Open a senescent's heart and look into his brain to find the Takotsubo trigger!

Abstract

We would like to thank for the very interesting comment on our case report, and fully agree that in the vast majority of patients with TTC can find the trigger. Our patient did not indicate that pain was preceded by mental stress or physical exertion. However, as she was 98 years old, her memories of the World War II returned, even several times a day. In our registry, about 10% of cases were not able to identify a specific triggering factor. In another registry it was possible only in 57% patients.[1] If the neurological diseases are concerned, the patient did not have such problems in the anamnesis. She did not have any symptoms at admission and during hospitalization, which indicating subarachnoid bleeding, epilepsy or stroke. Additionally, there were no abnormalities in the neurological physical examination. Because of hypotension, the patient received an infusion of dopamine in the regional hospital before transporting to our hospital. Dopamine was discontinued during coronary angiography. We would like to emphasize that intraventricular pressure gradient as well as left ventricular outflow tract obstruction was absent in this patient; and the first echocardiography exam was performed after 15 min from the admission to the cardiac intensive care unit. Fortunately, despite the risk of hemodynamic deterioration,[2] the patient was stable in further observation. The patient had not received beta-adrenolytic before occurrence of TTC because beta adrenolytic administration did not protect against TTC in predisposed patients in our observation.[3] The patient received dopamine during transport to our clinic as we mentioned above, aspirin, clopidogrel and unfractioned heparin, were discontinued after coronary angiography. She also received diuretic, statins and low molecular weight heparin until disappearance of wall motion abnormalities. Because of the trends to bradycardia she did not receive β-adrenaline. At discharge the patient received β-adrenaline, diuretic and statins. In the comment, there are the questions about creatinine clearance at admission and at discharge and on the liver function parameters of the patient. As we mentioned, the patient suffered from third stage of chronic kidney disease. The creatinine clearance at admission was 31 mL/min per 1.73 m2 and at discharge 30 mL/min per 1.73 m2. If the liver parameters are concerned aspartate aminotransferase was 51 U/L, alanine transaminase 34 U/L. The coagulation parameters were normal. The reason to implant dual chamber pacemaker was symptomatic bradycardia with pauses because of sinus node disease. The patient did not suffer from atrioventricular block. In our opinion, bradycardia was not the complication of TTC.