Case report: Takotsubo syndrome following percutaneous coronary intervention

doi:10.21203/rs.3.rs-2752776/v1

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Case Report

Case report: Takotsubo syndrome following percutaneous coronary intervention

https://doi.org/10.21203/rs.3.rs-2752776/v1

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published 16 Nov, 2023

Read the published version in Journal of Cardiothoracic Surgery →

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Background

Takotsubo syndrome (TTS), which is frequently secondary to severe emotional (fear, anxiety, etc.) or physical stress, is an acute reversible heart failure syndrome characterized by temporary left ventricular regional systolic dysfunction. Nevertheless, TTS after percutaneous coronary intervention (PCI) is rare, and its clinical characteristics are easily confused with complications after PCI.

Case presentation

This article reports a case of TTS induced by psychological and physical pressure after successful PCI in our institution. She had symptoms comparable to complications after PCI, including electrocardiogram (ECG) deviation and troponin elevation. Coronary angiogram, left ventricle contrast echocardiography (LVO), and cardiac magnetic resonance (CMR) were performed to exclude postoperative complications. Definite diagnosis of TTS was eventually achieved.

Conclusion

We cannot dismiss the risk of TTS in patients who have unexplained ECG deviation and troponin elevation following successful PCI. Meanwhile, medical personnel should provide mental, cultural, and emotional services to patients in addition to essential diagnostic and treatment technical services during the perioperative period.

Takotsubo syndrome (TTS)

percutaneous coronary intervention (PCI)

differential diagnosis

mental service

TTS occurs normally in postmenopausal women, which is an acute reversible left ventricular dysfunction caused by intense emotional or physical stress. Clinical features include chest pain, ST segment elevation seen on ECG, elevation of cardiac biomarkers, and abnormal ventricular wall motion [1–2]. An increase in the incidence of TTS appears to be a consequence of greater stress in modern life and growing knowledge of the disease among clinicians. However, TTS following PCI is rare, and there are many similarities between complications after PCI and it in clinical manifestations and auxiliary examinations, and both of them are often difficult to distinguish, which needs to be identified by coronary angiography and ventricular angiography. In this article, we reported one case of TTS induced by psychological and physical stress after PCI.

The patient, a 69 years old female, came to our institution for treatment because of repeated chest tightness for one week, which was located in the xiphoid process, and could appear during rest and activity. The symptoms improved after several hours without chest pain, palpitation and other discomfort. The patient had a history of erosive gastritis without other chronic history as hypertension, diabetes etc. Deny any smoking or drinking habits. Under the current situation, her hypersensitive troponin I (hs-TnI) level was 14.00pg/mL (normal value 0-17.5pg/mL), myoglobin level was 54.3ug/L (normal value < 70ug/L), Pro-B-type natriuretic peptide (Pro-BNP) level was 269.0pg/mL (normal value ≤ 300pg/mL) (Fig. 1), total cholesterol (TC) level was 5.98mmol/L (normal value 2.9-5.5mmol/L), low-density lipoprotein cholesterol (LDL-C) level was 3.85mmol/L (normal value 2.5-4.14mmol/L). ECG showed sinus rhythm (Fig. 2A). Echocardiography revealed that the size of each atrioventricular cavity was normal, the left ventricular ejection fraction (LVEF) was 73%(Fig. 3A). On the fourth day after admission, coronary angiogram showed that the bifurcation between the middle part of the left anterior descending artery (LAD) and the first diagonal branch (D1) of the LAD had a stenosis of about 80%. During the operation, a 3.0 * 18mm stent was placed in the LAD and D1 was protected with Jailed balloon technique (Fig. 4A-D). The procedure went smoothly without signs of vascular entrapment, stent strut malapposition and tissue prolapse. Tirofiban was continuously pumped after the operation in conjunction with oral antiplatelet drugs: 90 mg of Tigrenol twice a day and 100 mg of Indobufen twice a day.

On the first day after operation, the hs-TnI: 13045.50pg/mL, Pro-BNP: 5255.0pg/mL (Fig. 1), ECG showed sinus rhythm, V1-V5 ST segment elevation, T wave changes (Fig. 2B), emergency coronary angiogram showed stent shadow in the middle of LAD, and blood circulation in the stent was smooth. There is no obvious stenosis in the left circumflex coronary artery (LCX) and the right coronary artery (RCA) (Fig. 4E-F), and the blood flow in all three vessels is TIMI grade 3. LVO reveals that the middle and lower segments of the ventricular septum, the anterior wall of the left ventricle, and the ventricular wall of the apical segment become thinner, and the movement is weakened with decreased perfusion, with LVEF of 51% (Fig. 3B). Subsequent CMR presented that the motion of the middle and lower segments of the ventricular septum and the ventricular wall at the apex was weakened (Fig. 5A-D).

