A 65-year-old lady presents to the emergency division with complaints of shortness of breath, sore throat, fever, chills, productive cough, and substernal chest ache. She examined constructive for COVID-19 six days earlier.
On preliminary presentation, her oxygen saturation is 90% on room air and chest radiography reveals diffuse bilateral alveolar infiltrates and outstanding vascular congestion. A 12-lead electrocardiogram (ECG) reveals anterior ST elevation with deep anterior T-wave inversion. Outcomes of inflammatory markers and laboratory checks are proven in Desk 1.
Desk 1. Inflammatory Markers and Laboratory Check Outcomes
| Check | Outcome |
| BNP, pg/mL | 790 |
| C-reactive protein, mg/L | >300 |
| D-dimer, µg/mL | 2.184 |
| Ferritin, ng/mL | 320 |
| Interleukin 6, pg/nL | 724.38 |
| Troponin I, ng/mL | 0.90 |
Vital Medical Historical past
Medical historical past is critical for hypertension, hypothyroidism, glaucoma, and generalized anxiousness dysfunction. Treatment administration contains lisinopril 10 mg each day, latanoprost ophthalmic resolution for each eyes each day, and citalopram 20 mg each day.
Proceed Studying
Bodily Examination
The affected person is a middle-aged lady with weight problems in reasonable respiratory misery. Admission very important indicators embody blood strain 96/52 mm Hg, coronary heart price 107 beats per minute, and respiratory price 28 breaths per minute. Her oxygen saturation improves to 94% with initiation of 4 L/min oxygen through nasal cannula. Pulmonary examination reveals delicate expiratory wheezing. No murmurs or additional coronary heart tones are famous on cardiac auscultation. Delicate jugular venous distention is noticed.
After occlusive coronary illness was dominated out with angiography, she was recognized with Takotsubo syndrome (TTS).
Dialogue
Takotsubo syndrome is regarded as precipitated by extreme emotional or bodily stress, probably mediated by catecholamine surge resulting in myocardial beautiful.1 Takotsubo syndrome is mostly recognized in postmenopausal, White girls. Pathophysiology of TTS has been theorized to be secondary to a systemic inflammatory response,2 endothelial dysfunction resulting in impaired myocardial perfusion, and myocardial beautiful,1 in addition to a type of microvascular acute myocardial infarction.1-3 Though most sufferers (95%) absolutely get better from TTS, the in-hospital mortality threat is estimated to be 5%.4
A marked enhance within the incidence of TTS has occurred because the begin of the COVID-19 pandemic.5,6 Previous to the worldwide pandemic, the incidence of TTS in sufferers presenting with acute coronary syndrome was between 1.5% and 1.8%.5 One research discovered the incidence of TTS throughout the COVID-19 pandemic to be as excessive as 7.8%.5 Though a number of case stories of concurrent COVID-19 an infection and TTS may be discovered within the literature, a big enhance within the variety of instances of TTS with out concurrent COVID-19 an infection additionally has been noticed.6 Proposed mechanisms for the elevated incidence of TTS within the common inhabitants throughout the pandemic embody worsened anxiousness, panic, and despair ranges within the public secondary to the psychological misery from the pandemic.
