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      Delayed onset Takotsubo syndrome following exercise ECG: a case report

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          Abstract

          Background

          Takotsubo syndrome usually occurs immediately following a physical or emotional trigger. In some cases, a triggering stress may not be evident. A delayed manifestation of the syndrome may account for such cases.

          Case summary

          An asymptomatic 69-year-old woman presented for a routine cardiac check-up, which revealed normal electrocardiogram (ECG), echocardiography, and exercise ECG. She did not complain of any chest pain during or immediately after the tests. After about 24 h, she developed chest pain for which she was admitted with the provisional diagnosis of acute coronary syndrome. ECG showed dynamic T-wave changes with QTc prolongation. Cardiac biomarkers were mildly elevated. Characteristic reversible left ventricular dysfunction in absence of coronary stenosis ultimately led to the diagnosis of Takotsubo syndrome.

          Discussion

          Our case represents a delayed occurrence of Takotsubo syndrome triggered by a treadmill exercise stress test, which manifested about 24 h following the stressor. Such delayed manifestation may account for those cases of Takotsubo syndrome where no immediate triggering stressor is evident.

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          Most cited references6

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          Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan.

          K Tsuchihashi, K. Ueshima, T Uchida … (2001)
          To determine the clinical features of a novel heart syndrome with transient left ventricular (LV) apical ballooning, but without coronary artery stenosis, that mimics acute myocardial infarction, we performed a multicenter retrospective enrollment study. Only several case presentations have been reported with regard to this syndrome. We analyzed 88 patients (12 men and 76 women), aged 67 +/- 13 years, who fulfilled the following criteria: 1) transient LV apical ballooning, 2) no significant angiographic stenosis, and 3) no known cardiomyopathies. Thirt-eight (43%) patients had preceding aggravation of underlying disorders (cerebrovascular accident [n = 3], epilepsy [n = 3], exacerbated bronchial asthma [n = 3], acute abdomen [n = 7]) and noncardiac surgery or medical procedure (n = 11) at the onset. Twenty-four (27%) patients had emotional and physical problems (sudden accident [n = 2], death/funeral of a family member [n = 7], inexperience with exercise [n = 6], quarreling or excessive alcohol consumption [n = 5] and vigorous excitation [n = 4]). Chest symptoms (67%), electrocardiographic changes (ST elevation [90%], Q-wave formation [27%] and T-wave inversion [97%]) and elevated creatine kinase (56%) were found. After treatment of pulmonary edema (22%), cardiogenic shock (15%) and ventricular tachycardia/fibrillation (9%), 85 patients had class I New York Heart Association function on discharge. The LV ejection fraction improved from 41 +/- 11% to 64 +/- 10%. Transient intraventricular pressure gradient and provocative vasospasm were documented in 13/72 (18%) and 10/48 (21%) of the patients, respectively. During follow-up for 13 +/- 14 months, two patients showed recurrence, and one died suddenly. A novel cardiomyopathy with transient apical ballooning was reported. Emotional or physical stress might play a key role in this cardiomyopathy, but the precise etiologic basis still remains unclear.
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            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.

            Radhakrishnan Ramaraj, Mohammad Reza Movahed (2016)
            Takotsubo cardiomyopathy is usually caused by triggering stress. It has 4 different subtypes. There has been no consensus to differentiate various types with regard to characteristics of the patient population. The goal of this study was to evaluate any clinical differences between the reverse type in comparison to common apical and mid-cavitary types using case series of reported cases. The authors searched published articles in PubMed and Medline on takotsubo or stress-induced cardiomyopathy. They included only cases that reported different types of takotsubo cardiomyopathy with baseline clinical characteristics. They identified 60 patients for the final analysis. The types of takotsubo cardiomyopathy seen in this study are classified as classic (66.7%), mid-cavitary (10%), or reverse (inverted) (23.3%). Patients with reverse-type takotsubo cardiomyopathy were significantly younger compared with those with other types (mean age, 36 for reverse vs 62 for other types; P<.001). Furthermore, all patients with the reverse type had physical or mental stress, whereas those with other types had no triggering stress in 02% of the reported cases (P<.0001). Among patients presenting with takotsubo cardiomyopathy, the reverse or inverted variant presents at a younger age and is always associated with a triggering of emotional or physical stress. © 2010 Wiley Periodicals, Inc.
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              The clinical characteristics, laboratory parameters, electrocardiographic, and echocardiographic findings of reverse or inverted takotsubo cardiomyopathy: comparison with mid or apical variant.

