TAKOSTSUBO CARDIOMYOPATHY AND CARDIOGENIC SHOCK INDUCED BY GI BLEEDING: A CASE REPORT

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo Cardiomyopathy (TC), is a syndrome manifested by transient regional systolic dyskinesia of the left ventricle, mimicking myocardial infarction, in the absence of attributable coronary artery disease. Many psychological and physical stresses have been associated with TC, including several gastrointestinal conditions (eg, recurrent vomiting, achalasia, and acute pancreatitis. To the best of our knowledge, there is only one reported case of TC following upper gastrointestinal bleeding (UGIB). We report a second case of stress-induced cardiomyopathy associated with UGIB. CASE PRESENTATION: An 80-year-old lady was admitted to the intensive care unit with UGIB, evident by hematemesis and acute hemoglobin drop. Esophagogastroduodenoscopy revealed 2 peptic ulcers, with no signs of active bleeding and no bleeding stigmata. Colonoscopy showed polyps. She was managed with proton pump inhibitors. Abdomen/Pelvis CT done here showed diverticulitis. The patient remained hemodynamically stable, required no transfusions and hemoglobin remained stable over 3 days from admission. However, the patient developed hemorrhagic shock due to sudden recurrent hematemesis and acute hemoglobin drop to 4.8. She was resuscitated with IVF and transfusion of 4 units of blood. The patient developed chest pain, EKG showed ST elevation in anterolateral leads. Cardiology consulted, left heart catheterization demonstrated tortuous but otherwise normal coronary arteries. Left ventriculogram was typical for catecholamine CM, Transthoracic echo showed an ejection fraction of 20%. She was diagnosed with Takotsubo cardiomyopathy, resulted in a cardiogenic shock. The patient was managed aggressively for cardiogenic shock. However, her condition deteriorated with multiorgan failure and died 24 hours later. DISCUSSION: Takotsubo CM syndrome presents a diagnostic challenge, given the wide spectrum of responsible stressors and the inability to differentiate from acute coronary syndrome without angiography. The exact pathophysiology is not completely understood, but it has been proposed that it is related to transient catecholamine surges, resulting in either multivessel epicardial spasm, microvascular coronary spasm, or possible direct myocardial injury. We hypothesize that our patient had excessive and acute catecholamine release, induced by the stress of acute UGIB and hemorrhagic shock, causing Takotsubo CM. Although most patients with stress cardiomyopathy recover, the risk of severe in-hospital complications is similar to that of acute coronary syndrome. CONCLUSIONS: This case further supports the association between UGIB and Takotsubo CM. It also highlights that stress-induced cardiomyopathy should be suspected in any patient with acute medical illness as there is a direct causal role of catecholamine in the pathophysiology of Takotsubo cardiomyopathy. Reference #1: Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. The New England journal of medicine. 2015;373(10):929-38. Reference #2: Awais M, Hernandez RA, Bach DS. Takotsubo cardiomyopathy triggered by severe vomiting. The American journal of medicine. 2008;121(12):e3-4. Reference #3: Bibiano Guillén C, García Sanz MT, Serantes Pombo FJ. Vázquez Lima MJ. Transient apical dyskinesia associated with upper digestive tract bleeding. Emergencias. 2008;20:291–296. DISCLOSURES: No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Rita Medrano Juarez, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by MENFIL ORELLANA-BARRIOS, source=Web Response No relevant relationships by Pablo Paz, source=Web Response No relevant relationships by Victor Test, source=Web Response