A CHALLENGING CASE OF ACUTE HF
• Male, 55 yo
C A S E P R E S E N TAT I O N
• BP 136/89mmHg
• History of alcohol abuse • HR 110 bpm
• Psychiatric history of suicidal • SpO2 97%
ideation
• S1S2, no murmur
• Hospitalized due to fever of
• Normal chest and abdomen
unknown origin (39o C)
examination
• Lab tests on admission:
• COVID (-)
• CRP= 197 mg/L
• Awake- responding
• WBCs/NEU= 12.200/ 9.830
• CXR normal
K/μl
• HIV, HBV (-)
• PCT= 3,24 ng/mL
• Na= 135 mEq/L
• hsTrop= 30 pg/mL
 • Patient complains of dyspnea, BP 117/73 mmHg
THREE DAYS AFTER
• Increase in troponin without chest pain (30- 600- 700)
ADMISSION
• Cardiology consultation requested
 WHAT DOES THIS ECG SHOW?

1. STEMI
2. Ventricular tachycardia
3. Hyperkalemia
4. Pericarditis
5. I don’t know, but it’s bad!
 SHARK FIN ECG

• “Lambda- wave”, “giant R waves”, “triangular

QRS-ST-T waveform”
• QRS-ST-T fusion
• Rare pattern- only a few case reports
• Indicative of high risk (SCD, CS, VF)-
malignant prognosis
• STEMI- LM disease or proximal LAD
• 1,4% of STEMI patients in case series
• Often misdiagnosed as wide QRS tachycardia
or hyperkalemia
• The exact mechanism is unknown- many
hypotheses
 expansion of LV- “Brodys’s hypothesis”
 increase in tissue resistance affecting conductivity-
“the solid angle theorem”
 differences in endo & epicardial action potentials-
Ito, IK,ATP and early INa)
Cipriani A et al, J Electrocardiol. 2018 Jan-Feb;51(1):8-14.
 TRANSTHORACIC
ECHOCARDIOGRAPHY
 WHAT WOULD BE THE NEXT STEP

1. Cardiac magnetic resonance

2. Computed tomography coronary angiography
3. Invasive coronary angiography
4. Functional testing for ischemia and viability
5. No further testing needed- initiation of HF treatment
CORONARY ANGIOGRAPHY
 ACS (?) - HFREF

• Patient denied PCI • Next day (D4) patient

• NTproBNP 8120 pg/ml convinced to undergo PCI-
successful PCI to LAD (2 DES)
• Hs troponin remained stable
(700 pg/dl)

• CMR on Day 5: absent late

gadolinium enhancement
Post PCI ECG:
Medical treatment:
ASA 100mg
Ticagrelor 90mg bid
Ramipril 2,5mg
Metoprolol 25mg bid
Eplerenone 25mg
TTE 7 DAYS LATER
 WHAT IS YOUR DIAGNOSIS?

1. Acute coronary syndrome

2. Takotsubo syndrome triggered by ACS
3. Takotsubo syndrome- CAD was a bystander
4. 2 or 3
5. Cannot be TTS since we have significant CAD
 ACS OR TAKOTSUBO ?

• Red thin line!

• Coronary atherosclerosis may coexist in patients with Takotsubo syndrome
• ACS may trigger TTS
• Particularly tricky combination when the culprit lesion in coronary angiography
involves LAD (meaning that the affected territory includes apical left ventricle)
• Imaging (echo & CMR) revealed motion abnormalities beyond what was expected
from a mid-LAD stenosis
• Significant elevation of hs Trop (favors ACS- against TTS) & NtproBNP (favors
TTS- against ACS) in our patient
INTERTAK DIAGNOSTIC CRITERIA

Ghadri Jr et al, Eur Heart J. 2018 Jun 7;39(22):2032-2046.

 TRIGGERS &
PATHOPHYSIOLOGY

Lyon AR et al. Eur J Heart Fail. 2016 Jan;18(1):8-

 CAD IN TTS

• Prevalence of CAD in TTS is not negligible

• Unfavorable outcomes (death- cardiogenic
shock) in TTS patients with CAD
• Similar short- term prognosis in TTS with
CAD and ACS (death from any cause- 30
days after admission)

Napp LC et al, Eur Heart J. 2020 Sep 7;41(34):3255-3268.

 KEY MESSAGES- CONCLUSION

• Acute HFrEF differential diagnosis between ACS and TTS may be challenging
• Biomarkers (hs trop- proBNP) and their kinetics and ratio are helpful
• Multimodality imaging of great importance
• Close follow up and reassessment may pose the final diagnosis

Be aware of the shark!