Anterior ST Elevation Myocardial Infarction: A Presentation of Focal Takotsubo Cardiomyopathy

Abstract

Takotsubo cardiomyopathy (TCM) is a transient, non-obstructive dysfunction of the heart. Focal TCM is a rare variant where the dysfunctional wall segment is within one coronary artery distribution. Reported to occur in less than 1.5% of cases, the majority of incidences involve the anterolateral wall segment, which is consistent with left main coronary artery distribution. Here, we share the case of a 78-year-old female who presented with acute ST-segment myocardial infarction and who was found to have focal TCM involving the mid anterior, apical anterior, and inferioapical wall segments, consistent with left anterior descending artery distribution. This case is very rare and represents a variant of focal TCM that is isolated to the anterior wall, involving the left anterior descending artery distribution.

Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy or broken heart syndrome, is a transient, non-obstructive cardiomyopathy resulting in acute regional or global systolic dysfunction.¹ First described in Japan in 1990, the term Takotsubo in Japanese describes a pot with a narrow neck used to catch octopus. With “tako” meaning octopus and “subo” meaning pot, TCM was thought to resemble the appearance of the left ventriculogram during systole.² TCM is a rare occurrence estimated to encompass 1-2% of acute coronary syndrome (ACS) patients.³ Characterized into five different types, the focal variant is the rarest and only type where the dysfunctional myocardium is isolated to a particular coronary vessel distribution (Table 1). Focal TCM is estimated to occur in less than 1.5% of total cases.⁴ Recovery of cardiac dysfunction is typically seen within one to four weeks.⁵ We present the case of a 78-year-old female who presented with anterior ST-segment elevation myocardial infarction. She was found to have focal TCM with isolated hypokinesis of the mid anterior, apical anterior, and inferioapical wall segments, consistent with left anterior descending artery distribution.

Case Report

A 78-year-old female with a past medical history of coronary artery disease (CAD) treated with percutaneous coronary intervention (PCI), hypertension, carotid artery stenosis, and aortic stenosis presented to our institution for acute intermittent chest pain radiating to the neck. An initial electrocardiogram revealed ST-segment elevation in leads V1 and V2, T-wave inversion in V2, and an elevated troponin of 3.93 ng/mL (Figure 1). The patient was immediately started on heparin infusion and taken for emergent cardiac catheterization. Cardiac catheterization revealed non-obstructive CAD (Figure 2). An intraoperative left ventriculogram (LV gram) showed an ejection fraction of 40%, with severe mid anterior, apical anterior, and inferioapical hypokinesis (Figure 3). No intervention was done and the patient was treated aggressively with medical therapy by being placed on guideline-directed medical therapy (GDMT). Troponins decreased during her hospital stay and the patient had an uneventful recovery. She was discharged with follow-up in the outpatient cardiology clinic one week later. There were no identified physical or emotional stressors found to have contributed to this patient’s TCM. A subsequent echocardiogram performed at the one-week follow-up demonstrated total resolution of the cardiomyopathy with a left ventricular ejection fraction of 55-60% and no wall motion abnormalities.

Discussion

Takotsubo cardiomyopathy is a transient, non-obstructive, and reversible cardiac myopathy resulting in systolic dysfunction. While its true cause remains unknown, theories have been proposed regarding excess catecholaminergic effects on the myocardium, causing “myocardial stunning” and microvascular dysfunction.⁶ TCM is commonly characterized by dysfunctional myocardium that extends beyond a particular coronary artery territory, but in focal TCM, the dysfunction myocardium is isolated to a single vessel distribution. According to the Takotsubo Registry Study, the most commonly affected wall segment found in focal TCM is the anterolateral wall, which signifies left main coronary artery distribution. In our case of focal TCM, the mid anterior, apical anterior, and inferioapical wall segments were exclusively involved, suggesting solely left anterior descending artery distribution. This specific presentation is extremely rare, making this particular case even more uncommon. Treatment of TCM is varied, but the general approach to treatment is supportive care, since the cardiomyopathy is typically transient. In general, TCM carries an in-hospital complication rate of 19.1%, which is similar to the in-hospital complication rate for ACS, and an in-hospital mortality rate of up to 8%.^3,4

Conclusion

TCM is a potentially life-threating disease that can result in acute cardiac dysfunction and fulminant heart failure. Focal TCM is a very rare form, having been documented in less than 1.5% of reported TCM cases. The majority of focal TCM cases involve the anterolateral wall segment with left main coronary artery distribution; however, our case of focal TCM revealed mid anterior, apical anterior, and inferioapical hypokinesis consistent with a LAD distribution, making it an extremely rare presentation. Focal TCM is a very rare disorder and its presentation mimics that of ACS. 

¹Department of Internal Medicine, The University of Toledo, Toledo, Ohio;

²Department of Cardiology, The University of Toledo, Toledo, Ohio

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Zeid Nesheiwat, DO, at zeid.nesheiwat@utoledo.edu.

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