Case report
A rare case of concomitant stress (takotsubo) cardiomyopathy and acute myocardial infarction
Um caso raro de cardiomiopatia de stress (Takotsubo) e enfarte agudo do miocárdio concomitantes
Miguel Nobre Menezes
, Doroteia Silva, Ana G. Almeida, Fausto J. Pinto, Dulce Brito
Corresponding author
Cardiology Department, University Hospital Santa Maria, Centro Hospitalar de Lisboa Norte, CCUL, University of Lisbon, Portugal
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Almeida, Fausto J. Pinto, Dulce Brito" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Miguel" "apellidos" => "Nobre Menezes" "email" => array:2 [ 0 => "mnmenezes.gm@gmail.com" 1 => "mnmenezes@netcabo.pt" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Doroteia" "apellidos" => "Silva" ] 2 => array:2 [ "nombre" => "Ana G." "apellidos" => "Almeida" ] 3 => array:2 [ "nombre" => "Fausto J." "apellidos" => "Pinto" ] 4 => array:2 [ "nombre" => "Dulce" "apellidos" => "Brito" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, University Hospital Santa Maria, Centro Hospitalar de Lisboa Norte, CCUL, University of Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Um caso raro de cardiomiopatia de <span class="elsevierStyleItalic">stress</span> (Takotsubo) e enfarte agudo do miocárdio concomitantes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 522 "Ancho" => 1401 "Tamanyo" => 86315 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ventriculography showing mid-apical ballooning and basal hyperkinesis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Stress cardiomyopathy is generally an exclusion diagnosis after myocardial infarction (MI), myocarditis and pheochromocytoma have been ruled out. We report a rare case of concomitant stress cardiomyopathy and MI, which represented a challenge to current diagnostic criteria.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 54-year-old woman with a history of dyslipidemia and smoking went to the emergency department (ED) due to crushing chest pain, radiating to the back, with sudden onset at rest 16 hours previously. She had no other symptoms and had not suffered any stressful events that day or in the recent past. On arrival in the ED she was febrile (38<span class="elsevierStyleHsp" style=""></span>°C), but other vital signs and physical examination were normal. The electrocardiogram (ECG) presented an rS pattern in DIII and aVF only. The initial echocardiogram performed in the ED revealed left ventricular dilatation with mid-apical akinesis of all walls and hyperkinesis of all basal segments, producing an image of ventricular ballooning. The patient was immediately sent for emergency catheterization. Ventriculography showed the same findings as the initial echocardiogram (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>); coronary angiography revealed a subocclusive mid-distal lesion of the obtuse marginal coronary artery (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) and irregularities in the right coronary artery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The pain was found to have spontaneously resolved on admission to the cardiology ward, and hospital stay was uneventful. Peak troponin I was 42 ng/ml and serum catecholamines were normal. Serial ECGs during hospitalization were comparable to those at admission. Serial echocardiograms were also performed, which showed progressive regression of the findings observed at admission, except for the persistence of posterior wall hypokinesis. The clinical presentation, together with significant troponin I elevation and persisting wall motion abnormalities in a single territory, led us to consider the possibility that, besides stress cardiomyopathy, the patient may have suffered an MI or acute myocarditis. Cardiac magnetic resonance (CMR) was accordingly performed, which revealed subendocardial late enhancement of the posteroinferior wall consistent with an infarction scar in the territory of the circumflex artery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The discharge diagnoses were MI and stress cardiomyopathy. Six months later, echocardiography and CMR were repeated, which were comparable. The patient has remained asymptomatic.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Stress cardiomyopathy is not fully understood, but among the possible pathophysiological mechanisms are toxicity arising from catecholamine surge, microvascular dysfunction and multivessel spasm.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> At present there are no definitively established diagnostic criteria; the most commonly used are those of the Mayo Clinic,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> which require the presence of: (1) wall-motion abnormalities typical of the syndrome; (2) absence of obstructive coronary disease or evidence of acute plaque rupture; (3) new ECG abnormalities or modest elevation of cardiac troponin; and (4) absence of pheochromocytoma or myocarditis. There is frequently a physical or emotional stressor, but this is not necessary for the diagnosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">CMR is useful for differential diagnosis. Typically, patients with stress cardiomyopathy do not present significant late enhancement,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> while subendocardial late enhancement is common in MI and focal or subepicardial late enhancement is frequent in myocarditis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the present case, a marked rise in troponin, typical infarction scar, persistent hypokinesis restricted to a single coronary territory after resolution of other wall motion abnormalities, subendocardial late enhancement documented by CMR and a subocclusive lesion in the vessel irrigating the affected territory, made it clear that the patient had suffered an MI. However, the acute ischemic lesion does not explain the transient ballooning observed in this patient, a typical feature of stress cardiomyopathy. We thus concluded that the patient had suffered an MI and concomitantly developed stress cardiomyopathy, the acute coronary syndrome itself possibly being the stressor.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although stress cardiomyopathy can occur in patients with obstructive coronary disease, it is exceptionally rare, as pointed out by the authors of the Mayo Clinic criteria.