A Case of Takotsubo Cardiomyopathy - Apical Ballooning Syndrome Mimicking Myocardial Infarction after Colonoscopy

Abstract

Purpose: Takotsubo cardiomyopathy is a well known cardiac phenomenon also known as a transient apical ballooning syndrome (ABS) which mimics acute coronary syndrome (ACS) in 1 to 2% cases leading to angiography. These events result in EKG changes, moderate elevations of cardiac enzymes, and left ventricular (LV) wall motion abnormalities. Preceding emotional and physical stressors often trigger ABS in up to two-thirds cases. One theory describes a toxic stunning of myocardium by a catecholamine surge during stress. Nearly 90% cases occur in postmenopausal women for unclear reasons. Here we make a first time case report of ABS after an elective surveillance colonoscopy. Case: A 56 y/o female with Crohn's disease in remission with no cardiac history, underwent her 5th surveillance colonoscopy under anesthesia with propofol as usual for prior difficulty tolerating sedation. The colonoscopy was uneventful and biopsies were taken to rule out dysplasia. In the recovery room, she complained of chest pressure, shortness of breath, and lightheadedness. She remained stable and was initiated on routine ACS treatment protocol. EKG showed nonspecific changes. Troponin was elevated to 0.70. Echocardiogram showed a hypokinetic septum consistent with LAD distribution wall motion abnormalities, and a mildly reduced LVEF 45%. Cardiac catheterization finds angiographically normal coronary arteries despite hypokinetic anterolateral and inferior wall motion. She was diagnosed with Takotsubo variant cardiomyopathy-ABS. After observation overnight, she was discharged home to follow up with her PCP. She denied any recent viral illness and did not report any recent psychosocial stressors. Discussion: Diagnosis of ABS is often made after the exclusion of ACS and myocarditis. These transient phenomenon are usually triggered by common emotional and physical stressors, including: a recent death in the family, personal conflict, a new diagnosis of illness, or after having non-cardiac surgery and procedures. One review reports the exacerbation of IBD as inducing a case of ABS. In our case, recovery from anesthesia was likely the stressor. There are no reliable predictable factors for the initial occurrence of ABS and these events are not preventable. Recurrence can occur in 3 to 11% cases reported. In patients with chronic disease who will need routine scheduled procedures, e.g., surveillance colonoscopies, it raises the question of whether they will have recurrent ABS. Overall prognosis is good with relatively quick recovery, similar to an age and gender matched population. Future studies should investigate and address the recurrence rate of ABS after repeat scheduled procedures.