Prognosis
Most sufferers presenting with TTS complain of chest ache and dyspnea and have an ECG presentation of ST-segment elevation myocardial infarction (STEMI): elevated cardiac biomarkers, left ventricular (LV) dyskinesia, and usually some latest bodily or emotional set off.3,4 Prognosis of TTS is made when acute myocardial infarction is suspected with no angiographic proof of coronary blockage and 4 of the Revised Mayo Clinic Standards for Takotsubo cardiomyopathy are met4:
- Transient dyskinesia of the left ventricle midsegments; regional wall movement abnormalities past a single epicardial vascular distribution
- Absence of obstructive coronary artery illness or acute plaque rupture
- New ECG abnormalities or modest troponin elevation
- Absence of pheochromocytoma and myocarditis
Desk 2. Really helpful Diagnostic/Laboratory Exams for Takotsubo Syndrome3,7,8
| Troponin, BNP |
| 12-lead ECG |
| Coronary angiography |
| Echocardiography |
Laboratory Research
Troponin ranges are elevated usually of TTS and brain-type natriuretic peptide (BNP) degree is markedly elevated.3
12-Lead ECG
The 12-lead ECG could present proof of ST-segment elevation or ST-segment despair3; ST-segment elevation in 2 or extra contiguous leads is diagnostic for STEMI.8 Sufferers with TTS could present anterior ST elevation with deep anterior T-wave inversion.7
Coronary Angiography
The American Faculty of Cardiology Basis/American Coronary heart Affiliation (ACCF/AHA) pointers suggest emergent coronary angiogram within the setting of chest ache, elevated biomarkers, and ST-segment elevation on a 12-lead ECG.7,8 Coronary angiography is diagnostic for underlying coronary illness and might establish exact lesions precipitating coronary damage.8 If wrongdoer lesions are recognized, a reperfusion technique may be initiated. Sufferers with TTS can have no proof of obstructive coronary illness on angiography.4,7 Knowledge relating to intracardiac pressures, valvular operate, and structural impairments may also be recognized with angiography. A left ventriculogram can present details about LV systolic operate. Coronary angiogram is presently the definitive instrument for differentiating TTS from acute coronary syndrome.7
Transthoracic Echocardiogram
Transthoracic echocardiogram will show LV wall-motion abnormalities and might rule in or rule out LV outflow tract obstruction (LVOTO).7 Transthoracic echocardiogram can be used for analysis of LV thrombus.7
Administration and Therapy
Therapy for TTS contains supportive care and administration of problems reminiscent of shock, coronary heart failure, and LV thrombus.6 Case severity can vary from delicate, which can not want intervention, to extreme, which can require aggressive intervention.7 Administration suggestions are divided into 4 classes:
1. Takotsubo Syndrome With out Problems
Therapy for TTS is principally supportive till LV operate spontaneously improves.4,6,7 Enhancements in LV operate normally happen inside 21 days of symptom onset with most sufferers absolutely recovering inside 2 months.4,6 Therapy is often supplied for as much as 3 months and should embody twin antiplatelet remedy, anticoagulants for sufferers with massive areas of cardiac hypokinesis, beta-blockers, angiotensin-converting enzymes inhibitors (ACEI) or angiotensin receptor blockers (ARB), statins, and stress aid administration.7
2. Takotsubo Syndrome With Hypotension and Cardiogenic Shock
In sufferers who’ve TTS with hypotension and cardiogenic shock, steady monitoring of important indicators and end-organ perfusion are required.7 Cautious administration of fluids may be carried out in sufferers not exhibiting manifestations of pulmonary congestion.7 Optimistic inotropes, reminiscent of dobutamine or dopamine, and/or vasopressor infusions can function a short lived measure in instances of cardiogenic shock with out LVOTO.7 Optimistic inotropes and vasopressors can enhance the diploma of obstruction in instances of reasonable to extreme LVOTO and are subsequently contraindicated.4,7 The alpha agonist phenylephrine can be utilized cautiously in instances of LVOTO. Sufferers who’ve persistent hypotension regardless of preliminary measures may have mechanical circulatory help gadgets such because the intra-aortic balloon pump or extracorporeal membrane oxygenation.7
3. Takotsubo Syndrome With Coronary heart Failure
Besides in instances of LVOTO, normal coronary heart failure administration is advisable.7 This contains administration of oxygenation and air flow together with preload and afterload discount.7 Normal coronary heart failure drugs are used reminiscent of diuretics and ACEI/ARBs.7 In instances of coronary heart failure with LVOTO, normal preload and afterload discount therapies ought to be prevented.7
4. Takotsubo Syndrome With Thromboembolism
Sufferers with extreme LV dysfunction are at elevated threat for ventricular thrombus improvement. In instances of extreme LV dysfunction however no thrombus and low bleeding threat, anticoagulation is indicated till akinesia or dyskinesia is resolved or for 3 months, whichever is shorter.7 Within the presence of ventricular thrombus, anticoagulation is indicated for 3 months with the length of therapy modified primarily based on price of restoration of cardiac operate and backbone of thrombus.7
Dialogue/Observe-Up
Period of therapy for TTS usually ranges from 3 months to 1 12 months and might be decided primarily based on return of cardiac operate. Sufferers with TTS who expertise problems reminiscent of cardiogenic shock, coronary heart failure, or thromboembolism could require long-term care. Frequent assessments utilizing serial echocardiography might be wanted to test restoration of cardiac operate in these sufferers. Luckily, most sufferers absolutely get better inside weeks.4,7
Frances Stueben, DNP, RN, CHSE, is an assistant professor and simulation program coordinator on the College of Louisiana at Lafayette. She teaches within the graduate and undergraduate nursing applications.
