Obstructed Bowels Breaking Hearts: A Case Series of Takotsubo Cardiomyopathy in Patients With Small Bowel Obstruction

Abstract

Introduction: Stress cardiomyopathy is a transient systolic dysfunction in the absence of obstructive coronary artery disease. Takotsubo cardiomyopathy (TCM) is characterized by left ventricular apical akinesis, typically following intense emotional or physical stress. We report 2 cases of small bowel obstruction (SBO) precipitating TCM. Case 1: An 85 year-old female with HTN presented with diffuse abdominal pain associated with nausea and vomiting, diffuse abdominal tenderness on exam with no rebound or guarding. Electrocardiogram (ECG) showed sinus tachycardia. Troponin was 0.23 ng/mL and BNP was 239pg/mL. Abdominal CT revealed SBO with transition point in the anterior pelvis with associated pneumatosis intestinalis. She was placed on bowel rest. However, the troponin peaked at 8.75ng/mL and BNP rose to 3748pg/mL. She remained asymptomatic with no ECG changes. Transthoracic echocardiogram (TTE) showed severe mid-apical antero- and infero-septal hypokinesis with an ejection fraction (EF) of 20%. Angiogram revealed normal coronary arteries, with elevated left ventricular filling pressures. These findings were consistent with TCM. Case 2: An 83-year-old female with no cardiac history presented with a 2-day history of chest pain and dyspnea after a recent discharge from the hospital after being conservatively managed for SBO with transition point in the distal ileum. Physical exam was unremarkable. Troponin peaked at 0.34ng/mL with no ECG changes. TTE revealed an EF of 35% with akinetic apex, distal septum, and anterior apical wall segment-consistent with TCM. Both patients were started on a beta-blocker, ACE-inhibitor, and aspirin and they improved clinically. Discussion: TCM is a rare cardiac condition that classically presents with chest pain or dyspnea in post-menopausal women of East-Asian descent, following severe emotional or physiological stress. The pathogenesis involves diffuse catecholamine release leading to myocardial stunning. Both our patients were Caucasian post-menopausal women older than 80 years old, with no prior cardiac history who developed TCM in the setting of SBO managed with bowel rest/fluid resuscitation. Intravascular volume correction in the background of stunned myocardium may have propagated TCM due to fluid overload. Therefore, judicious fluid resuscitation coupled with more liberal pain control to minimize catecholamine release may help decrease the risk of this rare cardiac entity while managing elderly patients with SBO.