble ST2 and troponin I combination: Useful biomarker for predicting development of stress cardiomyopathy in patients admitted to the medical intensive care unit

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    It is easily missed entirely by focusing on only non-cardiac medical stress conditions, or it is misdiagnosed as an acute coronary syndrome (ACS) if noticing only chest pain, electrocardiographic changes, or elevated cardiac troponin I (cTnI). About 0.9% of patients presenting with ACS-like symptoms and percutaneous coronary angiograms were ultimately diagnosed as having SCM.6 While myocardial histopathological findings have not been studied in great detail, high catecholamine secretion may be one of the key findings in the onset of SCM.

  • Prevalence, etiology, and characteristics of patients with type-2 acute myocardial infarction

    2015, Revista Brasileira de Cardiologia Invasiva
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    Apical dyskinesia, which was found in a little more than one-third of the patients with type-2 AMI, is a characteristic compatible with Takotsubo syndrome, whose clinical presentation is chest pain, ST-segment elevation on the electrocardiogram, and increase in biomarkers, simulating an acute coronary syndrome, but with normal coronary arteries,23,24 with or without ventricular dysfunction. Absence of significant obstructive coronary artery disease and reversibility of left ventricular contractility dysfunction are the important aspects for this diagnosis.25–27 Perhaps, due to the possible inclusion of these patients in the type-2 AMI sample, a higher ejection fraction was obtained in this group, contrary to the findings of Saaby et al.,17 but corroborating those by Collste et al.,28 who also found patients with typical characteristics of Takotsubo in their study.

  • Systematic review and meta-analysis of incidence and correlates of recurrence of takotsubo cardiomyopathy

    2014, International Journal of Cardiology
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    Six out of 34 studies were noted to be duplicated (from the same group with overlapping patient data sets) and were excluded. Additional 3 articles were found on the hand search leading to a total of 31 [23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53] articles in the systematic review (Fig. 1). Authors were contacted to obtain details of the patients with recurrence where it was not reported in the study.

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