Takotsubo cardiomyopathy with marked ST-segment elevation and electrical alternans complicated with hyperglycemic hyperosmolar state

Plasma Hyperosmolality Prolongs QTc Interval and Increases Risk for Atrial Fibrillation in Traumatic Brain Injury Patients

Introduction: Hyperosmotic therapy with mannitol is frequently used for treatment cerebral edema, and 320 mOsm/kg H₂O has been recommended as a high limit for therapeutic plasma osmolality. However, plasma hyperosmolality may impair cardiac function, increasing the risk of cardiac events. The aim of this study was to analyze the relation between changes in plasma osmolality and electrocardiographic variables and cardiac arrhythmia in patients treated for isolated traumatic brain injury (iTBI). Methods: Adult iTBI patients requiring mannitol infusion following cerebral edema, and with a Glasgow Coma Score below 8, were included. Plasma osmolality was measured with Osmometr 800 CLG. Spatial QRS-T angle (spQRS-T), corrected QT interval (QTc) and STJ segment were calculated from digital resting 12-lead ECGs and analyzed in relation to four levels of plasma osmolality: (A) <280 mOsm/kg H₂O; (B) 280–295 mOsm/kg H₂O; (C) 295–310 mOsm/kg H₂O; and (D) >310 mOsm/kg H₂O. All parameters were measured during five consecutive days of treatment. Results: 94 patients aged 18-64 were studied. Increased plasma osmolality correlated with prolonged QTc (p < 0.001), intensified disorders in STJ and increased the risk for cardiac arrhythmia. Moreover, plasma osmolality >313 mOms/kg H₂O significantly increased the risk of QTc prolongation >500 ms. Conclusion: In patients treated for iTBI, excessively increased plasma osmolality contributes to electrocardiographic disorders including prolonged QTc, while also correlating with increased risk for cardiac arrhythmias.

Biventricular takotsubo cardiomyopathy in an elderly woman with uncontrolled type 2 diabetes: the biphasic echocardiographic and clinical pattern

We describe a case of an elderly woman who was diagnosed with a biventricular takotsubo cardiomyopathy (TTC) with combination of emotional stress and poorly controlled type 2 diabetes. We observed significant correlation between biphasic improvement of right (after 4 days) and left ventricle function (after 4 weeks) with normalization glycemic status. To our knowledge, this is the first reported case in the literature of biventricular TTC with such metabolic disturbances.

Initial clinical presentation of Takotsubo cardiomyopathy with-a focus on electrocardiographic changes: A literature review of cases

AIM: To review the initial presentation and demonstrate the importance of Takotsubo cardiomyopathy.

METHODS: A PubMed search using the terms “Takotsubo cardiomyopathy (TC)” and “apical ballooning syndrome” yielded 211 publications. Only those that were relevant were fully reviewed. The gender, age, precipitating stressor, main complaint at presentation, electrocardiogram (ECG) at admission and serum cardiac markers of patients diagnosed with TC, were extracted as available. The data were organized in tables and graphics, and the incidence of the disorder was calculated and analyzed.

RESULTS: A total of 250 clinical cases were examined. The predominant gender that was affected was female, with a prevalence of 87.5%. The mean age of presentation was 64 ± 14 years. The cases were divided by age into 10-year intervals. The age interval of 60-69 years showed the highest frequency of TC, accounting for 79 cases. The most common precipitating stressor was physical (50% of cases). Chest pain was the primary complaint at presentation (58.8% of cases) followed by dyspnea (30% of cases). The ST segment changes category was the most common (60%), followed by T wave changes (39.6%). Of the 60% of cases with ST segment changes, 12% had concomitant T wave changes. This means that for 27.6% of the cases, the primary abnormality in the ECG was T wave changes; 87.6% of cases with TC had a change in the ST segment, in the T wave or in both. The percentage of ECGs presenting with changes in the anterior wall was 54.4% (35.6% of ST segment elevation + 1.6% of ST segment depression + 17.2% of T wave inversion). The percentage of patients presenting with changes in the lateral segment of the heart was 46.8%, while the percentage of patients with changes in the inferior heart was 21.6% and the percentage of patients with changes in the apical region was only 16%. The prevalence of elevated creatinine kinase and/or troponin on initial presentation was 89.3%.

CONCLUSION: It is essential that every physician consider Takotsubo cardiomyopathy as a possible differential diagnosis when a patient is classified with acute coronary syndrome. To do so, it is necessary to know the clinical presentation of this syndrome in its early stages.

Takotsubo cardiomyopathy: definition and clinical profile

Takotsubo cardiomyopathy (TTC) is an increasingly recognized, reversible cardiomyopathy with a clinical presentation that mimics an acute coronary syndrome but without evidence of obstructive coronary lesions. Typical presentation involves chest pain and/or dyspnea, transient ST-segment elevation on the electrocardiogram, and a modest increase in cardiac troponin. Cardiac imaging demonstrates wall-motion abnormalities that extend beyond the territory of a single epicardial coronary artery, and the absence of obstructive coronary lesions. Supportive treatment leads to spontaneous, rapid recovery of ventricular function, but about 10% of patients have recurrent events. This article reviews the defining features and clinical profile of TTC.

Impact of severe earthquake on the occurrence of acute coronary syndrome and stroke in a rural area of Japan

BACKGROUND

Although acute coronary syndrome (ACS) and stroke are known to increase after earthquake, few data exist regarding the effect of earthquake on these cardiovascular events in rural areas.

METHODS AND RESULTS

The Noto Peninsula earthquake with a magnitude of 6.9 occurred at 9:45 a.m. on 25 March 2007. The first case of ACS occurred approximately 15 min later, whereas cerebral hemorrhage (CH) occurred 72 h after the onset of earthquake. During the 35 days after earthquake, among 49 patients who were attended by local ambulance, 5 patients with ACS (10.2%) and 8 with CH (16.3%) were documented and 4 died. The total number of both ACS and CH cases was greater than the averages for the same period of the past 3 years in this area (2.0 vs 5 and 2.3 vs 8, P<0.01). Interestingly, the most cases of ACS had occurred within 7 days after earthquake and for CH not until 35 days later.

CONCLUSIONS

Even in rural areas a severe earthquake results in increased incidence of ACS and CH, which can occur at different times after the event, although the effects of other environmental factors should be further investigated.