HEART BREAKS TO BREATHE: RECURRENT TAKOTSUBO CARDIOMYOPATHY IN COPD EXACERBATION

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo syndrome (TTS) is defined as reversible stress-induced cardiomyopathy presenting as apical ballooning or mid-ventricular, basal, or focal wall motion abnormalities in the absence of coronary artery disease. It can be provoked by a stressful emotional situation or exposure to catecholamine surge. It’s a rare phenomenon to have a lung-heart axis leading to recurrent TTS. Here we present a rare case of recurrent TTS in the setting of COPD exacerbations also termed as bronchogenic TTS CASE PRESENTATION: 64 years old female with presented with dyspnea secondary to COPD exacerbation due to bacterial pneumonia was noted to have EKG changes with T-wave inversion, mild troponin elevation consistent with an ischemic lesion, elevated BNP 6103, followed by urgent cardiac catheterization noted to have non-significant coronary artery disease. Transthoracic echocardiogram (TTE) reported left ventricular ejection fraction (LVEF) of 25-29% with moderate sized apical, septal, posterior and anteroseptal wall motion abnormalities with akinesis of the segment consistent with TTS. Work up was negative for infective endocarditis, neurological and neuroendocrine tumor. She was treated with guideline-directed medical therapy (GDMT). LVEF normalized to 55%-59% in a follow up TTE. Seventeen months later she got readmitted with another episode of acute hypoxic hypercapnic respiratory failure requiring intubation with cardiac collapse. Patient had similar cardiac Catheterization findings but reduced LVEF of 30-34% consistent with TTS, again treated with GDMT, followed by a return of LVEF to normalization in a repeat TTE DISCUSSION: Recurrent TTS in the setting of COPD exacerbation is an extremely rare phenomenon exact cause of which remains unknown. Catecholamine surge causing microvascular dysfunction leading to cardiac stunning is a leading hypothesis. In COPD exacerbation adding beta 2 adrenergic agonists in management might potentiate worsening of cardiac stunning. Recurrent TTS has 19% overall risk for serious complications such as cardiogenic shock similar to acute coronary syndrome. The first step toward treatment is the removal of precipitating etiology like stress and in our case COPD exacerbation. ACE-inhibitors and angiotensin receptor blockers have a protective effect in reducing recurrent TTS while beta blockers have shown limited benefit. Even after recovery patient with TTS remains at high risk for electrical and mechanical complications CONCLUSIONS: Recurrent TTS in setting of COPD exacerbation has unknown incidence yet it highlights the intricate relationship of heart-lung axis. While TTS might be reversible, underlying pathophysiological insult might be permanent. We encourage physicians to not consider TTS as benign pathology and do every effort to reduce its recurrence. COPD exacerbation with TTS has worse prognosis with higher risk of hypoxic injury warranting improved COPD management. Reference #1: Rennyson, S. L., Parker, J. M., Symanski, J. D., & Littmann, L. (2010). Recurrent, severe, and rapidly reversible apical ballooning syndrome in status asthmaticus. Heart & Lung: The Journal of Acute and Critical Care, 39(6), 537-539. Reference #2: Manfredini, R., Fabbian, F., De Giorgi, A., Pala, M., Menegatti, A. M., Parisi, C., ... & Bossone, E. (2014). Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: a systematic review. World journal of cardiology, 6(5), 338. DISCLOSURES: No relevant relationships by Sreelatha Naik, source=Web Response No relevant relationships by Muhammad Pir, source=Web Response No relevant relationships by najam saqib, source=Web Response