Trauma, a Matter of the Heart-Molecular Mechanism of Post-Traumatic Cardiac Dysfunction.

Trauma remains a leading global cause of mortality, particularly in the young population. In the United States, approximately 30,000 patients with blunt cardiac trauma were recorded annually. Cardiac damage is a predictor for poor outcome after multiple trauma, with a poor prognosis and prolonged in-hospitalization. Systemic elevation of cardiac troponins was correlated with survival, injury severity score, and catecholamine consumption of patients after multiple trauma. The clinical features of the so-called "commotio cordis" are dysrhythmias, including ventricular fibrillation and sudden cardiac arrest as well as wall motion disorders. In trauma patients with inappropriate hypotension and inadequate response to fluid resuscitation, cardiac injury should be considered. Therefore, a combination of echocardiography (ECG) measurements, echocardiography, and systemic appearance of cardiomyocyte damage markers such as troponin appears to be an appropriate diagnostic approach to detect cardiac dysfunction after trauma. However, the mechanisms of post-traumatic cardiac dysfunction are still actively being investigated. This review aims to discuss cardiac damage following trauma, focusing on mechanisms of post-traumatic cardiac dysfunction associated with inflammation and complement activation. Herein, a causal relationship of cardiac dysfunction to traumatic brain injury, blunt chest trauma, multiple trauma, burn injury, psychosocial stress, fracture, and hemorrhagic shock are illustrated and therapeutic options are discussed.

Recurrent Takotsubo Cardiomyopathy Secondary to Cyclical Vomiting Syndrome.

We present a case of a young woman having recurrent admissions secondary to cyclical vomiting syndrome complicated with stress-induced cardiomyopathy/takotsubo cardiomyopathy (TC). She not only had left ventricular dysfunction but also suffered from anxiety and post-traumatic stress disorder for which professional help was sought. TC is defined as reversible, transient ventricular dysfunction in the absence of coronary artery disease. Due to the similarity of TC to acute coronary syndrome, TC is often left as a diagnosis of exclusion as it relies heavily on diagnosis by history, physical examination, and ultrasound imaging. Extreme emotional or physical stress can act as a trigger and timely identification and management of triggers causing TC are important to improve the outcome. In addition to physiological impact, TC also puts a toll on psychological health. Although the mechanism is not completely understood, reportedly plasma levels of epinephrine and norepinephrine were significantly elevated in patients with TC which might contribute to depression, anxiety, and psychological distress. Along with proper medical care, psychological care is equally important for patients with TC.

Mid-ventricular Takotsubo Cardiomyopathy With Coexisting Myocardial Bridge.

Typical takotsubo cardiomyopathy (TCM) is a reversible form of myocardial injury that presents with a characteristic ballooning abnormality of the left ventricular apex. Typical TCM has been associated with myocardial bridging; however, mid-ventricular variant TCM has not. We describe a rare case of mid-ventricular variant TCM with a coexisting left anterior descending artery myocardial bridge and discuss management strategies. Furthermore, we propose potential pathophysiological mechanisms that may contribute to the symptomatic presentation of both conditions as a manifestation of common etiological factors.

Euglycemic Diabetic Ketoacidosis Induced by Sodium-Glucose Cotransporter-2 Inhibitor Use and Coronary Angiography: A Case Report.

Euglycemic diabetic ketoacidosis (EDKA) is an uncommon subtype of diabetic ketoacidosis (DKA) which presents with similar laboratory findings to classic DKA with the exception of blood glucose levels being under 250 mg/dl. EDKA has several etiologies including pregnancy, starvation and the use of sodium-glucose cotransporter-2 inhibitors (SGLT-2). SGLT-2 inhibitors such as empagliflozin and dapagliflozin are increasing in popularity due to their positive benefits for patients with diabetes mellitus and cardiac disease. EDKA is underdiagnosed as it presents with blood sugar levels lower than expected in classic DKA. This case report describes a well-controlled type 2 diabetic patient prescribed an SGLT-2 inhibitor who developed EDKA after undergoing coronary angiography for acute heart failure.

A Case Report on Takotsubo Cardiomyopathy.

