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      The electrocardiographic ‘triangular QRS-ST-T waveform’ pattern: a marker of severe haemodynamic compromise in Takotsubo syndrome—a case report

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          Abstract

          Background

          Takotsubo cardiomyopathy is characterized by transient regional systolic dysfunction of the left ventricle, mimicking myocardial infarction. Although systolic left ventricular (LV) function normalizes in most cases, the outcome is not always favourable. Recently, a rare electrocardiogram (ECG) finding, lambda wave ST elevation or ‘triangular QRS-ST-T waveform’, was suggested as a possible marker of poor outcome in Takotsubo patients

          Case summary

          After a brief episode of chest pain and shortness of breath, a 67-year-old woman developed cardiogenic shock. Her resting ECG showed widespread ST elevations, which soon evolved into a pattern of triangular QRS-ST-T waveforms in the inferior leads and V3–V6. Emergent coronary angiography was normal. The ejection fraction was 20% with apical ballooning and an LV thrombus. At 1-month follow-up, the patient was asymptomatic and the ECG showed only T-wave inversions.

          Discussion

          The triangular QRS-ST-T waveform ECG pattern has recently been introduced as a high-risk marker in the Takotsubo syndrome.

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          Meta-analysis of clinical correlates of acute mortality in takotsubo cardiomyopathy.

          Kuljit Singh, Kristin Carson, Ranjit Shah … (2014)
          The incidence and clinical correlates of acute in-hospital mortality of takotsubo cardiomyopathy (TTC) are not clear. We performed a systematic review and meta-analysis to consolidate the current evidence on acute mortality in TTC. We then assessed the impact of "secondary" TTC, male gender, advancing age, and catecholamine use on mortality. A comprehensive search of 4 major databases (EMBASE, Ovid MEDLINE, PubMed, and Google Scholar) was performed from their inception to the first week of July 2013. We included original research studies, recruiting ≥10 participants, published in English language, and those that reported data on mortality and cause of death in patients with TTC. Of 382 citations, 37 studies (2,120 patients with TTC) from 11 different countries were included in the analyses. The mean age of the cohort was 68 years (95% confidence interval [CI] 67 to 69) with female predominance (87%). The in-hospital mortality rate among patients with TTC was 4.5% (95% CI 3.1 to 6.2, I2=60.8%). Among all deaths, 38% were directly related to TTC complications and rest to underlying noncardiac conditions. Male gender was associated with higher TTC mortality rate (odds ratio 2.6, 95% CI 1.5 to 4.6, p=0.0008, I2=0%) so was "secondary" TTC (risk difference -0.11, 95% CI -0.18 to -0.04, p=0.003, I2=84%). The mean age of patients dying tended to be greater than that in the whole cohort (72±7 vs 65±7 years). In conclusion, TTC is not as benign as once thought. To reduce the mortality rate, greater efforts need to be directed to the diagnosis, treatment, and ultimately prevention of "secondary" TTC.
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            Clinical Profile of Patients With High-Risk Tako-Tsubo Cardiomyopathy.

            Scott W Sharkey, Victoria Pink, John Lesser … (2015)
            Although tako-tsubo cardiomyopathy (TTC) is regarded as a reversible condition with favorable outcome, a malignant clinical course evolves in some subjects. In this single-institution experience, we describe the clinical profile of patients with adverse TTC outcome. A cohort of 249 consecutive patients with TTC was interrogated for those with acute unstable presentation during the first 24 hours. Forty-seven patients (19%) experienced early complicated clinical course with cardiac arrest in 9 (ventricular fibrillation, n = 4, pulseless electrical activity, n = 3, and asystole, n = 2) or marked hypotension in 38 (systolic blood pressure ≤90 mm Hg requiring vasopressors and/or balloon pump). Of the 47 patients, Killip class III to IV heart failure was present in 30 (64%). Despite treatment, 8 patients (3%; all women) died inhospital due to respiratory failure, cardiogenic shock, or anoxic brain injury. All 8 inhospital deaths occurred among the 47 patients with unstable presentation, including 2 after cardiac arrest and 6 with marked hypotension. Post-TTC event mortality for a period of 4.7 ± 3.4 years significantly exceeded that in a matched general US population (standardized mortality ratio 1.4; 95% confidence interval 1.1 to 1.9; p = 0.005) largely due to noncardiac co-morbidities. In conclusion, contrary to widespread perception, TTC is not an entirely benign and reversible condition. Among this large cohort, a high-risk subgroup was identified with cardiac arrest or hemodynamic instability, accounting for all hospital deaths. Hospital nonsurvivors had a variety of irreversible co-morbid conditions with the potential to compromise clinical status and adversely affect short-term survival. Long-term survival after hospital discharge was also reduced compared with the general population because of noncardiac co-morbidities.
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              Characteristics of electrocardiographic repolarization in acute myocardial infarction complicated by ventricular fibrillation

              Yoshifusa Aizawa, Marek Jastrzębski, Takuya Ozawa … (2012)
              Some de- and re-polarization patterns can reflect an increased risk of ventricular tachyarrhythmias. We studied whether some electrocardiographic (ECG) patterns are able to predict the development of ventricular fibrillation (VF) during acute myocardial infarction (MI).
              Article 0 comments Cited 10 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Nikos Papageorgiou: Role: Handling Editor
                Domenico D'Amario: Role: Editor
                Magdy Abdelhamid: Role: Editor
                Amir Aziz: Role: Editor
                Peysh A Patel: 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 2020
                Publication date (Electronic): 25 April 2020
                Publication date PMC-release: 25 April 2020
                Volume: 4
                Issue: 3
                Pages: 1-6
                Affiliations
                [y1 ] Department of Cardiology, Central Hospital of Central Finland , Keskussairaalantie 19, 40600 Jyväskylä, Finland
                [y2 ] Faculty of Medicine and Health Technology, Tampere University , Tampere, Finland
                [y3 ] Faculty of Sport and Health Sciences, University of Jyväskylä , Jyväskylä, Finland
                Author notes
                Corresponding author. Tel: +358 445504234, Email: tuukka.Joki@ 123456ksshp.fi
                Author information
                http://orcid.org/0000-0002-1303-1522
                http://orcid.org/0000-0002-3738-1586
                Article
                Publisher ID: ytaa076
                DOI: 10.1093/ehjcr/ytaa076
                PMC ID: 7319850
                SO-VID: fd6797ef-4f79-4c70-b8ef-a7b8b3744649
                Copyright © © The Author(s) 2020. 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 : 27 March 2019
                Date revision received : 30 April 2019
                Date accepted : 17 March 2020
                Page count
                Pages: 6
                Categories
                Subject: Case Reports
                Subject: Coronary heart disease (incl. Cardiac Intervention)

                Keywords: takotsubo,qrs-st-t waveform,high-risk ecg,st elevation,cardiogenic shock,case report
                Data availability:
                Keywords: takotsubo, qrs-st-t waveform, high-risk ecg, st elevation, cardiogenic shock, case report

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