Stress-related Cardiomyopathy Research Articles

Pituitary apoplexy leading to stress-related cardiomyopathy and ischaemic stroke – A rare finding

Pituitary apoplexy leading to stress-related cardiomyopathy and ischaemic stroke – A rare finding

COVID-19 and cardiovascular complications: updates of emergency medicine.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and SARS-CoV-2 variants, has become a global pandemic resulting in significant morbidity and mortality. Severe cases of COVID-19 are characterized by hypoxemia, hyper-inflammation, cytokine storm in lung. Clinical studies have reported an association between COVID-19 and cardiovascular disease (CVD). Patients with CVD tend to develop severe symptoms and mortality if contracted COVID-19 with further elevations of cardiac injury biomarkers. Furthermore, COVID-19 itself can induce and promoted CVD development, including myocarditis, arrhythmia, acute coronary syndrome, cardiogenic shock, and venous thromboembolism. Although the direct etiology of SARS-CoV-2 induced cardiac injury remains unknown and under-investigated, it is suspected that it is related to myocarditis, cytokine-mediated injury, microvascular injury, and stress-related cardiomyopathy. Despite vaccinations having provided the most effective approach to reducing mortality overall, an adapted treatment paradigm and regular monitoring of cardiac injury biomarkers is critical for improving outcomes in vulnerable populations at risk for severe COVID-19. In this review, we focus on the latest progress in clinic and research on the cardiovascular complications of COVID-19 and provide a perspective of treating cardiac complications deriving from COVID-19 in Emergency Medicine.

Cerebral arterial gas embolism and neurogenic stunned myocardium in a previously healthy freediver

Cardiomyopathy is a known but rare sequelae of diving-related cerebral arterial gas embolism (CAGE). In previously reported cases, patient findings have been consistent with takotsubo cardiomyopathy (TCM) per the revised Mayo Clinic’s diagnostic criteria. A lesser-known variant of stress-related cardiomyopathy is neurogenic stunned myocardium (NSM), which occurs after a neurological event such as subarachnoid hemorrhage and typically presents in younger patients. Presentation tends to differ slightly to TCM with non-specific left ventricular dysfunction and T wave inversions. This case adds to the rare numbers of reported cardiomyopathy from diving and is the first reported case of suspected NSM associated with CAGE.

Takotsubo cardiomyopathy: a rare neuro-cardiological entity with its challenges

Takotsubo cardiomyopathy (TCM) is a type of neuro cardiological disorder that evince as acute but reversible heart failure. On the whole, it occurs by stress-related cardiomyopathy which illustrates the heart-brain connection. It was first discovered in 1990, by a Japanese cardiovascular specialist. That's the beginning of this heart disease in gaining worldwide acceptance as an independent disease entity. TCM is entirely different from acute myocardial infarction as usually occurs in postmenopausal elderly women due to emotional or physical stress. It is characterized by transient hypokinesis of the left ventricular apex. However, there are complications too that need to be addressed. Some reports of serious TCM include hypotension, thrombosis involving LV apex, heart failure, and ventricular rupture. It is also suggested that coronary spasms, myocarditis, and coronary microvascular dysfunction might contribute to the pathogenesis of TCM. But in total, its pathophysiology is unclear. In this review article, we review the pathogenesis and etiology of this rare complex disorder along with its clinical features, findings, challenges in diagnosis, and a comprehensive discussion on the same.

Takotsubo syndrome in New Zealand: current knowledge and future challenges.

Takotsubo syndrome (TS), also known as apical ballooning syndrome, is a transient stress-related cardiomyopathy characterised by acute but reversible left ventricular dysfunction. The condition tends to occur in postmenopausal women after a stressful event. At presentation, TS typically mimics acute myocardial infarction (MI) and the incidence of TS has been increasing worldwide. This is likely a consequence of an improved awareness of the existence of this syndrome and easier access to early echocardiography and coronary angiography. However, its aetiology remains poorly understood and it is probably still underdiagnosed. Similar to other countries, TS is being increasingly recognised in New Zealand. In this review, we discuss the demographics, clinical features and outcomes of patients with TS in New Zealand. Doing so informs us not only of the pattern of disease in New Zealand but it also provides insights into the condition itself.