A 71-year-old female with a past medical history of hypertension, seizure disorder, chronic obstructive pulmonary disease, coronary artery disease, chronic kidney disease, open abdominal aortic aneurysm repair complicated by spinal cord infarction resulting in lower extremity paraparesis with chronic urinary retention, and sacral decubitus ulcer initially presented to the emergency department (ED) complaining of a one-week history of chest pain. During her inpatient stay, acute myocardial infarction and pulmonary embolism were ruled out and the patient was hemodynamically stable for discharge until she started experiencing new-onset nausea and dyspnea. Bedside electrocardiogram demonstrated ST elevations in the anterior leads with concomitant T-wave inversions in the inferolateral leads as well as a prolonged QTc. Troponin-HS was elevated at 907.69. Bedside transthoracic echocardiogram (TTE) demonstrated a severely decreased left ventricular ejection fraction of 10%-15% (representing an acute decrease from a left ventricular ejection fraction of 55%-60% from a TTE performed seven days prior). Cardiac catheterization demonstrated mild non-obstructive coronary artery disease and no interventions were conducted. Such signs and symptoms of acute myocardial infarction, without demonstrable coronary artery stenosis, are consistent with stress induced or Takotsubo cardiomyopathy. This phenomenon occurs in approximately 1%-2% of patients presenting with troponin-positive suspected acute coronary syndrome (ACS) or suspected ST-elevation myocardial infarction (STEMI).

Transient Mid-Ventricular Ballooning Syndrome: An Atypical Variant of Stress Cardiomyopathy.

Takotsubo cardiomyopathy, also known as stress cardiomyopathy (SCM) or broken heart syndrome, is characterized by transient systolic dysfunction of the left ventricle (LV). It typically affects the apical segment, but several rare variants exist. This report represents a rare variant of atypical stress cardiomyopathy that mimics territorial regional wall motion abnormalities of a blocked epicardial vessel.

A systematic cohort review of pheochromocytoma-induced typical versus atypical Takotsubo cardiomyopathy.

BACKGROUND: A rare presentation of pheochromocytoma (PCC) is catecholamine-induced-cardiomyopathy, or Takotsubo cardiomyopathy (TCM). PCC-induced TCM(PCC-TCM) can present as a typical or atypical type, based on the location of cardiac wall motion abnormalities. In this review, we sought to assess features and outcomes for PCC-TCM, and to compare typical and atypical subtypes. METHODS: A search was conducted on two databases (PubMed and Embase) for case series or reports on PCC-TCM from 2006 to 2020. RESULTS: One-hundred-and-two papers with a total of 104 cases of PCC-TCM were retrieved: 67(64.4%) typical and 37(35.6%) atypical subtypes. Overall median age was 50[range:23-86] years, the atypical group about a decade younger(p < 0.001). A female preponderance was seen for either subtype (∼75%). The most common presentations were chest pain(n = 60;58%), dyspnoea(n = 46;44%), and headache(n = 41;39.4%). Those with atypical subtype more often presented with fluid overload (typical:3% versus atypical:60%); acute pulmonary oedema (35% versus 60%); and cardiogenic shock (22% versus 43%) (all p < 0.05). Six patients (6%) died pre-operatively (typical:8% versus atypical:3%; p = 0.32). Non-fatal pre-operative complications occurred more among those with atypical TCM(p < 0.001), specifically cardiac arrest (typical:5% versus atypical:32%) and respiratory failure (9% versus 24%; both p < 0.05). Overall, 98 underwent surgery, majority undergoing laparoscopic adrenalectomy (81%); similar among the subtypes(p = 0.71). No robust data was provided on short-term outcomes, although two patients suffered from post-operative complications. CONCLUSION: Although quite similar in presentation to either standalone TCM or PCC, PCC-TCM seems to be associated with a higher degree of morbidity and mortality. The atypical PCC-TCM subgroup seems to have a more severe course with possibly a poorer outcome. Further research is needed to make more reliable inferences.

Reverse Takotsubo Cardiomyopathy During Immediate Post-partum: A Case Report.

Takotsubo cardiomyopathy or stress-induced cardiomyopathy is a particular entity with a transient left ventricular dysfunction without significant coronary artery obstruction, preceded by a stressful circumstance. Clinical presentation may mimic myocardial infarction, acute heart failure among the most common conditions. If suspected, the integration of clinical aspects, imaging results, and laboratory tests allows its diagnosis and proper management. Once described as a post-menopausal women's disease, is now recognized as a more frequent condition of young women, especially after stressful conditions such as post-surgical status and peripartum period, rendering as a disease with a certain predisposition to female patients, with a not always benign evolution. This case remarks an atypical presentation experiencing a first nigh fatal evolution but a later satisfactory recuperation.

