Takotsubo Cardiomyopathy In Patient Research Articles

Incidence of Takotsubo cardiomyopathy in patients with acute coronary syndrome: a single center retrospective analysis

BackgroundTakotsubo cardiomyopathy (TTC) is an acute and usually reversible condition that often mimics the course of acute coronary syndrome (ACS), making it particularly challenging to differentiate, especially in the initial phases. In this study, we retrospectively analyzed the incidence, clinical course, examination results, and in-hospital mortality of TTC in patients with ACS hospitalized at our cardiology center from January 2018 to October 2023.ResultsDuring the study period, a total of 3835 selective coronary angiograms were urgently performed at our facility, with a diagnosis of TTC established in 52 (1.35%) patients, the majority of whom were females—48 (93%), with an average age of 64.2 ± 10.2 years. Stress-induced mechanisms were identified in 36 (69%) patients. The most common symptom was chest pain (86.5%). Electrocardiographic changes primarily included ST-segment elevations (61.6%) and depressions (14%). The average left ventricular ejection fraction was 45.1 ± 8.3 (33–57%), typically with an echocardiographic pattern of apical ballooning dysfunction followed by midventricular dyskinesia. In-hospital mortality was zero.ConclusionsTTC is a reversible condition with a low incidence of complications. Its occurrence in our patient cohort is lower compared to international registries. However, as demonstrated in this study, it is associated with significant in-hospital morbidity.

Takotsubo Cardiomyopathy in Patients with Myasthenia Gravis, 2023

Takotsubo Cardiomyopathy in Patients with Myasthenia Gravis, 2023

Takotsubo Cardiomyopathy in Patients with Cancer

Takotsubo cardiomyopathy (TC) in cancer patients has been predominantly noted as a cardiotoxic complication of oncologic therapy or secondary to catecholamine overload in specific tumors such as pheochromocytomas. The underlying pathophysiological mechanisms that lead to TC are not entirely understood. The diagnosis of TC can be challenging and may be neglected during cancer treatment, given the wide range of cardiotoxic effects of antineoplastic therapies. However, TC in oncology exists more often than formerly assumed, and it should be included [...]

Abstract 15587: Combined Spontaneous Coronary Artery Dissection and Takotsubo Cardiomyopathy in a Patient With Chest Pain

Introduction: Spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TCM) are uncommon non-atherosclerotic causes of acute myocardial infarction (MI). These patients have fewer cardiovascular risk factors than those who have atherosclerotic MI. Clinical presentation in both subsets of MI is identical due to which diagnosis requires echocardiography and coronary angiography. The incidence of TCM and SCAD in the same patient is scarce and only documented in a few case reports and a case series. Case presentation: We present the case of a 50-year-old female with a past medical history of hypertension, hypothyroidism, and median arcuate ligament syndrome. She presented to the emergency department with intermittent chest pain radiating to her upper back, both arms, and her left jaw and it was associated with nausea. On examination, she was tachycardic, tachypneic, and anxious. She had normal heart sounds with no chest tenderness. Her EKG demonstrated ST-elevations in leads II, III, aVF, V4, V5, and V6. Laboratory results showed elevated high sensitivity troponin of 11,949 (pg/ml) and 30,256 (pg/ml) four hours later. The patient underwent emergent coronary angiography, which revealed diffuse tubular stenosis suggestive of type 2 SCAD in the second obtuse marginal artery but otherwise normal coronary anatomy with minimal stenosis. Left ventriculogram showed antero-apical, apical, and infero-apical hypokinesis and basal hyperkinesis, suggestive of Takotsubo cardiomyopathy. Transthoracic echocardiogram (TTE) completed 48 hours later demonstrated improved contractility with lateral wall hypokinesis. The patient was managed conservatively with medical management, and she was discharged on aspirin, plavix, carvedilol, isosorbide mononitrate, and losartan. Conclusions: SCAD and TCM are uncommon diagnoses that can rarely co-exist. TTE can help diagnose TCM in patients with chest pain and elevated cardiac biomarkers. Non-occlusive coronary vasculature is a diagnostic criterion per the proposed Mayo Clinic criteria. This case highlights the importance of coronary angiography in patients with TCM for assessment of potential co-existent coronary vascular pathology; SCAD in our case.