VENTRICULAR TACHYCARDIA ELECTRICAL STORM AS A MANIFESTATION OF REVERSE VARIANT TAKOTSUBO CARDIOMYOPATHY

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Takotsubo cardiomyopathy (TTC) is a syndrome with transient systolic dysfunction in the absence of obstructive coronary arteries with the reverse variant being a rare entity (1,2). Here, we report a case of reverse TTC presenting with monomorphic ventricular tachycardia (VT) electrical storm. CASE PRESENTATION: A 76 year-old female with a history of recently diagnosed Stage IIIB lung adenocarcinoma presented to the emergency room with shortness of breath. On presentation, her vitals were: BP 134/82, pulse 120 beats/min, SPO2 93% in room air. Initial EKG showed no significant ST-T wave changes and normal QTc. Labs were significant for uptrending troponin from 0.8 to 4 ng/mL. Aspirin and heparin infusion were started for possible NSTEMI with a plan for catheterization. That night, she developed unstable, monomorphic VT (Figure 1). Consecutive synchronized cardioversions and amiodarone boluses were unsuccessful. Patient's VT terminated with repeated boluses of lidocaine followed by lidocaine infusion. Stat echocardiogram showed an ejection fraction of 25-30% with anterior and anteroseptal hypokinesis. Emergency cardiac catheterization revealed non-obstructive coronary arteries with akinesis of the basal wall and sparing of the apex suggesting reverse TTC (Figure 2). She was transferred to the critical care unit where she was transitioned to amiodarone infusion with no further VT episodes and was initiated on guideline-directed medical therapy. DISCUSSION: TTC usually occurs due to a surge of catecholamines leading to myocardial damage. The typical variant demonstrates apical ballooning with basal hypokinesis. Rarely, there may be basal hypokinesis with apical sparing, the reverse variant (2). Arrhythmias are uncommon in typical TTC and prior studies have indicated a low incidence of VT (3.2%) (3). There is sparse literature describing the incidence of VT or VT storm in the reverse variant. One of the postulated mechanisms for VT in TTC is transient QTc prolongation, however this remains controversial. (3). The incidence of arrhythmias is thought to be more prevalent during the acute phase leading to increased in-hospital mortality (3). Additionally, it remains uncertain whether prophylactic antiarrhythmics are beneficial in this population subset. Further studies are warranted to understand which variants of TTC develop critical arrhythmias. CONCLUSIONS: Reverse variant is a rare subset of TTC which can present with critical arrhythmias including VT storm. Awareness of this manifestation can help clinicians with early recognition and management of these critical arrhythmias. REFERENCE #1: Bybee KA., Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118(4):397–409. Doi: 10.1161/CIRCULATIONAHA.106.677625. REFERENCE #2: Templin C., Ghadri JR., Diekmann J., et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. New England Journal of Medicine 2015;373(10):929–38. Doi: 10.1056/NEJMoa1406761. REFERENCE #3: Pant S, Deshmukh A, Mehta K, et al. Burden of arrhythmias in patients with Takotsubo Cardiomyopathy (Apical Ballooning Syndrome). International Journal of Cardiology [Internet] 2013;170(1):64–68. Available from: https://doi.org/10.1016/j.ijcard.2013.10.041 DISCLOSURES: No relevant relationships by Anneka Hutton, source=Web Response No relevant relationships by Gagan Neupane, source=Web Response No relevant relationships by Enoemem Okpokpo, source=Web Response No relevant relationships by Bharadwaj Satyavolu, source=Web Response No relevant relationships by Raksha Sharma, source=Web Response No relevant relationships by Tracey Topacio, source=Web Response

Case report: takotsubo cardiomyopathy after transcatheter aortic valve-in-valve replacement.

Background Transcatheter aortic valve implantation (TAVI) has become a first-line therapeutic option in patients with severe, symptomatic aortic stenosis at increased surgical risk. Despite its success, the TAVI procedure has been associated with acute life-threatening complications as myocardial infarction secondary to periprocedural coronary occlusion, annular rupture, or vascular injury.Case summary A 79-year-old woman with a dysfunctional bioprosthetic valve following previous surgical valve replacement was hospitalized in our institution to perform a Valve-in-Valve Transcatheter Aortic Valve Replacement (ViV TAVR). Shortly after the implantation of an Evolut R valve (without complication), left ventricle dysfunction with apical akinesia and basal hyperkinesia was identified during bedside transthoracic echocardiography, in spite of a good prosthesis implantation and function. A concomitant Troponin elevation was noted, and the day-after resting electrocardiogram showed a lateral T-wave inversion. Coronary computed tomography angiography showed no coronary stenosis or occlusion, cardiac magnetic resonance imaging showed no necrosis or fibrosis, and no argument for myocarditis. The patient remained asymptomatic during her hospital stay, and the aforementioned anomalies spontaneously regressed after an in-hospital 2-week surveillance. In the presence of these transient anomalies and after ruling out myocardial infarction and myocarditis, post-procedural stress cardiomyopathy (takotsubo) was diagnosed.Discussion Post-TAVR stress-related cardiomyopathy seems to be an extremely rare entity. To our knowledge, this is the first case of a takotsubo cardiomyopathy after ViV TAVR. Though the association between the two seems likely to be causal, no clear physiopathological explanation can be formulated.