One Patient: Two Variants of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TCM) is a form of non-ischemic cardiomyopathy that can present with signs of heart failure and volume overload; it often mimics acute coronary syndrome. It is characterized by stress-induced transient left ventricular (LV) dysfunction. Echocardiography classically demonstrates LV apical ballooning and akinesis in typical TCM, although other less common variants exist. Patients typically present with one variant. A 32-year-old woman with a past medical history of alcohol use disorder, anxiety, and hypertension presented to the hospital with chest pain, shortness of breath, nausea, vomiting, and diarrhea. She was diagnosed with cardiogenic shock in the setting of a newly identified LV ejection fraction (EF) of 24% on echocardiogram with findings consistent with typical apical TCM. Ischemic workup was unremarkable, and she was medically managed with clinical improvement and subsequent recovery of cardiac function. Four months later, the patient presented with similar symptoms at which time she was found to have a recurrence of heart failure with reduced LV EF; echocardiography showed reverse TCM. Patients with TCM who develop a recurrence typically maintain the same variant. The recurrence of TCM in a single patient with different anatomical variants is rare and poorly understood. We presented a case of a patient with alcohol use disorder who developed a recurrence of TCM with two anatomical variants. Further studies are necessary to investigate the predictors of recurrence and better understand the underlying mechanisms behind the different variants.

A Myasthenic Crisis Complicated by a Takotsubo Cardiomyopathy.

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction that affects skeletal muscles causing weakness, typically the ocular, facial, oropharyngeal, respiratory, and limb muscles. Patients can present as either an MG exacerbation with weakness of any muscle group or an MG crisis which is a life-threatening weakness of the respiratory muscles that usually requires intubation and mechanical ventilation; however, though rare, cardiac manifestations must be considered in the management of such patients.

A Broken Heart After Witnessing a Dying Heart: A Case of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy is a form of non-ischemic cardiomyopathy characterized by transient systolic dysfunction. The prevalence of Takotsubo cardiomyopathy has been estimated to be about 2% overall but about 10% amongst women presenting with clinical manifestations of acute coronary syndrome. The overall mechanism of the disease still remains unclear. However, treatment of Takotsubo cardiomyopathy appears to be similar to congestive heart failure (CHF) medical management. This case highlights the classic presentation exhibited very similar to acute coronary syndrome and diagnostic criteria for Takotsubo (stress-induced) cardiomyopathy.

Stress-Induced Subarachnoid Hemorrhage: A Case Report.

While there are many forms of intracranial hemorrhage (ICH), the most common form affecting young to middle-aged patients is subarachnoid hemorrhage (SAH). SAHs are primarily traumatic, while a minority of cases are spontaneous. The majority of spontaneous SAHs occur due to the rupture of a cerebrovascular aneurysm. A small number of spontaneous SAHs occur without any objective findings of an aneurysm. Most of these cases are in older patients with certain risk factors such as smoking, hypertension, and alcohol use. This article reports a young female patient without any known significant risk factors who developed an acute spontaneous SAH while experiencing a significant psychological stressor. Recent literature has focused on certain somatic manifestations of psychological stressors, such as stress-induced (Takotsubo) cardiomyopathy. We postulate that our patient's SAH was a sequela of psychological stress and that the pathophysiology may be similar to Takotsubo cardiomyopathy.

Coronavirus Disease 2019 (COVID-19)-Induced Takotsubo Cardiomyopathy Prognosis in Geriatric Setting.

An 86-year-old female with a past medical history of hypertension, vertebral fractures with chronic lumbar pain, hip fracture, osteoporosis, deafness, and microcytic anemia underwent hospital admission for emergency medical management of her respiratory distress. The (overall) diagnostic workup confirmed COVID-19, the patient presented with 50% SPO2 (oxygen saturation), sinus tachycardia, diffuse bilateral pulmonary crackles, mild jugular venous distention (JVD), minimal bilateral pitting edema, elevated cardiac enzymes, bilateral pulmonary opacities, and ST-segment elevation. The cardiovascular assessment indicated stress-induced cardiomyopathy/Takotsubo cardiomyopathy (TCM) determined by 35%-40% LVEF (left ventricular ejection fraction), mid to apical left ventricular (LV) akinesia with preserved function in the proximal segment, aortic valve sclerosis, reduced excursion of Trileaflet valve (without stenosis), and mild-to-moderate tricuspid regurgitation with moderate pulmonary artery systolic pressure (PASP). The treatment protocol relied on 81 mg aspirin, 75 mg plavix, 20 mg lipitor, remdesivir, dexamethasone, ceftriaxone, azithromycin, red blood cells transfusion (pRBCs), endotracheal intubation for respiratory support, and systemic hemodynamic support. The patient's condition did not improve despite all treatment, and she passed away after seven days following her hospital admission.

Africanized Honey Bee Sting-Induced Stress-Related Cardiomyopathy: A Bee or Octopus Trap.