              Bong Gun Song, Woo Chun, Yong Hwan Park … (2011)
              Although takotsubo cardiomyopathy (TTC) typically affects the apical and/or midventricular segments, several recent cases have reported a reverse or inverted variant of TTC. The aim of this study was to investigate the clinical characteristics, laboratory parameters, electrocardiographic, and echocardiographic findings in patients presenting as inverted TTC and compare those parameters to those presenting as mid or apical variant. The clinical features of inverted TTC are different from those of other types of TTC. Of 103 patients enrolled from the TTC registry database, 20 showed inverted TTC (inverted TTC group), and 83 showed mid or apical variant (other TTC group). Clinical presentations and in-hospital courses were mostly similar between the groups. However, the inverted TTC group was younger (median, 54.5 vs 64.0 years; P = 0.006) than other TTC and had a higher prevalence of triggering stress (100% vs 77%, P = 0.018), whereas other TTC group had higher prevalence of dyspnea (58% vs 30%, P = 0.025), pulmonary edema (46% vs 20%, P = 0.035), cardiogenic shock (36% vs 10%, P = 0.023), T-wave inversion (81% vs 60%, P = 0.049), and significant reversible mitral regurgitation (MR) (19% vs 0%, P = 0.033). Also, the inverted TTC group had significantly higher creatine kinase MB fraction (CK-MB); CK-MB (median, 30.7 vs 7.6 ng/mL; P = 0.001) and troponin-I (median, 13.1 vs 1.6 ng/mL; P = 0.001), but lower N-terminalpro-brain natriuretic peptide (NT-proBNP) levels (median, 613.3 vs 4987.0 pg/mL; P = 0.020). Inverted TTC presents at a younger age and has a higher prevalence of triggering stress, whereas other TTC has a higher prevalence of heart failure symptoms, significant reversible MR, and T-wave inversion and higher NT-proBNP levels despite other clinical features that are mostly similar. © 2011 Wiley Periodicals, Inc.
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                Author and article information

                Contributors
                Nikos Papageorgiou: Role: Handling Editor
                Domenico D'Amario: Role: Editor
                Rafael Vidal-Perez: Role: Editor
                Mohammed Majid Akhtar: Role: Editor
                Peregrin Green: Role: Editor
                Journal
                Journal ID (nlm-ta): Eur Heart J Case Rep
                Journal ID (iso-abbrev): Eur Heart J Case Rep
                Journal ID (publisher-id): ehjcr
                Title: European Heart Journal: Case Reports
                Publisher: Oxford University Press
                ISSN (Electronic): 2514-2119
                Publication date Collection: June 2019
                Publication date (Electronic): 28 April 2019
                Publication date PMC-release: 28 April 2019
                Volume: 3
                Issue: 2
                Electronic Location Identifier: ytz040
                Affiliations
                [1 ]Nil Ratan Sircar Medical College & Hospital, 138 A.J.C. Bose Road, Kolkata, India
                [2 ]Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata, India
                Author notes
                Corresponding author. Tel: +91 983 002 4131, Fax: +91 33 2320 5184, Email: drsuvrob@ 123456gmail.com
                Article
                Publisher ID: ytz040
                DOI: 10.1093/ehjcr/ytz040
                PMC ID: 6601237
                SO-VID: a76b31ac-a301-498a-b8c7-e00227860959
                Copyright © © The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date received : 15 November 2018
                Date accepted : 10 April 2019
                Page count
                Pages: 4
                Categories
                Subject: Case Reports

                Keywords: takotsubo syndrome,delayed onset,treadmill exercise ecg,case report
                Data availability:
                Keywords: takotsubo syndrome, delayed onset, treadmill exercise ecg, case report

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