Peri-Operative Stress-Related Cardiomyopathy Following Paediatric Liver Transplant– A Case Series

Perioperative stress-related cardiomyopathy has been extensively described in adults undergoing liver transplantation to be associated with adverse outcomes. Reports of stress-related cardiomyopathy among children is scarce and is usually associated with better clinical outcomes compared to adults. We describe 3 instances of pediatric liver transplantation who developed stress-related cardiomyopathy during the perioperative period and had adverse clinical outcomes. Keywords: Liver Transplantation; Stress-related cardiomyopathy; Heart failure.

Reverse takotsubo cardiomyopathy in fulminant COVID-19 associated with cytokine release syndrome and resolution following therapeutic plasma exchange: a case-report

BackgroundFulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE).Case presentationA 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition.ConclusionStress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.

Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome.

Coronavirus disease 2019 (COVID-19) is a rapidly expanding global pandemic caused by severe acute respiratory syndrome coronavirus 2, resulting in significant morbidity and mortality. A substantial minority of patients hospitalized develop an acute COVID-19 cardiovascular syndrome, which can manifest with a variety of clinical presentations but often presents as an acute cardiac injury with cardiomyopathy, ventricular arrhythmias, and hemodynamic instability in the absence of obstructive coronary artery disease. The cause of this injury is uncertain but is suspected to be related to myocarditis, microvascular injury, systemic cytokine-mediated injury, or stress-related cardiomyopathy. Although histologically unproven, severe acute respiratory syndrome coronavirus 2 has the potential to directly replicate within cardiomyocytes and pericytes, leading to viral myocarditis. Systemically elevated cytokines are also known to be cardiotoxic and have the potential to result in profound myocardial injury. Prior experience with severe acute respiratory syndrome coronavirus 1 has helped expedite the evaluation of several promising therapies, including antiviral agents, interleukin-6 inhibitors, and convalescent serum. Management of acute COVID-19 cardiovascular syndrome should involve a multidisciplinary team including intensive care specialists, infectious disease specialists, and cardiologists. Priorities for managing acute COVID-19 cardiovascular syndrome include balancing the goals of minimizing healthcare staff exposure for testing that will not change clinical management with early recognition of the syndrome at a time point at which intervention may be most effective. This article aims to review the best available data on acute COVID-19 cardiovascular syndrome epidemiology, pathogenesis, diagnosis, and treatment. From these data, we propose a surveillance, diagnostic, and management strategy that balances potential patient risks and healthcare staff exposure with improvement in meaningful clinical outcomes.

(Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance.

Angina pectoris is a chest discomfort caused by myocardial ischaemia, and it is classified as ‘typical’ or ‘atypical’ if specific features are present. Unfortunately, there is a heterogeneous list of cardiac diseases characterized by this symptom as onset sign. Mostly, angina is due to significant epicardial coronary artery stenosis, which causes inadequate oxygen supply increase after raised myocardial oxygen demand. In the absence of significant epicardial stenoses, another potential cause of angina is microvascular dysfunction, related to inadequate response of resistance coronary vessels to vasodilator stimuli. The unique capability of cardiovascular magnetic resonance (CMR) in providing extremely detailed morphological and functional information, along with precise stress perfusion defects and wall motion abnormalities depiction, translates it into the test with one of the best diagnostic performance and prognostic stratification among non-invasive cardiac imaging modality. Moreover, CMR is also extremely accurate in detecting non-ischaemic cardiac causes of chest pain (such as myocardial and pericardial inflammation, or stress-related cardiomyopathy), and is very useful in helping physicians to correctly approach patients affected by chest pain.