Based on the patient's medical history, symptoms, laboratory examination, imaging and other auxiliary examination results, the diagnosis is considered as 1. Takotsubo syndrome (TTS); 2. Coronary atherosclerotic heart disease. We provide this patient furosemide 60mg/d、β blocker 2.5mg/d as TTS pharmacological therapies. Simultaneously, the patient with coronary atherosclerotic heart disease received a stent and continued to be treated with dual antiplatelet drugs and statins. On the 4th day after surgery, the re-examination ECG revealed that the T wave of lead V2∼V4 was inverted, broad, and deep (Fig. 2C), and that the levels of hs-TnI and Pro-BNP were significantly reduced (Fig. 1). On the seventh postoperative day, LVO revealed that the left ventricular wall motion was greatly improved compared to before, with good myocardial perfusion and LVEF of 65% (Fig. 3C). The patient was discharged after receiving an additional 12.5mg of Sakubatravalsartan twice day. .

2 months later, the patient returned to the institution for a check, she had a hs-cTnI level of 12.30pg/mL, a pro-BNP level of 324.00pg/mL, and no evidence of ST-T segment changes on ECG. LVO demonstrated no obvious motion abnormalities in the myocardial segments of each ventricular wall, and the perfusion was adequate, with LVEF of 59% (Fig. 3D). CMR demonstrated improvement in left ventricular systolic function in comparison with the former (Fig. 5E-H). Changes of echocardiography was shown in Table 2.

A significant emotional or physical stressor typically precedes the development of TTS. Recent research has discovered that significant emotional and physical stressors can interact to generate TTS [3]. The pathophysiological mechanism of TTS remains unclear, but a significant body of research indicates that sympathetic overactivity and catecholamine surge are the most essential pathological mechanism of patho genesis [1, 4].

The patient in this case is an elderly female. Several illnesses can explain her clinical symptoms following PCI, so distinguishing between them is critical (Table 1). Firstly, the operation was a success, with no coronary artery dissection, incomplete stent apposition, tissue prolapse, or other complications. Moreover, she was given anticoagulants and antiplatelet agents after the operation, so postoperative complications (such as coronary artery dissection, stent thrombosis) are unlikely to occur. Secondly, coronary angiography can detect dissection and thrombus in the case of coronary artery dissection and stent thrombosis, which is not the case in our patient. Thirdly, abnormalities in ventricular wall motion caused by coronary artery dissection and stent thrombosis are typically restricted to locations innervated by a single coronary artery. This patient's ECG, echocardiography, and CMR show that the distribution of abnormal ventricular wall motion exceeds the area supplied by the left anterior descending artery. Last but not least, all clinical characteristics of the patient can be explained using TTS alone for the following reasons.

The patient's education level is primary school. She has insufficient awareness of primary disease as a result of the language barrier between her and her doctors, limited knowledge and information, and lack of medical expertise during perioperative time, resulting in negative feelings such as anxiety and fear. Meanwhile, the invasive PCI treatment enhanced sympathetic activity and catecholamine release throughout the body much more. As a result, patients are under emotional and physical duress. Besides, the ECG showed ST-segment elevation in V1-V5 and T-wave alternans, and blood chemistry showed a significant rise in hs-TnI on the first post-procedure day. Nonetheless, emergency coronary angiography revealed that the blood flow at the stent implantation site was smooth. At the same time, Echocardiography and CMR revealed that the mobility of the ventricular septum's middle and lower segments, as well as the ventricular wall at the apex, was weakened, and the patient's heart function improved rapidly after short-term symptomatic treatment. Therefore, the patient could be diagnosed with TTS based on the 2018 TTS international consensus [1]. This case highlights the difficulty of diagnosing TTS after PCI and the necessity of coronary angiography, echocardiography, and CMR in its differential diagnosis.

Finally, TTS has been regarded as a relatively benign condition with a generally favorable prognosis since its discovery. Recent investigation, however, has indicated that patients experienced substantial mortality and morbidity following the acute phase of TTS, with all-cause mortality at 1 year being 5.6% [5]. Therefore, early clinical identification will aid in the development of individualized treatment strategies and clinical management. The primary goal of treating heart failure in TTS patients is to relieve pulmonary congestion and provide hemodynamic support [6-7]. Treatment of TTS patients differs significantly depending on whether or not the left ventricular outflow pathway is obstructed. We used furosemide to control volume and beta-blockers to reduce excessive myocardial contraction, increase left ventricular filling, reduce heart rate, and improve cardiac remodeling in this TTS patient who developed acute heart failure without the left ventricular outflow tract obstruction during the acute phase. A number of randomized clinical trials have indicated that sarcubatrixartan reduces renal and cardiac adverse events in patients with heart failure with maintained ejection fraction when compared to valsartan [8-9]. Consequently, we began treatment with sacubitril valsartan sodium tablets on the 7th day after PCI. After a follow-up period of 2 mouths the patient is free of cardiac symptoms with a good functional capacity. The left ventricular ejection fraction appears normal.

