Journal of Pharmacy and Pharmacology 6 (2018) 248-253

doi: 10.17265/2328-2150/2018.03.006
D DAVID PUBLISHING

Stress Related Takotsubo Cardiomyopathy: A Case

Report

Ana Beatriz Boamorte Cortela1, Franciele Silva Bernardo2, Marcos Tadao Kavanishi1, Vilmar Queiroz de
Menezes3 and Nivaldo Cortela3
1. Faculty of Medicine, Centro Universitário de Várzea Grande, Várzea Grande 78110-000, Brazil
2. Faculty of Medicine, Universidade do Estado de Mato Grosso, Cáceres 78200-000, Brazil
3. Hospital Regional de Cáceres Dr. Antônio Fontes, Universidade do Estado de Mato Grosso, Cáceres 78200-000, Brazil

Abstract: First described in Hiroshima City Hospital in 1990, Takotsubo Cardiomyopathy emerged as an important differential
diagnosis for acute coronary syndrome, since this disease mimics some commemoratives presentations of acute coronary syndrome
such as chest symptoms, electrocardiographic changes and cardiac injury biomarker alteration. Also, it’s important to emphasize that,
although it commonly occurs among woman, TCC can happen in males, as demonstrated in other studies which 10% of the cases
occurred in male sex. In this way, this study shows the importance of Takotsubo Cardiomyopathy as a differential diagnosis for acute
coronary syndrome.

Key words: Takotsubo cardiomyopathy, apical ballooning, broken-heart syndrome.

1. Introduction experiences of anger, frustration, anxiety, panic, or fear,

major surgical procedures, acute respiratory failure,
The broken-heart syndrome, also known as TTC
orthopedic trauma, and many others [8].
(Takotsubo Cardiomyopathy), is a stress-induced
condition with emotional or physical triggers 2. Case Report
depending on the patient clinical history. It was first
A 73-years-old male patient sought cardiac care for
described in the 1990’s and since then was best studied
evaluation due to an episode of precordial pain,
and described as a transient left ventricular apical
characterized as a strong retrosternal pain, which
ballooning, associated with chest pain, high levels of
happened 2 days ago and lasted 3 hours. During these
catecholamines and electrocardiographic waves
symptoms, the BP (blood pressure) was 70/40 mmHg.
abnormalities in the absence of coronary stenosis [1, 2]
At the moment of the medical appointment, the patient
Despite the TTC was extremely rare in male
was asymptomatic and denied medical history of chest
population, recently they constitute over 10% of the
pain, acute myocardial infarction, diabetes and other
cases and are mostly related to physical stress triggers
comorbidities. In addition he was not using any
[3]. On the other side, the female population
medications.
corresponds to 80%-100% of the reported cases [4-7]
The physical examination presented BP of 130/80
especially in the postmenopausal years and commonly
mmHg and normal auscultation. The laboratorial tests,
related to emotional stress triggers.
including blood count, blood glucose, lipidogram,
Actually, there are an amount of stress causes such
renal and hepatic function, uric acid and thyroid
as: loss of a beloved one, financial problems, personal
stimulating hormone showed normal results.
The ECG (electrocardiography) demonstrated sinus
Corresponding author: Ana Beatriz Boamorte Cortela,
medicine student, research fields: cardiology. rhythm with ventricular repolarization changes
 Stress Related Takotsubo Cardiomyopathy: A Case Report 249

observed in the D1, aVL and V1 to V6 leads,
suggesting an extensive lateral and antero-lateral walls
ischemia (Fig. 1). The echocardiography showed apical
left ventricle hypokinesis. With a diagnostic hypothesis
of acute myocardial infarction (AMI), the following
procedure was adopted: request of Cardiac Catheterism
(CAT) and treatment with propranolol, acetylsalicylic
acid, clopidogrel and simvastatin. These medications
were taken for six days only, until the return with the
CAT images.
After 4 days the patient underwent CAT, which
revealed very tortuous coronaries, but without
obstructions and left ventricle with increased systolic
and diastolic volumes, exhibiting hypocontractility in
all anterior and apical segments, suggesting TTC (Fig. 2).
Two days after the CAT, the patient returned to
medical appointment and stated that in the last few
days he was nervous because of problems with his son
and that the pain has started since then. Thus, TTC was
confirmed. The previous treatment was suspended and
the new prescription was Somalgin, Sustrate and
Simvastatin. The patient evolved with no
hemodynamic complication and the return was
scheduled to six months later.
After this period, patient returns without complaints
and only using Simvastatin. At the physic evaluation,

Fig. 1 ECG abnormalities observed in the first clinical appointment.

250 Stress Related Takotsubo Cardiomyopathy: A Case Report

Fig. 2 From the left to the right: CAT during diastole, CAT during systole, CAT showing left coronary with no obstructions.