QT延長症候群にカテコラミン心筋症を合併しTorsades de Pointesが誘発された1例

QT延長症候群にカテコラミン心筋症を合併しTorsades de Pointesが誘発された1例

MON-395 Takotsubo Cardiomyopathy And Metanephrines

Takotsubo (stress) cardiomyopathy, is defined by transient left ventricular systolic dysfunction without epicardial coronary disease. Case report A 50-year-old man presented with headache and visual disturbance with no past medical history of note. He had recently separated from his wife and children had moved out of the family home. He was very depressed and stressed due to this. His blood pressure was 180/110 mmHg and bloods showed creatinine of 442 umol/L; potassium 3.6 mmol/L; eGFR 13 mL/min/1.73m2. Renal Ultrasound and virology/immunology screen were normal. Echocardiogram showed severe left ventricular (LV) dysfunction with an ejection fraction (EF) of 35% with LV hypertrophy. Plasma normetanephrine and metanephrine levels were elevated at 4805 pmol/L (120-1180) and 819 (80 - 510) respectively. Urine 24 hour metanephrines showed elevated urine normetanephrine output of 7.62 umol/24 h (0-3.3) and mildly elevated urine metanephrine output of 1.31 umol/24 h (0-1.2). CT Adrenals showed a low density 1 cm left adenoma with benign washout characteristics. He was started on alphablocker and amlodipine with good effect. 2 months later, repeat Echo normalised with LVEF of 55-60%. Repeat urine metanephrines were normal. Plasma normetanephrine dropped to 1253 pmol/L and plasma metanephrine to 338 pmol/L. I123 MIBG (meta-iodo-benzyl guanidine) SPECT-CT normal uptake. Overnight dexamethasone suppression test and aldosterone renin ratio were normal. Discussion: This 50-year-old gentleman under considerable emotional stress, presented with severe hypertension and severely impaired LV function. On follow-up, the LV impairment returned to normal and the initially elevated plasma and urine metanephrines normalised. The adrenal tumour was an incidental benign non-secretory tumour. There are several reports of phaeochromocytomas presenting with stress cardiomyopathy, however stress cardiomyopathy mimicking phaeochromocytoma is not well reported. A study by Wittstein et al reported significant elevations of metanephrines in patients with stress cardiomyopathy. However this has not been universally accepted and subsequent studies have not fully replicated this. As per a 2017 metanalysis by Darr et al the sensitivity and specificity of plasma metanephrines for phaeochromocytoma/paraganglioma is 94% and 93% and for urinary metanephrines, 91% and 93%. Critical illness can elevate plasma and urinary metanephrines. In this case, the patient did have severe hypertension, but was not critically ill. The current case report provides a cautionary example that the specificity of plasma and urinary metanephrines in the diagnosis of phaeochromocytoma and paraganglioma may be impaired in people presenting with stress related cardiomyopathy. This is especially true in this case given that this patient also had an incidental adrenal tumour.

SHORT TERM RECURRENCE RATE OF TAKOTSUBO CARDIOMYOPATHY

Takotsubo cardiomyopathy is a stress related cardiomyopathy. Although considered reversible, many reports have described varying recurrence rate of Takotsubo cardiomyopathy. We aimed to study the short-term recurrence of Takotsubo cardiomyopathy using the Nationwide Readmission database (NRD) for

AN UNCOMMON PRESENTATION, AN UNUSUAL ASSOCIATION: A STROKE, DEMYELINATING DISORDER, OR AN INFECTION?

