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A Woman in Her 70s With Hypotension, Diffuse ST-Elevation, Murmurs, and an Intracardiac Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A previously healthy woman in her early 70s was referred to our emergency department with exertional dyspnea. She reported recent physical and emotional stress from work and dizziness 2 days prior to presentation. She denied fever or palpitations. Her blood pressure was 84/59 mm Hg. A harmonic, musical systolic murmur was heard at the left third intercostal space. An electrocardiogram (ECG; Figure 1A) showed diffuse ST-segment elevation, most prominently in the anterior precordial leads. Laboratory evaluation revealed elevated levels of troponin (1.33 ng/mL; normal range: ≤0.016 ng/mL [to convert to micrograms per liter, multiply by 1.0]), brain natriuretic peptide (376.5 pg/mL; normal range: ≤18.4 pg/mL [to convert to nanograms per liter, multiply by 1.0]), creatinine phosphokinase (96 U/L; normal range: 41-153 U/L), and D-dimer (0.68 μg/mL; normal range: ≤1.00 μg/mL [to convert to nanomoles per liter, multiply by 5.476]). Echocardiography showed left ventricular (LV) wall-motion abnormalities involving the mid and apical segments and an LV apical mass with protruding features. Noncontrast computed tomography confirmed the high-density LV mass (Figure 1B). Coronary angiography revealed mild to moderate coronary atherosclerosis without obstructive coronary artery disease.

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Takotsubo cardiomyopathy complicated by hypotension secondary to LV outflow tract obstruction and LV thrombus

C. Administer bisoprolol

Takotsubo cardiomyopathy (TTC), also called stress-induced cardiomyopathy, is characterized by transient, reversible, regional systolic and diastolic dysfunction, usually involving the LV apex and midventricle, with hyperkinesia of the basal LV segments.1 Unfortunately, the patient also developed LV outflow tract (LVOT) obstruction and hemodynamic instability. This is more frequent in elderly patients with TTC and is associated with septal bulging and systolic anterior motion of the anterior mitral valve leaflet.2 It was confirmed by cine cardiovascular magnetic resonance (CMR), which demonstrated an interventricular septal thickness greater than or equal to 12 mm and a systolic jet in the LVOT because of dynamic obstruction (Video). The prevalence of LVOT obstruction in TTC ranges from 19% to 25%, whereas 10% to 20% of patients with TTC develop cardiogenic shock.3 Thus, in patients presenting with ST-segment elevation complicated by hypotension, swift recognition of TTC is clinically imperative because of its unique clinical management requirements. Inotropic agents and intra-aortic balloon pumps used for the treatment of cardiogenic shock attributable to ST-segment elevation myocardial infarction (STEMI) can exacerbate shock and catastrophic sequelae in patients with TTC and LVOT obstruction.

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Article Information

Published Online: June 30, 2021. doi:10.1001/jamacardio.2021.2012

Correction: This article was corrected on August 4, 2021, to fix the corresponding author’s email address.

Corresponding Author: Shiro Nakamori, MD, Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 5148507, Japan (n-shiro@med.mie-u.ac.jp).

Conflict of Interest Disclosures: Dr Dohi reported receiving lecture fees equal to or more than 1 000 000 yen from Otsuka Pharmaceutical Co Ltd in 2020. No other disclosures were reported.

Additional Contributions: We thank Masaaki Ito, MD, and Kei Sato, MD, Mie University Hospital, for their inspirational guidance, and Susan M. Miller, MD, MPH, Houston Methodist Hospital for reviewing the manuscript and editorial assistance. They were compensated for their contributions. We also thank the patient for granting permission to publish this information.

References
1.
Sato  H , Tateishi  H , Uchida  T . Takotsubo-type cardiomyopathy due to multivessel spasm. In: Kodama  K , Haze  K , Hon  M , eds.  Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Kagakuhyouronsha:1990;56-64.
2.
De Backer  O , Debonnaire  P , Gevaert  S , Missault  L , Gheeraert  P , Muyldermans  L .  Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy.   BMC Cardiovasc Disord. 2014;14:147. doi:10.1186/1471-2261-14-147PubMedGoogle ScholarCrossref
3.
Sharkey  SW , Lesser  JR , Zenovich  AG ,  et al.  Acute and reversible cardiomyopathy provoked by stress in women from the United States.   Circulation. 2005;111(4):472-479. doi:10.1161/01.CIR.0000153801.51470.EBPubMedGoogle ScholarCrossref
4.
Santoro  F , Stiermaier  T , Tarantino  N ,  et al.  Left ventricular thrombi in takotsubo syndrome.   J Am Heart Assoc. 2017;6(12):e006990. doi:10.1161/JAHA.117.006990PubMedGoogle Scholar
5.
Frangieh  AH , Obeid  S , Ghadri  JR ,  et al; InterTAK Collaborators.  ECG criteria to differentiate between takotsubo (stress) cardiomyopathy and myocardial infarction.   J Am Heart Assoc. 2016;5(6):e003418. doi:10.1161/JAHA.116.003418PubMedGoogle Scholar
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