Fig. 3 ECG after 6 months.

 Stress Related Takotsubo Cardiomyopathy: A Case Report
BP of 120/80 mmHg, normal heart auscultation,
ECG within normal limits (Fig. 3) and echocardiogram:
discrete aortic insufficiency and normal cardiac
contractility. With TTC resolved, the Somalgin and
Sustrate were discontinued, but the Simvastatin was
maintained. The return was oriented to happen within
one year.
3. Discussion
The Takotsubo Syndrome is a reversible situation,
characterized by a transient dysfunction of the left
ventricle, which mimics the acute coronary syndrome
(ACS). TTC occurs after a physic or emotional stress
event, especially in postmenopausal woman as many
studies have showed as Refs. [4-7, 9]. The present
description shows a TTC in male patient, situation that
occurs in nearly 10% of the reported cases [3, 9, 10].
Also, studies have shown that the majority of cases in
man happened due to a physical stress, for instance,
acute respiratory failure, AMI, and others [3, 10-13].
Other physical stress includes surgery procedures,
subarachnoid hemorrhage, hypertensive crisis, cancer,
etc. [8]. However, our patient presented an emotional
stress triggering the syndrome, more specifically, an
interpersonal problem between him and his son. The
possible association is the adrenergic discharge
stress-provoked [5].
Many etiologies and pathophysiology mechanisms
where proposed such acute myocarditis, diffuse
coronary spasm, non-occlusive plaque rupture
followed by spontaneous thrombolysis, and others [5].
New hypothesis has been accepted as cardio toxicity
catecholamine-mediated, which causes an overload of
calcium to the cardiac myocytes, unleashing a
ventricular contraction and ventricular function disturb
[14]. It is possible that the endothelial dysfunction is
related to the menopausal decrease of estrogen [15].
The mental stress may have a direct effect over the
endothelial function on account of the endothelin
receptor type A activation. Nevertheless, the
pathophysiology remains undetermined and it’s likely
251
to be multifactorial, involving the vascular, endocrine
and nervous systems.
The symptoms of TTC include chest pain or dyspnea
but they do not present the same severity as the ACS
[17]. Clinical state is associated to electrocardiographic
alterations such ST-segment elevation and T-wave
inversion respecting the leads of a single coronary
territory. Our patient had a left anterior descending
coronary pattern, which is similar in patients with this
artery obstruction. Ref. [16] made a comparison
between those two conditions and found that the only
difference was the ST-segment amplitude, which is
lower in TTC.
While the etiology of the ECG alterations is not
defined, it’s important to treat AMI and request an
imaging exam. Echocardiography, cardiac magnetic
tomography or even resonance is useful in this case,
and they consist in non-invasive methods of evaluation.
With them it’s possible to analyze the segments with
abnormal contraction, reveal presence of apical
thrombosis, cardiac rupture and other conditions that
evolve to cardiogenic shock [1].
It is essential to require CAT in the acute phase of
ST-segment elevation, due to the possibility of
coronary obstruction [1]. In TCC, the coronary
angiography reveals totally normal blood vessels in
most cases, but non-critical luminal stenosis can be
found. In fact, the presence of coronary artery disease
does not exclude the possibility of TTC involvement,
since it was found to participate on the TCC
development [17, 18]. On the other side, patients under
hemodynamic risks or in which the CAT’s harm
exceeds its benefits must undergo echocardiography
first [1].
Essentially, the treatment basis is support and
observation as the spontaneous and complete reversion
of the cardiac dysfunction occurs in days or weeks. The
prognostic of the illness itself is benign, but the
previous condition and the presence of comorbidities
are the most important predictors of complications and
adverse outcomes [19]. Possible complications are
252 Stress Related Takotsubo Cardiomyopathy: A Case Report
cardiogenic shock, ventricular arrhythmia, ventricular
fibrillation, ventricular rupture and others [19]. In our
case, the patient evolved with no complications and
returned to the cardiologic clinic after six months and
therefore it’s not possible to assume how much time
took to the syndrome to reverse. TCC is characterized
of resolving spontaneously in most of the cases, taking
over days or few weeks to reverse. Curiously, there are
cases reporting more than 3 months of abnormalities
persistence [20].
4. Conclusions
As TTC is a rare disease, many things remain
unknown about it, especially its etiology. On the other
hand, it’s always important to maintain TTC as a
differential diagnosis for ACS, mainly in patients
whose chest symptoms started post a stressful event,
since the treatment and the prognosis of both
pathologies are different. Finally, the purpose of this
study is to implement the database about TTC and
reinforce the importance of the diagnosis in the male
gender, as demonstrated in this study. Furthermore, it’s
expected that more knowledge about the disease will be
discovered as more searches about the theme are
developed.
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