To summarize, the diagnosis of TTS in the patient is clear, and the combined impact of emotional and physical stressors contribute to the incidence of TTS. This case also reminds us that when patients after PCI experience unexplained electrocardiogram changes and elevated troponin, we cannot ignore the possibility of TTS while considering the complications after PCI. Additionally, TTS caused by emotional stimulation is not rare, especially under the influence of negative emotional events [10–12]. In the perioperative period of patients receiving interventional therapy, good physician-patient communication is particularly significant. As a doctor should attach importance to the entire medical procedure, in addition to providing patients with appropriate diagnostic and therapeutic technical services, but also need to timely explain the changes of the condition to patients and their families, and properly eliminate the anxiety and fear caused by the intervention of patients. These not only improve the postoperative rehabilitation but also lower the incidence rate of TTS.

Acknowledgement

This case report was supported by ward doctors and nurses in acquisition, analyzing and interpretation of data.

Author contributions

Mingjun Lu, Rui Lu, Min Wang, Shangfei He participated in manuscript writing, in addition to diagnose and treat the patient. Jing Lu performed the literature search, the systematic review. Yi Liao and Tongtao Cui drafted the figures and tables. Mingjun Lu conceived the study, critically revised the whole manuscript, in addition to proofreading. All authors read and approved the final manuscript.

Funding

This study was supported by Mingjun Lu’s and Tongtao Cui’s funding: 1. Science and Technology project of Guangzhou (202102010180), 2. Guangdong Province aid Xinjiang science and technology project (2017B0202470), 3. Science and Technology project of Guangzhou (202102010142).

Availability of data and materials

The data underlying this article will be shared upon reasonable request to the corresponding author.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient to publish this report and its accompanying images.

Competing interests

The authors declare that they have no competing interests.

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Table 1: Differential diagnosis between TTS and Complications after PCI.

	Takotsubo syndrome	Complications after PCI (coronary-artery dissection, stent thrombosis)
Symptoms	heart failure is the primary symptom. Chest tightness can occur, but it is usually mild, with less chest pain, nausea, and vomiting.	Severe chest pain, chest tightness, palpitations, nausea, and vomiting are common symptoms.
ECG	In 12-lead that are beyond the blood supply area of a single vessel, extensive ST segment elevation or T wave changes appear. There are dynamic changes as the disease progresses.	The corresponding lead ST-T changes in the occluded vessel's blood supply area, which changes dynamically as the disease progresses.
Echocardiography	The abnormal range of ventricular wall motion usually exceeds the area dominated by a single coronary artery, accompanied by abnormal myocardial perfusion.	The area dominated by a single coronary artery usually corresponds to the abnormal range of ventricular wall motion.
CMR	The aberrant range of ventricular wall motion typically surpasses the area dominated by a single coronary artery, and the severity of local myocardial edema, perfusion deficiency, and delayed enhancement varies significantly.	The area dominated by a single coronary artery usually corresponds to the aberrant range of ventricular wall motion. Local myocardial edema, perfusion deficit, and delayed enhancement are are usually significant.
Operation	The operation went without a hitch.	There may be factors such as the formation of vascular wall dissection, poor stent attachment, and tissue prolapse during the operation.
Coronary angiograms	3 coronary arteries are smooth and the blood flow are unobstructed, without thrombus shadow and contrast agent retention.	Vascular occlusion, thrombosis and contrast agent retention may be seen.

Table 2: Changes of echocardiography.

	At admission	Day 1 after PCI	Day 7 after PCI	2 months later
LAs (mm)	24	31	28	32
LVDd (mm)	48	40	37	45
LVDs (mm)	28	26	22	28
LVEF (%)	73	51	65	59

No competing interests reported.

Download PDF

Journal Publication

published 16 Nov, 2023

Read the published version in Journal of Cardiothoracic Surgery →

Editorial decision: Major revision
28 Jun, 2023
Reviews received at journal
18 Apr, 2023
Reviewers agreed at journal
17 Apr, 2023
Reviewers invited by journal
17 Apr, 2023
Editor assigned by journal
03 Apr, 2023
Submission checks completed at journal
03 Apr, 2023
First submitted to journal
29 Mar, 2023

You are reading this latest preprint version

Case report: Takotsubo syndrome following percutaneous coronary intervention

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