SESSION TITLE: Critical Care 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Rhombencephalitis, a rare manifestation of listeria is seen in immunocompetent young adults. Reverse takotsubo(r-TTC) is an unusual association described with listeria rhombencephalitis (LRE). CASE PRESENTATION: A 42-year-old Brazilian female with medical history of migraine presented with headache, nausea, vomiting, photophobia, left facial numbness and fevers for four days. Physical findings remarkable for bilateral horizontal nystagmus, left facial numbness and left upper extremity dysdiadochokinesia. Multiple lower cranial nerves were involved subsequently leading to compromised airway, hypoxia, orotracheal intubation and mechanical ventilation. She was treated with ceftriaxone, vancomycin and acyclovir initially. Later ampicillin and double strength trimethoprim/sulfamethoxazole (DS-TMP/SMZ) were added based on the magnetic resonance imaging (MRI) brain results. MRI revealed a ring-enhancing central T1 hypointense lesion in the left cerebral peduncle with extension to posterolateral pons and medulla suspicious for LRE. Chest computerized tomography (CT) was suggestive of pulmonary edema. Echocardiography revealed left ventricular global hypokinesis sparing the apex suggestive of r-TTC. Given her worsening hemiparesis and altered mentation, dexamethasone was initiated on day 4 and continued for seven days. Blood and cerebrospinal fluid culture (CSF) were negative. However, CSF polymerase chain reaction (PCR) confirmed the diagnosis of listeria. Subsequently all antimicrobials were discontinued except ampicillin and DS-TMP/SMZ. A gradual recovery of mentation and hemiparesis was evident. Echocardiography on day 9 showed improvement in the ejection fraction (50-55%). She underwent tracheostomy and subsequently weaned from mechanical ventilation. She was then discharged to acute rehabilitation where she completed 6 weeks of DS-TMP/SMZ and ampicillin. DISCUSSION: Mortality with LRE is high and approaches 51%. CSF culture is the gold standard for diagnosis. Real time PCR, a reliable diagnostic modality is relatively new but not widely available. MRI brain is the preferred radiological investigation. Prognosis depends on timely diagnosis and therapy. rTTC, a form of stress-induced myocardial injury is reversible with recovery from the inciting illness. The role of dexamethasone is controversial and lacks supporting evidence except as reported in case series. In retrospect, corticosteroid was probably beneficial in our patient. Increased penetration into the meninges and bactericidal properties of the ampicillin plus DS-TMP/SMZ combination is an effective therapy for LRE. CONCLUSIONS: LRE is a life-threatening illness and warrants early diagnosis and management in order prevent adverse outcomes and minimize morbidity. Stress related cardiomyopathy, a well-known entity needs prompt identification and supportive therapy. Reference #1: Armstrong RW, Fung PC. Brainstem encephalitis (rhombencephalitis) due to Listeria monocytogenes: case report and review. Clinical Infectious Diseases. The University of Chicago Press; 1993;16(5):689–702. Reference #2: Ruggieri F, Cerri M, Beretta L. Infective rhomboencephalitis and inverted Takotsubo: neurogenic-stunned myocardium or myocarditis? The American journal of emergency medicine. Elsevier; 2014;32(2):191–e1. Reference #3: Merle-Melet M, Dossou-Gbete L, Maurer P, Meyer P, Lozniewski A, Kuntzburger O, et al. Is amoxicillin-cotrimoxazole the most appropriate antibiotic regimen for listeria meningoencephalitis? Review of 22 cases and the literature. Journal of Infection. Elsevier; 1996;33(2):79–85. DISCLOSURES: No relevant relationships by Ricardo de la Villa, source=Web Response No relevant relationships by Alejandro Diaz Chavez, source=Web Response No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Sathish Pondaiah, source=Web Response No relevant relationships by Christine Stavropoulos, source=Web Response

Healthy hearts at hectic pace: From daily life stress to abnormal cardiomyocyte function and arrhythmias.

The hectic pace of contemporary life is a major source of acute and chronic stress, which may have a deleterious impact on body health . In the field of cardiovascular disease, acute emotional stress has been associated with coronary spasm and Takotsubo cardiomyopathy, whereas the manifestations of chronic stress have been overlooked, and most underlying pathophysiology remains to be elucidated. Chronic stress affects the neuronal circuitry composed of cortico-limbic structures and the nuclei regulating autonomic function, eliciting a sympatho-vagal imbalance, characterised by adrenergic activation and vagal withdrawal. Sympathetic terminals are connected to cardiomyocytes in a quasi-synaptic way, producing the so called 'neuro-cardiac junction'. During chronic stress, norepinephrine release is increased, leading to overstimulation of cardiomyocytes via β1-adrenergic receptors, influencing mainly calcium dynamics, and β2-adrenergic receptors, which control housekeeping functions. The circadian rhythm of cardiomyocytes is then impaired, with elongation of the catabolic ('light' phase) over the anabolic ('nocturnal') phase. This leads to a depletion of cell energy storage, and a decreased turnover of cell constituents. Even cell interactions are affected, as coupling between cardiomyocytes decreases while coupling between cardiomyocytes and fibroblasts increases. The ultimate results are changes in the shape and velocity of action potential, fibroblast activation and deposition of extracellular matrix. These alterations may predispose to arrhythmias and may favour the development of a stress-related cardiomyopathy. A better comprehension of this cascade of events may allow us to identify screening protocols and treatment strategies (meditation, yoga, physical activity, psychological assistance, β-blockers) to prevent or relieve ongoing cardiac damage.

Prevalence and risk factors for postoperative stress-related cardiomyopathy in adults.