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> We found only one case report of concomitant acute coronary syndrome and stress cardiomyopathy in the same patient.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">However, as this case illustrates, MI does not completely rule out the possibility of stress cardiomyopathy, and may itself be the stressor.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres538936" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec558605" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres538937" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec558606" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-01" "fechaAceptado" => "2015-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec558605" "palabras" => array:4 [ 0 => "Stress cardiomyopathy" 1 => "Takotsubo syndrome" 2 => "Acute myocardial infarction" 3 => "Cardiac magnetic resonance" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec558606" "palabras" => array:4 [ 0 => "Cardiomiopatia de <span class="elsevierStyleItalic">stress</span>" 1 => "Síndrome Takotsubo" 2 => "Enfarte agudo do miocárdio" 3 => "Ressonância magnética cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Stress cardiomyopathy and myocardial infarction are generally regarded as mutually exclusive diagnoses. We report the case of a 54-year-old woman who presented with acute chest pain. Her echocardiogram and ventriculography were typical of stress cardiomyopathy, but she had one subocclusive coronary lesion, a highly significant rise in troponin and a subendocardial myocardial infarction scar documented on cardiac magnetic resonance. This is a rare case of concomitant myocardial infarction and stress cardiomyopathy, in which the acute coronary syndrome itself may have been the stressor, given the absence of other identifiable causes.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cardiomiopatia de <span class="elsevierStyleItalic">stress</span> e o enfarte agudo do miocárdio são geralmente considerados diagnósticos mutuamente exclusivos. Neste artigo reportamos o caso de uma doente de 54 anos com um quadro clínico de angor inaugural em repouso, cujo ecocardiograma e ventriculografia eram típicos de cardiomiopatia de <span class="elsevierStyleItalic">stress</span>. Não obstante, a coronariografia revelou uma lesão coronária suboclusiva, verificou-se elevação muito significativa de troponina e documentou-se uma cicatriz de enfarte subendocárdico por ressonância magnética cardíaca. Este é um caso raro em que um enfarte agudo do miocárdio e uma cardiomiopatia de <span class="elsevierStyleItalic">stress</span> ocorreram simultaneamente, em que o primeiro poderá ter sido o <span class="elsevierStyleItalic">stressor</span> que despoletou o segundo, dada a ausência de outras causas identificáveis.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nobre Menezes M, Silva D, Almeida AG, et al. Um caso raro de cardiomiopatia de <span class="elsevierStyleItalic">stress</span> (Takotsubo) e enfarte agudo do miocárdio concomitantes. Rev Port Cardiol. 2015;34:499.e1–499.e3.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 522 "Ancho" => 1401 "Tamanyo" => 86315 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ventriculography showing mid-apical ballooning and basal hyperkinesis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 697 "Ancho" => 1302 "Tamanyo" => 79040 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography showing subocclusive lesion of the obtuse marginal artery (left) and subendocardial late enhancement of the left ventricular posterior wall, compatible with an infarction scar (right).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The “broken heart syndrome”: state of the art" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. 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Rihal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ahj.2007.11.008" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2008" "volumen" => "155" "paginaInicial" => "408" "paginaFinal" => "417" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18294473" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Eitel" 1 => "F. von Knobelsdorff-Brenkenhoff" 2 => "P. Bernhardt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2011.992" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2011" "volumen" => "306" "paginaInicial" => "277" "paginaFinal" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21771988" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular magnetic resonance in myocarditis: a JACC White Paper" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.G. Friedrich" 1 => "U. Sechtem" 2 => "J. Schulz-Menger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2009.02.007" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2009" "volumen" => "53" "paginaInicial" => "1475" "paginaFinal" => "1487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19389557" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Takotsubo triggered by acute myocardial infarction: a common but overlooked syndrome?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Redfors" 1 => "T. Råmunddal" 2 => "Y. Shao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3969/j.issn.1671-5411.2014.02.001" "Revista" => array:6 [ "tituloSerie" => "J Geriatr Cardiol" "fecha" => "2014" "volumen" => "11" "paginaInicial" => "171" "paginaFinal" => "173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25009569" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000078/v1_201508050210/S2174204915001506/v1_201508050210/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003400000078/v1_201508050210/S2174204915001506/v1_201508050210/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915001506?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2023 June | 25 | 18 | 43 |
| 2023 May | 52 | 23 | 75 |
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| 2016 September | 47 | 5 | 52 |
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| 2016 May | 17 | 9 | 26 |
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| 2016 March | 46 | 14 | 60 |
| 2016 February | 75 | 36 | 111 |
| 2016 January | 50 | 24 | 74 |
| 2015 December | 55 | 23 | 78 |
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