The Africanized honey bee commonly referred to as the "killer bee," is a hybrid of the East African lowland honey bee with various European honey bees. These bees tend to be more hostile as compared to other bee species. Their stings may have devastating clinical sequelae, including cardiovascular, cerebrovascular events, and fatalities. We report the first-in-Caribbean case of a middle-aged woman who experienced stress-related, Takotsubo cardiomyopathy (also known as stress-related cardiomyopathy [SRC]) after being afflicted with innumerable Africanized honey bee stings. Key clinical message: The clinician should be cognizant of Takotsubo's cardiomyopathy as a potential sequela of Hymenoptera envenomation and anaphylaxis.

Stress Cardiomyopathy Triggered by Status Epilepticus Secondary to Herpes Simplex Virus Encephalitis: Case Report and Literature Review.

Stress cardiomyopathy (SCM) occurs in approximately 1% of patients presenting with troponin-positive suspected acute coronary syndrome (ACS). We present here a 50-year-old female who presented to the emergency department (ED) with altered mental status. In the hospital, she was found to have status epilepticus (SE) secondary to Herpes simplex virus encephalitis. Her hospital stay was complicated by high troponins and a transthoracic echocardiogram showed reduced ejection fraction and wall motion abnormality. Repeat echo five days later showed normal ventricular systolic function with no wall motion abnormality. Extensive ischemia workup was negative. A diagnosis of stress cardiomyopathy has been made. We urge physicians to include SCM in their differential diagnosis especially in cases of status epilepticus in order to avoid invasive procedures and for better management of patients.

Takotsubo Cardiomyopathy and QTc Prolongation with Subsequent Improvement of QTc Interval and Resolution of Apical Ballooning: A Case Report.

Stress-induced cardiomyopathy, also known as Takotsubo cardiomyopathy (TTS), is characterized by transient regional systolic dysfunction. Furthermore, electrocardiogram (ECG) changes can vary as TTS evolves. We report a case of a 67-year-old woman who presented to the ER after cardiac arrest. She was found to have stress-induced cardiomyopathy with prolonged QTc interval. The patient developed torsades de pointes for which she required cardioversion, followed by improvement of QTc interval corresponding to resolution of echocardiographic evidence of apical ballooning.

A Mid-Ventricular Variant of Takotsubo Cardiomyopathy: A Case Study and Review of Literature.

Different variants of Takotsubo cardiomyopathy (TC) have been described recently. In the present case, we report a post-menopausal woman who had been experiencing significant emotional distress, admitted with typical chest pain, electrocardiographic changes, and elevated troponin levels. She underwent left heart catheterization that demonstrated mild non-obstructive coronary disease and mid-ventricular focal wall motion abnormality, consistent with the mid-ventricular variant of TC. One month after her discharge, a repeated echocardiogram showed preserved ejection fraction and no wall motion abnormalities. In the mid-ventricular variant, we usually observe a unique end-systolic appearance that resembles a Greek vase. It is possible that atypical patterns of left ventricle (LV) dysfunction related to TC are being underrecognized. Therefore, this case study highlights the importance of recognizing less frequent variants of TC.

Pulmonary Edema and Stunned Myocardium in Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage is a life-threatening event that can cause permanent disability. This life-threatening event can be further complicated by subsequent cardiac and pulmonary disability. The presence of a neurogenic cardiomyopathy and pulmonary edema increases the morbidity and mortality of patients who suffer from aneurysmal subarachnoid hemorrhage.  In this paper, we discuss a 39-year-old woman who presented to the emergency department (ED) with a chief complaint of a pounding headache with associated nausea and vomiting for the past three days. She had a past medical history significant only for migraines. During her stay in the ED, she began to exhibit signs of altered consciousness, hemoptysis, and respiratory compromise. Neuroimaging showed evidence of subarachnoid hemorrhage. The exact source of her subarachnoid hemorrhage could not be located with neuroimaging or angiography. Her clinical course was complicated by pulmonary edema and neurogenic stunned myocardium, and is still ongoing.

Contrast Media-Induced Anaphylaxis Causing a Stress-Related Cardiomyopathy Post Percutaneous Coronary Intervention: Case Report.

Anaphylaxis is a sudden-onset, severe hypersensitivity reaction that can be potentially fatal. It can often transition to refractory hemodynamic instability, eventually resulting in death. Stress-related cardiomyopathies (SRCs) have multifactorial etiologies, including being linked to excessive catecholamine release in periods of intense stress. This novel case report recounts a SRC caused by contrast-induced anaphylaxis within 1 hour post percutaneous coronary intervention. Both acutely life-threatening conditions may occur simultaneously and are implicated with devastating complications. Further research is required to understand this cardiac-neuroaxis interplay in SRC to identify risk factors and develop management strategies.