Abstract 13369: Takotsubo Cardiomyopathy Following Electroconvulsive Therapy

Case Presentation: A 71-year-old woman presented to our institution for treatment-refractory depression requiring electroconvulsive therapy (ECT). She underwent a transthoracic echocardiogram (TTE) during a pre-ECT evaluation, which demonstrated no regional wall motion abnormalities and a left ventricular ejection fraction (LVEF) of 60 - 65%. The patient subsequently underwent ECT. During the procedure, sinus tachycardia with associated ST-segment changes were noted on telemetry. Esmolol was administered with subsequent improvement in her tachycardia, however ST-segment changes persisted. A twelve-lead electrocardiogram was obtained and was notable for new T-wave inversions in leads V1-V4 and Q-waves in leads III and aVF. However, STEMI criteria was not met. A TTE obtained shortly after her ECT demonstrated ballooning of the LV apex and an LVEF of 35%, consistent with takotsubo cardiomyopathy. Laboratory evaluation was notable for a high sensitivity troponin peak of 130 ng/L and a brain natriuretic peptide level of 746 pg/mL. Cardiac catheterization was not performed as the patient had a negative stress test prior to admission. The patient’s symptoms improved over the next two days, and she was discharged with close outpatient follow-up. Discussion: Takotsubo cardiomyopathy occurs following physical or psychological stress. Greater than half of patients with takotsubo cardiomyopathy have neurologic or psychiatric disorders. Takotsubo cardiomyopathy is an increasingly recognized serious complication of ECT and can be seen in post-menopausal women with depression. The introduction of beta blocker therapy has been used to prevent recurrent episodes of post-ECT takotsubo cardiomyopathy. Despite this, there are reports of post-ECT takotsubo cardiomyopathy in patients on chronic beta blocker therapy. Thus, the risks and benefits of proceeding with additional ECT treatments must be weighed after an initial episode of takotsubo cardiomyopathy.

The Incidence of Takotsubo Cardiomyopathy in Patients with Intracerebral Hemorrhage: A US Nationwide Study.

Takotsubo cardiomyopathy (TC) is a commonly observed complication among patients with intracerebral hemorrhage (ICH); however, the incidence of TC in patients with ICH have not been investigated yet. The goal of this study was to examine the incidence of TC in ICH and identify its risk factors, incidence rate, and outcomes of TC in patients with ICH in a US nationwide scale. Data for patients with ICH between the years of 2015 and 2018 were extracted from the Nationwide Inpatient Sample and stratified based on the diagnosis of TC. Our results showed that the incidence rate of TC in ICH discharges was 0.27% (95% confidence interval [CI] 0.24-0.31). The mean age of patients with ICH developing TC was 66.28years ± 17.11. There were significantly more women in the TC group, with an odds ratio (OR) of 3.65 (95% CI 2.63-5.05). Acute myocardial infarction (OR 7.91, 95% CI 5.80-10.80) was significantly higher in the TC group. The mortality rate of patients with ICH who had TC was significantly higher (33.48%, p < 0.0001). Length of stay (mean days; 15.72 ± 13.56 vs. 9.56 ± 14.10, p < 0.0001) significantly increased in patients with ICH who had TC. Patients with intraventricular ICH (OR 2.46, 95% CI 1.88-3.22) had the highest odds of TC. Takotsubo cardiomyopathy is associated with a higher mortality, longer hospitalization period, and more acute myocardial infarctions in patients with ICH. It is illustrated that intraventricular ICH is associated with higher odds of TC.

Takotsubo cardiomyopathy in patients suffering from acute non-traumatic subarachnoid hemorrhage—A single center follow-up study

