Takotsubo Cardiomyopathy in Elderly Female Trauma Patients

A Case Series

Vishal Patel; Shuli Levy; Iqbal Malik; Michael B. Fertleman; Louis J. Koizia

Disclosures

J Med Case Reports. 2021;15(451) 

In This Article

Case Presentations

Case 1

A 79-year-old Caucasian woman with a past medical history of chronic obstructive pulmonary disease and ischemic heart disease (previous myocardial infarction in 2012 medically managed) was brought by ambulance to a major trauma center following presentation to her local emergency department with an accidental fall down 13 stairs at home. She reported feeling well prior to the fall and denied any central chest pain or shortness of breath on admission.

On examination, she was hemodynamically stable, with peripheral oxygen saturation of 88% and respiratory rate of 18 breaths per minute with a 24% oxygen requirement. Her arterial blood gas showed type 2 respiratory failure. She was found to have multiple left-sided rib fractures on an initial trauma computed tomography (CT) scan (2nd–8th with flail segments 4th–6th) and bilateral pretibial lacerations on physical examination.

On admission, her troponin I was elevated at 2485 ng/L (normal < 16 ng/L), and ECG showed rate-controlled atrial fibrillation with ST elevation in leads V2–V3 (Figure 1). Repeat troponin I was 1788 ng/L, and she was managed as for ACS, with dual antiplatelet therapy. An echocardiogram showed normal left ventricular size with severely impaired systolic function (estimated left ventricular ejection fraction [LVEF] 32%) with akinesis in the mid to apical segments and hypokinetic basal segments. B-type natriuretic peptide (BNP) was elevated at 2410 ng/L (< 266 ng/L).

Figure 1.

Admission (a) and discharge (b) electrocardiogram showing resolution of ST elevation in leads V2–V3 and echocardiography (c)

Her rib fractures were managed with a thoracic epidural for 7 days and tibial lacerations sutured. Due to an increasing oxygen requirement, a CT pulmonary angiogram ruled out a pulmonary embolism, but showed a left pleural effusion which required chest drain insertion.

An inpatient CT coronary angiogram showed dense calcification of all three main coronary arteries which was very similar to previous angiography. A repeat echocardiogram prior to discharge showed improved left ventricular function, making the diagnosis of Takotsubo cardiomyopathy secondary to trauma. She was discharged following a 14-day inpatient stay on single antiplatelet therapy and anticoagulation for atrial fibrillation.

Case 2

An 81-year-old Caucasian woman presented to the emergency department following a multifactorial fall onto her left side while mobilizing with a stick at home. Her past medical history included osteoporosis with a previous fragility fracture, asthma, myasthenia gravis, and previous thyroidectomy and thymectomy.

On examination, she was tachycardic at 103 beats per minute, with a blood pressure of 131/77. She required 24% oxygen to maintain peripheral saturation of 93%. Bloods revealed a raised troponin I of 1080 ng/L and 2300 ng/L on repeat 4 hours later. BNP level was 924 ng/L. ECG showed a sinus tachycardia with septal Q-waves, ST elevation in V1–V2, and inferior T-wave inversion (Figure 2). Hip X-ray revealed a left traverse fracture though the midshaft of the femur with proximal overlap requiring operative management. She had no chest pain. A bedside handheld echocardiography showed severe left ventricular impairment (LVEF < 25%) with anterior, anterolateral, and anteroseptal akinesia. She was managed as a high-risk ACS and given dual antiplatelet therapy. A departmental echocardiogram revealed normal left ventricular size with septal bulge and severely impaired systolic function (LVEF 30–35%).

Figure 2.

Admission electrocardiogram showing ST segment elevation in leads V1–2 (a), echocardiography showing septal bulge (b), and coronary angiography showing unobstructed coronary arteries (c)

The anesthetic team were concerned due to possible ACS and delayed operative management. She eventually went on to have definitive fixation (left closed reduction and femoral nailing) on day 6 of her admission with no perioperative complications. Her clopidogrel was held 24 hours prior to surgery (at the request of the surgeons), and restarted 3 days postoperatively.

Following the operation, she underwent an inpatient coronary angiogram at day 15. It showed mild atheroma in left anterior descending, left circumflex, and right coronary arteries with no occlusion. The patient was followed up in the cardiology clinic 6 weeks following her admission. She denied any chest pain and was at her baseline preadmission functional status. A cardiac magnetic resonance imaging (MRI) showed improvement in left ventricular function with an ejection fraction of 64%. Her BNP and troponin I levels had normalized by this time.

Case 3

An 82-year-old Caucasian woman was brought in by ambulance as a primary percutaneous coronary intervention (PCI) call following findings of anterolateral ST elevation following an unwitnessed fall while at home with a long lie. Her past medical history included left-sided breast cancer (wide local excision May 2019), asthma, hypertension, osteoarthritis, and osteopenia.

On physical examination, she was tachycardic at 115 beats per minute with a blood pressure of 129/56 mmHg. There was no respiratory distress or oxygen requirement. She was noted to have a shortened and externally rotated left lower limb. Her ECG showed sinus tachycardia with ST elevation in leads V3–5 with Q waves. Bloods showed raised troponin of 12,428 ng/L, BNP of 1368 ng/L, impaired renal function, and raised creatinine kinase 2023 U/L. X-ray of the left hip showed a left subcapital neck of femur fracture. A bedside handheld echocardiogram showed apical akinesia and hyperdynamic basal-to-mid systolic function with mild systolic dysfunction. Regional wall motion abnormalities did not follow a typical coronary distribution. Her working diagnosis by the reviewing cardiologist was Takotsubo cardiomyopathy, and she continued on single antiplatelet therapy. She did not undergo formal coronary angiography.

She had an uneventful left bipolar cemented hip hemiarthroplasty 48 hours following admission. Postoperatively, her echocardiogram showed improved biventricular function. Her ECG showed T wave inversion and resolution of ST segment elevation (Figure 3).

Figure 3.

Electrocardiograms of patient 3 performed on admission (a) and on discharge (b) showing resolution of ST elevation in leads V3–V5

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