Stress-related cardiomyopathy can develop during the postoperative period due to surgery-related stress factors. However, the prevalence and risk factors for this condition are not yet known. During a retrospective, observational study, patients older than 19 years who underwent procedures from January 2011 to December 2015 at a tertiary hospital were included. The main aim was to identify the prevalence and related risk factors for postoperative stress-related cardiomyopathy. To estimate the incidence per risk factor, univariate and multivariate Poisson regression analyses were performed. During the 5-year period, 95,840 patients older than 19 years underwent 125,314 procedures, and the prevalence of postoperative stress-related cardiomyopathy was 17.74 per 100,000 (95% confidence interval, 9.31–26.17), with an in-hospital mortality of 23.5%. As a result, three risk factors were significantly associated: preoperative American Society of Anesthesiologists classification (incidence rate ratio, 5.901 for American Society of Anesthesiologists class 1–2 [ref] versus 3–6; 95% confidence interval,1.289–27.002; P = 0.022); preoperative body mass index (incidence rate ratio, 1.247 for increases of 18.5 [ref] to 30; 95% confidence interval, 1.067–1.458; P = 0.006); and preoperative serum sodium (incidence rate ratio, 0.830 for each increase of 10 mmol/L from 130; 95% confidence interval, 0.731–0.942; P = 0.004). The incidence rate ratio for age for each increase of 10 years from 50 years was 1.057, but it was not statistically significant (P = 0.064). Our study found that the prevalence of postoperative stress-related cardiomyopathy was 17.74 patients per 100,000 adult patients over the course of 5 years, with four cases of in-hospital mortality. Factors that increased the risk of postoperative stress-related cardiomyopathy included higher American Society of Anesthesiologists class (≥3), preoperative hyponatremia, and higher preoperative body mass index.

Takotsubo Cardiomyopathy-Associated Ventricular Standstill in a Peripartum Patient

Takotsubo cardiomyopathy (tako tsubo translates to “octopus pot” in Japanese) is a stress-related cardiomyopathy in which weakening of the cardiac musculature leads to left ventricular failure with apical akinesis and ballooning. Takotsubo Cardiomyopathy is hypothesized to be triggered by emotional stress leading to a catecholamine surge and symptoms that can mimic acute coronary syndrome. It has been well documented that Takotsubo cardiomyopathy can lead to several fatal ventricular arrhythmias. What we describe here is the first reported case of symptomatic ventricular standstill in Takotsubo Cardiomyopathy. We noted persistent failure of the conduction system leading to degeneration of the circuit and ventricular standstill six (6) days after initial presentation. It should be noted that in Takotsubo cardiomyopathy, symptoms typically resolve in approximately 24-48 hours. We suspect that ventricular ballooning impairs the cardiac conduction system such that the AV node and His-Purkinje system can no longer effectively communicate electrical impulses to the remainder of the electrical circuit. In our case, a previously healthy 24-year-old, six-month-postpartum, Egyptian female presented to the ED with complaints consistent with acute coronary syndrome. Multiple syncopal episodes were witnessed and a new right bundle branch block was noted with intermittent complete atrioventricular blocks progressing to a ventricular standstill. Cardiac catheterization and serology was used to rule out other underlying etiologies of this patient’s cardiac symptoms. An emergent transvenous pacemaker was then inserted due to the instability of the patient’s clinical condition leading to placement of a dual-chambered pacemaker. The patient also expressed concerns for returning to breastfeeding her infant son during the course of her hospital stay. During follow-up, the patient has reported no further syncopal episodes and has had no complications since pacemaker placement. Our findings highlight the medical management for prolonged ventricular standstill of the cardiac conduction system in a symptomatic postpartum patient with Takotsubo cardiomyopathy.

Contrast Media-Induced Anaphylaxis Causing a Stress-Related Cardiomyopathy Post Percutaneous Coronary Intervention: Case Report.

Anaphylaxis is a sudden-onset, severe hypersensitivity reaction that can be potentially fatal. It can often transition to refractory hemodynamic instability, eventually resulting in death. Stress-related cardiomyopathies (SRCs) have multifactorial etiologies, including being linked to excessive catecholamine release in periods of intense stress. This novel case report recounts a SRC caused by contrast-induced anaphylaxis within 1 hour post percutaneous coronary intervention. Both acutely life-threatening conditions may occur simultaneously and are implicated with devastating complications. Further research is required to understand this cardiac-neuroaxis interplay in SRC to identify risk factors and develop management strategies.

Stress-related takotsubo cardiomyopathy despite “optimal” medical therapy

Stress-related takotsubo cardiomyopathy despite “optimal” medical therapy