Takotsubo Syndrome in the Emergency Room - Diagnostic Challenges and Suggested Algorithm.

Takotsubo syndrome is an important condition to consider among patients with acute chest pain in the emergency room. It often mimics acute coronary syndrome since chest pain and ECG changes are key features in both conditions. The hallmark of takotsubo syndrome is transient left ventricular dysfunction (characterized by apical ballooning) followed by complete echocardiographic recovery in most cases. Although most patients exhibit a benign course, lethal complications may occur. The use of hand-held point-of-care focused cardiac ultrasound may be helpful for early identification of takotsubo syndrome and distinguishing it from acute coronary syndrome and other cardiovascular emergencies. Emergency room physicians should be familiar with typical and atypical presentations of takotsubo syndrome and its key electrocardiographic changes. The approach in the emergency room should be based on a combination the clinical presentation, ECG, and handheld echocardiography device findings, rather than a single electrocardiographic algorithm.

The Risk of Left Atrial Appendage Thrombus in Patients With Atrial Flutter Versus Atrial Fibrillation.

Objective: Patients with atrial fibrillation (AF) are at increased risk of thromboembolic events originating mainly from left atrial appendage thrombus (LAAT). Patients with atrial flutter (AFL) are treated with anticoagulation based on the same criteria as patients with AF. However, whether patients with AFL have similar thromboembolic risk as AF is unclear. In the current study we aimed to estimate the prevalence of LAAT in patients with AFL undergoing trans-esophageal echocardiography (TEE). Methods/results: We included 438 patients (404 with AF and 34 with AFL) scheduled for TEE to rule out LAAT before cardioversion (patients who reported no or inadequate anticoagulation before cardioversion). Demographic and echocardiographic data were compared between patients with and without LAAT. Despite a similar CHA2DS2-VASC score (3.8 ± 1.3 vs 3.4 ± 1.5 in the AF and AFL groups, respectively, P = .09), LAAT was documented in 12 (2.8%) in the AF group and in no patient in the AFL group (P < .0001). Conclusion: Based on our results and previous studies, it seems reasonable to re-evaluate the need for oral anticoagulation in specific populations with AFL such as those with solitary AFL (without a history of AF episodes) undergoing successful ablation and in those with low CHA2DS2-VASC score.