Takotsubo cardiomyopathy (left ventricular ballooning syndrome) induced during dobutamine stress echocardiography

Abstract

A 75-year-old woman presented with left ventricular apical ballooning syndrome mimicking acute anterior myocardial infarction. She had a long history of chest tightness and was undergoing a contrast stress echocardiogram because of frequent re-admissions with chest pain, all with normal ECGs and troponins. A standard dobutamine/atropine protocol had been used. The patient developed central crushing chest pain, marked ST elevation, transient slowing of heart rate and left ventricular apical ballooning. She was admitted to the coronary care unit and received thrombolysis. Echocardiography showed no mitral regurgitation, normal pulmonary artery systolic pressure and no intraventricular gradient. Immediate troponin T was significantly raised and peaked at 6 h. The patient underwent coronary angiography the next day. This showed systolic left ventricular apical ballooning and no coronary lesions or vasospasm. A further contrast echo 2 weeks later showed complete resolution of the wall motion abnormalities. Left ventricular apical ballooning or takotsubo syndrome can lead to cardiogenic shock but has a favourable prognosis compared to myocardial infarction. This patient was noted to be unusually anxious about having a stress echocardiogram and mental stress might be a precipitating factor, furthermore, this response during dobutamine stress echocardiography favours a catecholamine related disease mechanism.

Mid-ventricular variant of dobutamine-induced stress cardiomyopathy

“…Mechanism of dobutamine induced wall motion abnormality in the absence of obstructive epicardial disease is unclear. Several theories have been postulated including multivessel coronary vasospasm, severe systemic hypertension, systolic anterior motion leading to mitral regurgitation and dynamic intracavity pressure gradient secondary to left ventricular outflow tract obstruction or mid cavity obstruction (4,5). In a systematic review, 90% of study population had hypertension, hyperlipidemia and smoking as predisposing risk factors (6).…”

Stress-induced cardiomyopathy

“…Silberbauer et al [47] described a 75-year-old woman with higher levels of anxiety having a classic takotsubo-like apical ballooning during regular dobutamine-atropine stress echocardiography. In this case, apical ballooning was reversible, and troponin I and echocardiography changes were present associated with classic chest pain in a patient with normal coronaries, without the demonstration of coronary spasm [47].…”

No Myocardial Vulnerability to Mental Stress in Takotsubo Stress Cardiomyopathy

“…There is evidence of a strong relationship between TSC and acute mental or physiological stress [2]. Case studies have reported TSC occurring during dobutamine stress echocardiography (DSE) [3], [4]. However, a recent study on the effect of DSE in patients with a previous episode of TSC could not show a difference in tissue doppler imaging (TDI) variables during stress [5].…”