Takotsubo cardiomyopathy (TTC) is an important complication of subarachnoid hemorrhage (SAH), that may delay surgical or endovascular treatment and may influence patient outcome. This prospective follow-up study intended to collect data on the prevalence, severity, influencing factors and long-term outcome of TTC in patients suffering from non-traumatic SAH. Consecutive patients admitted with the diagnosis of non-traumatic SAH were included. Intitial assessment consisted of cranial CT, Hunt-Hess, Fisher and WFNS scoring, 12-lead ECG, transthoracic echocardiography (TTE), transcranial duplex sonography and collecting laboratory parameters (CK, CK-MB, cardiac troponin T, NT-proBNP and urine metanephrine and normetanephrine). Diagnosis of TTC was based on modified Mayo criteria. TTC patients were dichotomized to mild and severe forms. Follow-up of TTE, Glasgow Outcome Scale assessment, Barthel's and Karnofsky scoring occurred on days 30 and 180. One hundred thirty six patients were included. The incidence of TTC in the entire cohort was 28.7%; of them, 20.6% and 8.1% were mild and severe, respectively. TTC was more frequent in females (30/39; 77%) than in males (9/39; 23%) and was more severe. The occurrence of TTC was related to mFisher scores and WFNS scores. Although the severity of TTC was related to mFisher score, Hunt-Hess score, WFNS score and GCS, multivariate analysis showed the strongest relationship with mFisher scores. Ejection fraction differences between groups were present on day 30, but disappeared by day 180, whereas wall motion score index was still higher in the severe TTC group at day 180. By the end of the follow-up period (180 days), 70 (74.5%) patients survived in the non-TTC, 22 (81.5%) in the mild TTC and 3 (27%) in the severe TTC group (n = 11) (p = 0.002). At day 180, GOS, Barthel, and Karnofsky outcome scores were higher in patients in the control (non-TTC) and the mild TTC groups than in the severe TTC group. Takotsubo cardiomyopathy is a frequent finding in patients with SAH, and severe TTC may be present in 8% of SAH cases. The severity of TTC may be an independent predictor of mortality and outcome at 6 months after disease onset. Therefore, a regular follow-up of ECG and TTE abnormalities is warranted in patients with subrachnoid hemorrhage for early detection of TTC. The study was registered at the Clinical Trials Register under the registration number of NCT02659878 (date of registration: January 21, 2016).

The Connection Between Opioid Withdrawal and Takotsubo Cardiomyopathy: Case Reports of ‘Opioid Octopus Heart’

Introduction Takotsubo Cardiomyopathy (TCM) is an incompletely understood diagnosis. The leading hypothesis of its pathogenesis is that a hyperadrenergic state leads to cardiotoxicity, which is supported by case findings. Withdrawal from opioids is one potential etiology of an excessive adrenergic response and, therefore, may precipitate TCM. Case Presentations Here, we present 2 cases of TCM in patients who chronically used opioids, both at the same institution within 1 month of each other. The first patient is a 68-year-old man who presented with a chronic obstructive pulmonary disease exacerbation and did not disclose his long-standing opioid use disorder. One day after admission, he was found to be in opioid withdrawal and, soon after, developed TCM. He was originally treated for non-ST elevation myocardial infarction and opioid withdrawal but decompensated. He was sent to the intensive care unit (ICU) to receive pressors and fluid resuscitation. He soon recovered and his cardiac function returned to baseline. The second patient is a 33-year-old woman with opioid use disorder taking methadone who presented with lower extremity weakness, edema, and pain. She was diagnosed with infective endocarditis. While awaiting surgery and receiving antibiotics, she developed respiratory failure and was upgraded to the ICU. There was a lapse in her opioid treatment, and she subsequently developed TCM. She was treated with pressors and fluids in the ICU, and eventually recovered with reduced cardiac function at the time of discharge. Conclusions While clinical evidence indicated opioid withdrawal as the likely provoking factor for development of TCM in the first case, the second patient’s symptoms from other clinical complications confounded the cause of her TCM. Twelve similar cases have been reported in the literature, suggesting that opioid withdrawal may be associated with development of TCM. Further quantitative research is required to establish this relationship. Our findings contribute to the theoretical pathophysiology of TCM and offer important considerations for clinical management of opioid withdrawal.

Abstract 13701: Short Term Outcomes of Takotsubo Cardiomyopathy in Patients With Right Ventricular Dysfunction in the US Veteran Affairs Healthcare System