Deedra Harrington, DNP, MSN, APRN, ACNP-BC, is affiliate professor on the Faculty of Nurse and Allied Well being Professions, College of Louisiana at Lafayette. Dr Harrington is a complicated observe registered nurse-acute care who works with an inpatient cardiology intensivist group in Louisiana.
Christy L. McDonald Lenahan, DNP, FNP-BC, ENP-C, CNE, is a complicated observe registered nurse in household and emergency medication who works for an emergency medication and hospitalist staffing company. She can be an affiliate professor on the College of Louisiana at Lafayette and teaches within the masters and doctoral applications.
Hyperlinks to different articles on this sequence:
1. Administration of NSTEMI/STEMI in sufferers with COVID-19, click on here
2. Venous thromboembolism administration in sufferers with COVID-19, click on here
3. Atrial fibrillation and different dysrhythmias in sufferers with COVID-19, click on here
4. Acute pericarditis, myopericarditis, and perimyocarditis in sufferers with COVID-19, click on here
5. Coronary heart failure in sufferers with COVID-19, click on here
6. Cardiogenic shock in sufferers with COVID-19, click on here
References
- Chiu S, Nayak R, Lin B, Duan L, Shen AY, Lee MS. Clinical characteristics and outcomes of patients with Takotsubo syndrome. Can J Cardiol. 2021;37(8):1191-1197. doi:10.1016/j.cjca.2021.01.014
- Ruzzenenti G, Maloberti A, Giani V, et al; COVID-19 Niguarda Working Group. COVID and cardiovascular diseases: direct and indirect damages and future perspective. Excessive Blood Press Cardiovasc Prev. 2021;28(5):439-445. doi:10.1007/s40292-021-00464-8
- Lüscher TF, Templin C. Is Takotsubo syndrome a microvascular acute coronary syndrome? Towards of a new definition. Eur Coronary heart J. 2016 Oct 1;37(37):2816-2820. doi: 10.1093/eurheartj/ehw057
- Boyd B, Solh T. Takotsubo cardiomyopathy: review of broken heart syndrome. JAAPA. 2020;33(3):24-29. doi:10.1097/01.JAA.0000654368.35241.fc
- Jabri A, Kalra A, Kumar A, et al. Incidence of stress cardiomyopathy during the Coronavirus disease 2019 pandemic. JAMA Netw Open. 2020;3(7):e2014780. doi:10.1001/jamanetworkopen.2020.14780
- Shah RM, Shah M, Shah S, Li A, Jauhar S. Takotsubo syndrome and COVID-19: associations and implications. Curr Probl Cardiol. 2021;46(3):100763. doi:10.1016/j.cpcardiol.2020.100763
- Sattar Y, Siew KSW, Connerney M, Ullah W, Alraies MC. Management of Takotsubo syndrome: a comprehensive review. Cureus. 2020;12(1):e6556. doi:10.7759/cureus.6556
- O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019
This text initially appeared on Clinical Advisor
