Takotsubo is an acute myocardial ischaemic syndrome

Abstract

Takotsubo is an acute ischaemic syndrome: a case illustration. A 68-year-old woman with a history of treated hypertension and dyslipidaemia experienced acute chest pain while attending a funeral. Following the involvement of the emergency services, an initial 12-lead electrocardiogram revealed ST-segment elevation in the precordial leads (V2–V6) and T-wave inversion (upper row, right). The peak high-sensitivity troponin T concentration was 692 ng/L. Echocardiography revealed left ventricular systolic dysfunction (ejection fraction 46%) due to anterolateral hypokinesis coupled with hyperdynamic contractility in the basal and inferolateral regions. Urgent, invasive coronary angiography revealed smooth, patent coronary arteries (middle row). Adjunctive coronary function tests (upper row, right) involving bolus saline thermodilution (Coroventis, Uppsala, Sweden) in the left anterior descending coronary artery disclosed a reduced coronary flow reserve (2.0, abnormal ≤ 2.5), an increased index of microvascular resistance (29 mmHg.s, abnormal ≥ 25 mmHg.s), and an increase in myocardial resistance reserve (3.5, abnormal > 3.0). Left ventriculography revealed typical, apical ballooning (middle row, right). Cardiovascular magnetic resonance imaging (MRI) at 1.5 T (Avanto-fit, Siemens Healthcare), performed 13 days from the index presentation, revealed improved left ventricular systolic function (ejection fraction 64%), hyperintense myocardial oedema with an apical distribution [left ventricular four-chamber view, native transverse relaxation time (T2) 65 ms (apex), 44 ms remote zone, basal; reference range 42–52 ms; bottom row, left], and no evidence of scar tissue or fibrosis (four-chamber view, no myocardial late gadolinium enhancement; bottom row, middle). At clinical follow-up 6 months later, the patient had persisting anginal symptoms on exertion, consistent with Canadian Cardiovascular Society angina class 2 and New York Heart Association functional class II. Intravenous adenosine (140 μg/kg/min) stress perfusion cardiovascular MRI revealed a reduction in subendocardial myocardial blood flow during hyperaemia (1.88 mL/min/g; normal > 1.96 mL/min/g) and epicardial hyperaemia, consistent with persistent subendocardial coronary microvascular dysfunction. Left ventricular systolic function and myocardial oedema imaging had normalized.

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