Introduction: Takotsubo cardiomyopathy is characterized by significant transient left ventricular dysfunction that is not due to obstructive coronary artery disease, but concurrent right ventricular (RV) dysfunction has been described previously. The aim of our study was to investigate the rates and outcomes of patients diagnosed with Takotsubo cardiomyopathy with RV dysfunction in the Veteran Affairs (VA) system. Methods: We performed a retrospective study using chart review for patients diagnosed with Takotsubo cardiomyopathy between 2005 and 2018 in the VA national database. We included patients who met the Mayo Clinic diagnostic criteria for Takotsubo cardiomyopathy. We collected data for demographics, clinical course, and outcomes. Results: 276 patients (70% males) were included. Median age was 64 years, 18.5% were known to have coronary artery disease, 34.8% had Diabetes and 58.1% had hypertension. 96.3% of patients had apical variant of Takotsubo cardiomyopathy. Biventricular dysfunction was identified in 14.1% of patients; of those 71.8% were identified as new RV dysfunction in which 92.3% were apical. There was no significant difference in the in-hospital mortality rates between patients with new biventricular dysfunction compared to patients with normal RV function or old RV dysfunction (10.7% vs 8.1%, p = 0.63). There was also no significant difference in 30-day mortality rates between patients with new biventricular dysfunction compared to patients with normal RV function or old RV dysfunction (4.2% vs 1.8%, p = 0.45). Similar findings were observed when patients with previous RV dysfunction were excluded. On follow up echocardiogram 96.3% of patients who survived had full recovery of their RV function. Conclusions: In patients diagnosed with Takotsubo cardiomyopathy with new RV dysfunction, there was no significant difference in mortality rates in the hospital or at 30-day follow up.

P46 Takotsubo cardiomyopathy in a GPA patient receiving rituximab therapy

Abstract Background Cardiac involvement in GPA is quite rare. Patients with GPA are two times more likely to die of cardiovascular complications as compared to the general population due to accelerated atherosclerosis. Cardiac involvement in GPA is secondary to necrotising vasculitis with granulomatous infiltrates, usually resulting in coronary artery thrombosis. We present a case of Takotsubo cardiomyopathy in a patient of GPA treated with rituximab. There has previously only been one case report of a patient on rituximab therapy developing Takotsubo cardiomyopathy. Methods This 67-year-old woman was diagnosed with GPA in January 2018 when she presented with a necrotic lung lesion along with nasal crusting and leg ulcers. Her ANCA was 102 i.u./ml at the time. We treated with cyclophosphamide and azathioprine to good effect. Then she had a relapse six months later and presented to the hospital with stridor due to subglottic stenosis. At this point we switched to rituximab and methotrexate to induce remission, her ANCA titres settled to 3.4 i.u./ml at this point. After her second cycle of rituximab, she presented to the hospital with shortness of breath, chest pain and stridor in November 2018. Results At her presentation with chest pain in November 2018, an ECG was performed, which showed an incomplete LBBB with ST elevation in anterior leads with a troponin level of 550ng/ml. A repeat ECG after 2 hours, showed ST elevations in anterolateral leads with a troponin level of 1259ng/ml. We treated this as an acute myocardial infarction. An echocardiogram was obtained, which was remarkable in that it showed no new regional wall motion abnormalities. A subsequent coronary angiogram confirmed that there was no coronary artery disease raising the possibility of Takotsubo cardiomyopathy. Conclusion Rituximab is implicated in cardiac arrhythmia and coronary vasospasm during the infusion, reduction in LVEF, non-ischaemic cardiomyopathy, cardiogenic shock after. Our patient had a myocardial infarction with normal coronaries, and she was going through a very emotionally stressful period with her husband’s illness at the time of her presentation, which makes Takatsubo cardiomyopathy a very likely diagnosis. There are few case reports in the literature and, clinicians should be aware of this rare complication. Disclosures S.P. Jayanti None. S. Nair None. D. Makkuni None.

