Takotsubo cardiomyopathy caused iatrogenic thyrotoxicosis

http://crim.sciedupress.com Case Reports in Internal Medicine, 2015, Vol. 2, No. 2 CASE REPORT Takotsubo cardiomyopathy caused iatrogenic thyrotoxicosis Lana Maričić1, 2, Sandra Makarović1, 2, Kristina Selthofer-Relatić1, 2, Krešimir Jelić1, Robert Steiner1, 2 1. Department of Cardiovascular Diseases, University Hospital Osijek, Osijek, Croatia. 2. Faculty of Medicine, University J.J. Strossmayer Osijek, Osijek, Croatia. Correspondence: Lana Maričić. Address: Department of Cardiovascular Diseases, University Hospital Osijek, J. Huttlera 4 Osijek, Croatia. Email: [email protected] Received: February 26, 2015 DOI: 10.5430/crim.v2n2p82 Accepted: April 16, 2015 Online Published: April 27, 2015 URL: http://dx.doi.org/10.5430/crim.v2n2p82 Abstract The patient was a 34-year-old woman presented to the emergency department with a chest pain. During the last two years she took replacement therapy with levothyroxine because of lymphocytic thyroiditis. The ECG upon admittance verifies tall T waves in the precordial leads and the subsequent ECG shows a negativation of the T wave in the precordial leads. In the patient’s echocardiographic findings, dyskinesia of the apical anterior segment is found, in laboratory findings increased levels of cardioselective biomarkers are present. Afterwards, a coronary angiography is done and no significant stenosis was detected in any coronary arteries, and ventriculography showed hypokinesia anterior mid segments. Considering all this, the diagnosis of Takotsubo cardiomyopathy is set, iatrogenically caused by thyrotoxicosis in combination with the recent Caesarean section. Keywords Takotsubo cardiomyopathy, Thyrotoxicosis 1 Introduction Takotsubo cardiomyopathy, also known as the broken-heart syndrome, was described by scientists in Japan in the beginning of the nineties. It is characterized by akinesia or dyskinesia of the apical or middle ventricular segment with the absence of obstructive coronary artery disease, pheochromocytoma or myocarditis (Mayo criteria) [1]. The syndrome is accompanied by a newly created ST-segment elevation or T wave inversion, with a moderate increase of the cardiac biomarkers. It is often associated with intense emotional and psychological stress. Among the factors that are important in the induction of Takotsubo cardiomyopathy are an acute exacerbation of COPD, thyrotoxicosis, Addison’s crisis, general anesthesia, septic shock, anaphylaxis, acute cholecystitis, acute pancreatitis, pregnancy, cerebrovascular disease [2]. The appearance of Takotsubo cardiomyopathy is predominantly described in postmenopausal women and in 5%-11% of cases it occurs in women younger than 50 [3, 4]. 2 Case presentation The patient was a 34-year-old woman presented to the emergency department with a chest pain that had lasted for two hours. The chest pain started during a normal physical activity. The patient has not been more seriously ill. Her history 82 ISSN 2332-7243 E-ISSN 2332-7251 http://crim.ssciedupress.com Case Reporrts in Internal Meedicine, 2015, V Vol. 2, No. 2 revealed medically m contrrolled chronic lymphocytic thyroiditis andd she has beeen taking a reeplacement theerapy with levothyroxine at the dose of 75mcg. Thee last control off the thyroid hoormone was a ffew months agoo, during pregnnancy. She n and the last was w ten weekss ago. Immediaately upon the admit of the patient, she has had two births by Caaesarean section underwent physical exam mination and an a anamnesis was taken, theen an electroccardiogram andd a complete laboratory hy (ECG) upon n admittance veerifies tall T waaves in the preecordial leads (see Figure analysis weere made. Electrocardiograph 1A) and reepeated ECG shows s a negattivation of the T wave in thhe precordial leeads (see Figuure 1B). In thee patient’s echocardio ographic finding gs, dyskinesia of o the apical an nterior segmentt is monitored. In laboratory ffindings, increaased levels of cardioseelective biomaarkers (creatinee kinase 78-15 55-218 U/L; crreatine kinase--MB 15-28-400 U/L; troponinn I 1,00716.164-16,640- 13.258 to 8.503 μg/L). Afterwards, A a coronary angioggraphy is done by which clearr test results off epicardial a ventriculog graphy shows hypokinesia h annterior mid seggments (see Fiigure 2). The ssubsequent arteries aree determined, and laboratory findings of th hyroid hormon nes have deterrmined thyrotooxicosis (FT4 35 pmol/L; F FT3 7.25 pmool/L; TSH 0.008 mIU//L; anti TPO > 7500 IU/mL) and levothyrox xine is excludeed from the therrapy. The comb mbination of history, ECG changes, echocardiographic findings, and a a normal finding of corronary blood vvessels, as weell as in similaar studies, indicates Takotsubo T cardiiomyopathy diaagnosis [5]. Con nsidering all thhis, the diagnossis of Takotsubbo cardiomyopaathy is set, iatrogenicaally caused by thyrotoxicosis t in combination n with the receent Caesarean ssection. While hospitalized, tthe patient was treated d with a beta blocker, b the ang giotensin-conv verting enzymee inhibitor. Durring the follow wing period thee patient is hemodynam mically stable, without chest pain. She has been followedd at the outpatieent clinic reguularly and the ssubsequent echocardio ogram showed no n excesses in contractility, and a the ECG shhowed no scar formations. Figure 1A. EC CG on the adm mission Figure 1B. R Repeated ECG G after 6 hours Figure 2. Ven ntriculography shows hypokinnesia anterior m mid segments Published byy Sciedu Press 83 http://crim.sciedupress.com Case Reports in Internal Medicine, 2015, Vol. 2, No. 2 3 Discussion Pathophysiology of Takotsubo cardiomyopathy is not completely clarified. The most common theory talks about coronary vasospasm, microvascular dysfunction [6]. In patients, an increase of catecholamines was determined compared to patients with myocardial infarction, which justifies the belief that stress is one of the key triggers for this type of cardiomyopathy. The effect of thyroid hormone on the heart is evident at several levels, thus it simultaneously affects the heart rate, myocardial contractility, peripheral vascular resistance, and at the same time they are responsible for the expression of structural and regulatory genes in myocytes [7]. The combination of iatrogenically caused thyrotoxicosis (taking levothyroxine), physical stress (the recent birth by Caesarean section) and emotional stress (a working mother of two children) resulted in transient left ventricular dysfunction. The pathophsiology of Takotsubo cardiomyopathy in this case is a combination of physiological stress and thyrotoxicosis. The physiological stress leads to the activation of cortisol, catecholamines and cytokine that affect contractility of the myocardium. Simultaneously, elevated levels of FT3 in combination with the aforementioned pathophysiological mechanisms themselves significantly affect the structure and function of the myocardium. Certainly, the adrenergic system plays a key role in the development of stress-induced cardiomyopathy. 4 Conclusion This case confirms that the presence of two factors, iatrogenically caused thyrotoxicosis and a recent Caesarean section which led to an increase in the levels of catecholamines, increases the risk for the development of Takotsubo cardiomyopathy in younger women, although it predominantly occurs in elderly women. References [1] Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-tsubo stress cardiomyopathy): A mimic of acute myocardial infarction. Ann Intern Med. 2004; 141: 858-65. PMid:15583228 [2] Gianni M, Dentali F, Grandi AM, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: A systemic review. Eur Heart J. 2006; 27:1523-29. PMid:16720686 http://dx.doi.org/10.1093/eurheartj/ehl032 [3] Bybee KA, Kara T, Prasad A, et al. Systemic reciew: Transinet left venntricular apical balooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004; 858-65. PMid:15583228 http://dx.doi.org/10.7326/0003-4819-141-11-200412070-00010 [4] Patel Sm, Chokka RG, Prasad K, et al. Distinctive clinical characteristics according to age and gender in apical ballooning syndrome (takotsubo stress cardiomyopathy): An analysis focusing on men and young women. J Card Fail. 2013; 19: 306-10. PMid:23663812 http://dx.doi.org/10.1016/j.cardfail.2013.03.007 [5] Kurisu S, Kihara Y. Diagnosis and management of takotsubo cardiomyopathy. Intern Med. 2015; 54(1): 1-2. PMid:25742885 http://dx.doi.org/10.2169/internalmedicine.54.3454 [6] Pernicova I, Garg S, Bourantas CV, et al. Takotsubo cardiomyopathy: a review of the literature. Angiology. 2010; 61(2): 166-73. PMid:19625263 http://dx.doi.org/10.1177/0003319709335029 [7] Irwin Klein, Sara Danzi. Thyroid Disease and the Heart. Circulation. 2007; 116: 1725-35. PMid:17923583 http://dx.doi.org/10.1161/CIRCULATIONAHA.106.678326 84 ISSN 2332-7243 E-ISSN 2332-7251