BROKEN HEART AND BROKEN FEET: TAKOTSUBO CARDIOMYOPATHY IN THE SETTING OF ACCIDENTAL HYPOTHERMIA AND FROSTBITE

Document Type

Conference Proceeding

Publication Date

6-23-2023

Publication Title

J Gen Intern Med

Abstract

CASE: A 58-year-old man presented on a snowy winter night with severe bilateral foot pain for one week in addition to shortness of breath and bilateral lower limb swelling for several days. He was experiencing unstable housing and often slept without adequate shelter or heating. On examination, he was normothermic, tachycardic, hypertensive, and tachypneic. He had bilateral pitting pedal edema and his feet were erythematous and blistered, consistent with frostbite from environmental injury. Workup was notable for an elevated creatine phosphokinase consistent with rhabdomyolysis. High-sensitivity troponin was high at 75 ng/L, it rapidly increased to 2355 and peaked at 7649 within ten hours of presentation. Brain natriuretic peptide was high at 135 pg/mL. Electrocardiogram showed anterolateral t-wave inversions. Throughout this course, the patient denied chest pain. Given the laboratory and electrocardiogram abnormalities, acute coronary syndrome was suspected and the patient was treated with antiplatelets, statin, and intravenous heparin. Transthoracic echocardiogram demonstrated a left ventricular (LV) ejection fraction of 21% with aneurysmal LV wall deformity. Invasive coronary angiography had no evidence of coronary artery disease. Repeat echocardiogram showed severe hypokinesis of the middle and distal LV wall segments with preserved basal wall motion. In the context of the clinical presentation, these echocardiographic findings supported the diagnosis of stress cardiomyopathy, termed Takotsubo Cardiomyopathy (TCM). The patient was treated with guidelinedirected medical therapy (GDMT) for heart failure with beta-blockers, angiotensin II receptor blockers, and diuretics after which he clinically recovered. IMPACT/DISCUSSION: TCM is an entity in which left ventricle (LV) dilation and ballooning, notably in the apex, results in a decline in systolic function that manifests as heart failure. It is classically described in the setting of emotional stress, although, recent literature suggests that this condition is underdiagnosed and frequently occurs after physical and physiological stress. Pathophysiology is uncertain but the surge in stress- associated hormones has been implicated in myocardial toxicity. This case offers an atypical presentation for TCM. The diagnosis warrants extensive workup including ischemic evaluation to rule out common causes of heart failure. Diagnostic criteria includes LV regional wall motion abnormalities that exceed a single vascular distribution, evidence of myocardial injury, and the absence of significant coronary artery disease. Management consists of medical optimization with GDMT. Most patients recover well with low mortality rates. CONCLUSION: Internists should be aware of TCM and consider it in patients experiencing significant stress who present with features of heart failure and laboratory testing suggestive of myocardial injury. This case highlights the different triggers for stress response, whether emotional, physical, or physiological.

Volume

38

Issue

Suppl 3

First Page

S435

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