TAKOTSUBO CARDIOMYOPATHY AS AN ADVERSE EVENT POST BRONCHOSCOPY

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome characterized by acute dilated cardiomyopathy following emotional or physical stress. It presents with sudden onset of cardiac symptoms with electrocardiogram(ECG) changes and left ventricular dysfunction. Echocardiogram findings are characteristic of apical ballooning with a wide base and long thin neck at end-diastole. The prevalence of TTC in patients with known vasculitis is not well described. CASE PRESENTATION: Our patient is a 46 Chinese lady with known history of migraine and anxiety. She first presented with non-resolving oto-mastoditis despite multiple courses of antibiotics. She subsequently developed bilateral cavitary lung lesions for which a bronchoscopy was performed. The work-up was negative for microbiology including mycobacterium and fungal organisms. Her antiPR3 antibodies were markedly raised and a diagnosis of Granulomatosis with Polyangiitis (GPA) was made. She was treated with intravenous pulsed steroids and cyclophosphamide. However, she developed fever and cough with worsening of bilateral cavitary lung lesions and neutrophilia. Bronchoscopy and transbronchial lung biopsy were repeated in view of concerns of infection in a immunocompromised host. 2 hours post procedure, she developed sinus tachycardia and type 1 respiratory failure requiring intubation and mechanical ventilation. Cardiac enzymes trended were not suggestive of myocarditis or acute myocardial infarct. ECG showed new T-wave inversions in the anterior leads. A bedside echocardiogram showed dilated cardiomyopathy with an ejection fraction(EF) of 10-15%. She was subsequently extubated and a repeat echocardiogram confirmed the characteristic findings of TTC with apical ballooning and akinesia and improvement in EF to 30-35%. DISCUSSION: One of the proposed pathophysiology behind TTC is the abnormally high levels of catecholamines resulting in catecholamine-associated cardiotoxicity post physical or emotional stressors. Previous papers have described TTC post bronchoscopy to be more common in post-menopausal women, history of asthma; and in more invasive procedures such as transbronchial lung biopsies and adrenaline administration intra-tracheally; therefore benefit-risk ratio for adrenaline administration needs to be considered in patients at risk. Treatment is usually supportive with treatment of heart failure and reassurance. CONCLUSIONS: TTC post bronchoscopy is an uncommon but life threatening adverse event. This case highlights the need to identify patients who are at risk of developing TTC post bronchoscopy and ensure preventive measures such as adequate counselling are carried out pre-procedure. The diagnosis of TTC should be suspected in high risk patients with cardiac symptoms and close monitoring post procedure should also be implemented as the complications of TTC can be severe and life threatening as demonstrated in our patient. Reference #1: Nyquist KE, Abramson DW, Huffman JC. Apical ballooning syndrome: the "broken heart" syndrome. Prim Care Companion J Clin Psychiatry. 2010;12(5):PCC.10r00949. Reference #2: Four cases of clinical analysis with Takotsubo cardiomyopathy associated with bronchoscopy: Manabu Suzuki et al. European Respiratory Journal 2017 50: PA3803; https://doi.org/10.1183/1393003.congress-2017.PA3803 Reference #3: Takotsubo Cardiomyopathy and Subsequent Seizures Induced by Flexible Bronchoscopy Shion Miyoshi MD, Yuichiro Takeda MD PhD, Shoki Ro MD, Haruna Masaki MD, Masayuki Hojo MD, and Haruhito Sugiyama MD PhD. DISCLOSURES: No relevant relationships by Adrian Kwok Wai Chan, source=Web Response No relevant relationships by Sandra HUI, source=Web Response No relevant relationships by Keng Leong TAN, source=Web Response

Clinical characteristics of stress cardiomyopathy in patients with acute poisoning

Patients who attempt intentional suicide suffer from physical or emotional stress. This situation might be an important factor that causes takotsubo cardiomyopathy. We retrospectively investigated the clinical features of Takotsubo cardiomyopathy in patients with acute poisoning. This study included patients who were admitted from January 2010 to December 2015 because of intentional poisoning by ingestion. Among these patients, we selectively collected data of patients who underwent an echocardiogram. We divided the patients into three groups according to the echocardiogram; the non-cardiomyopathy group, the global hypokinesia group, and the takotsubo cardiomyopathy group. One hundred forty-seven patients were analyzed in this study. One hundred thirty-one patients had normal cardiac function without regional wall motion abnormality. Global hypokinesia was observed in five patients. The overall incidence of takotsubo cardiomyopathy was 7.5% (11/147). Levels of cardiac enzymes including CK-MB, Troponin T, a marker of cardiac muscle ischemia, were higher in the global hypokinesia group and the takotsubo cardiomyopathy group compared with the non-cardiomyopathy group. The most commonly consumed poison was organophosphate in the takotsubo cardiomyopathy group. In conclusion, takotsubo cardiomyopathy may be one of the cardiac complications in patients who attempt suicide by consuming a poison.

Rare Cardiac Manifestation of a Commonly Prescribed Drug: Takotsubo Cardiomyopathy Caused by Allopurinol Induced Dress Syndrome

It presents a case of 42-year-old male with history of chronic kidney disease stage with rash, itching and swelling. Two weeks before he was started on allopurinol for hyperuricemia. Exam showed swelling of face, extremities with diffuse papular rash. Temperature 99.3, BP 122/93, RR 18. Blood work showed worsening renal function (Cr 3.10), transaminitis (LDH 184, AST 104, ALT 136) and eosinophilia of 13.6%. RegiSCAR score of 6 was highly suggestive of Dress Syndrome. Patient's allopurinol was discontinued. Patient was started on steroids and showed improvement. Patient returned three weeks later with chest pain and shortness of breath. BP 110/68, Pulse rate 132, respiratory rate 30 breaths/min, Sat O2 87%.CK-MB 30 and troponin 10. Eosinophil count 19%. EKG showed sinus tachycardia and diffuse ST elevation. Emergent cardiac catheterization showed no coronary artery disease, severe LV systolic dysfunction with apical dilation. Ejection fraction was 20% (EF of 55%-60% baseline). Findings were consistent with Takotsubo Cardiomyopathy (TS). He was continued on steroids and lasix. Skin biopsy showed superficial perivascular dermatitis. Subendocardial biopsy showed mild perivascular and subendocardial infiltrates not suggestive of active eosinophilic myocarditis. Patient condition stabilized, and EF improved to 45%-50%. He was discharged on prednisone taper. Discussion: DRESS syndrome is rare, potentially life-threatening hypersensitivity reaction. Early recognition is important as it has associated mortality of 10%. European Registry (RegiSCAR) is the most commonly used diagnostic criteria. Drug induced Takotsubo cardiomyopathy is mostly associated with medication causing direct or indirect catecholamine stimulation. Although a common association with Dress Syndrome, allopurinol induced takotsubo cardiomyopathy is extremely rare. To our knowledge only one other case has reported. We aim to highlight the importance of clinical suspicion for takotsubo cardiomyopathy in patients with new onset heart failure treated with allopurinol that remains a common prescription medication.

Basal wall hypercontraction of Takotsubo cardiomyopathy in a patient who had been diagnosed with dilated cardiomyopathy: a case report

BackgroundTakotsubo cardiomyopathy is characterized by the basal hypercontractility and apical ballooning of the left ventriculum and T-wave inversion in the electrocardiogram. It has been suggested that Takotsubo cardiomyopathy might underlie the pathogenesis of persistent cardiac dysfunction; however, few reports are present demonstrating the advent of Takotsubo cardiomyopathy in patients with idiopathic cardiomyopathy.Case presentationA 64-year-old women was admitted due to dyspnea on effort and lower extremity edema. She had been diagnosed with idiopathic dilated cardiomyopathy 2.5 years before owing to the reduced left ventricular ejection fraction (24%), normal coronary artery, and interstitial fibrosis of the myocardial samples. On admission, her electrocardiogram showed giant negative T wave in II, III, aVF, and precordial leads. Echocardiography showed dyskinesis of the left ventricular apex and hypercontraction of the basal wall, which had not been observed in the previous examinations. Coronary angiography showed normal coronary arteries, and apical ballooning and basal hypercontractility was confirmed by left ventriculography. On day 15 of admission, contraction of apical wall was recovered, and basal hypercontraction was disappeared.ConclusionThe present case is the first report demonstrating appearance the transient basal wall hypercontraction along with the advent of Takotsubo cardiomyopathy in a patient diagnosed with dilated cardiomyopathy. Whether such findings are indicative of fair prognosis and have the utility of understanding the pathogenesis of dilated cardiomyopathy needs further investigation.

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

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.

The Role of Early Focused Cardiac Ultrasound in a Not-So-Typical Presentation of Takotsubo Cardiomyopathy: A Case Report

BackgroundFocused cardiac ultrasound (FoCUS) can be extremely helpful in identifying unexpected diagnoses that can significantly alter treatment options. The diagnosis of Takotsubo cardiomyopathy (TCM) may be difficult to identify. Case ReportWe describe a 47-year-old woman who presented to the emergency department (ED) with atypical features of TCM. Her clinical features included being a premenopausal woman with mild chest pain with a lack of identifiable emotional or physical stressors or significant electrocardiographic changes. Initial findings on FoCUS were consistent with TCM, with these findings replicated on repeat bedside echo performed in the ED by the cardiology fellow. A subsequent comprehensive echo showed marked improvement of the TCM pattern within 24 hours. Why Should an Emergency Physician Be Aware of This?TCM may present in younger women or men, without obvious preceding physical or emotional stressors and with nonspecific ECG findings. FoCUS performed in the ED may suggest a diagnosis of TCM in patients with chest pain or dyspnea of uncertain etiology. The performance of FoCUS, as highlighted by this case report, can lead to timely intervention and follow-up of a variety of cardiac conditions.

Abstract 042: Association Between Preexisting Valvular Heart Disease and Takotsubo Cardiomyopathy Among Hospitalized Patients in the United States

Background: The pathogenesis of Takotsubo Cardiomyopathy (TTCM) remains poorly understood. Several case reports have described the occurrence of TTCM in patients with preexisting valvular heart disease (VHD). We sought to examine the association between preexisting VHD and TTCM in hospitalized patients. Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), all hospitalizations between 2007 and 2011 with preexisting diagnosis of VHD and admitting diagnosis of TTCM were extracted using ICD-9 CM codes. We compared patients admitted for TTCM who had preexisting VHD to those without. We excluded patients below the age of 18 as well as those diagnosed with TTCM who later underwent percutaneous coronary intervention (PCI). Multivariate logistic regression was used to assess the independent effect of preexisting VHD on both occurrence of TTCM and clinical outcomes (length of stay (LOS), stroke and in-hospital mortality). Results: In our study, 613 (0.06%) out of the 1,084,719 hospitalized patients with preexisting VHD, had TTCM, compared to 13,381 (0.04%) out of the 31,460,000 with no preexisting VHD (p&lt;0.0001). In adjusted models, patients with preexisting VHD had a lower risk of being hospitalized for TTCM in the index hospital admission (adjusted odds ratio (aOR) =0.83, 95% confidence interval (CI) =0.77-0.90), independent of potential demographic, comorbid and lifestyle confounders. However, preexisting VHD was significantly associated with longer LOS (aOR=2.59, 95% CI=1.95-3.23), increased stroke rate (aOR=2.49, 95% CI=1.75-3.54) and higher in-hospital mortality (aOR=1.48, 95% CI=1.05-2.09). Conclusion: In this large, nationwide study, preexisting VHD was associated with worse clinical outcomes in patients hospitalized for TTCM. Our results can guide future clinical decision-making regarding prompt risk factor identification for poor prognosis in TTCM patients. Future prospective studies are needed to further evaluate this association.

CRT-800.53 Association Between Preexisting Valvular Heart Disease and Takotsubo Cardiomyopathy among Hospitalized Patients in the United States

The pathogenesis of Takotsubo Cardiomyopathy (TTCM) remains unknown. Several case reports have described the occurrence of TTCM in patients with preexisting valvular heart disease (VHD). We sought to examine the association between preexisting VHD and TTCM in hospitalized patients. Using the

Takotsubo Cardiomyopathy after Hybrid Repair of Thoracic and Thoracoabdominal Aortic Aneurysm

Context: Takotsubo cardiomyopathy is characterized by transient and acute left ventricular dysfunction with apical dyskinesia in the absence of coronary artery disease. The pathophysiology of this rare disease is considered to be associated with physical and psychological stress. Recently published case reports have described the association between Takotsubo syndrome and various surgical procedures as the causative stress factors. However, Takotsubo cardiomyopathy is extremely rare in patients who have undergone cardiovascular surgery. Case report: Here, we report a rare case of Takotsubo cardiomyopathy developing after thoracic endovascular aortic repair for chronic dissecting aortic aneurysm. Conclusion: This patient developed Takotsubo cardiomyopathy 14 days after thoracic endovascular aortic repair, potentially because of the prolonged perioperative physical and psychological stress induced by multi-stage surgery. To our knowledge, this is the first report of Takotsubo cardiomyopathy after thoracic endovascular aortic repair. Through this report, we emphasize the importance of considering the possibility of Takotsubo cardiomyopathy in patients presenting symptoms of cardiogenic shock and unexplained hemodynamic deterioration, despite having undergone relatively less-invasive cardiovascular surgery. Early diagnosis is required to initiate appropriate treatment and to minimize the chance of complications.

Takotsubo cardiomyopathy in patient with hypertrophic cardiomyopathy : A case report

Takotsubo cardiomyopathy in patient with hypertrophic cardiomyopathy : A case report