A LABILE EQUILIBRIUM: THE CONTROVERSIAL ROLE OF BETA–BLOCKERS IN A CASE OF MID–VENTRICULAR TAKOTSUBO SYNDROME

Abstract Case Report Takotsubo syndrome (TTS) is a non–ischemic heart disease mimicking acute coronary syndrome. The mid–ventricular variant is almost rare (15% of TTS cases). A 62 years old woman was referred to our hospital for oppressive chest pain radiating to the jaw lasting at least 30 minutes...

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Published in:European heart journal supplements 2024-05, Vol.26 (Supplement_2), p.ii115-ii115
Main Authors: Falagario, A, Pedio, E, Antonacci, A, Colucci, C, Mannarini, A, Camassa, N, Pansini, M, D‘Agostino, C
Format: Article
Language:English
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Summary:Abstract Case Report Takotsubo syndrome (TTS) is a non–ischemic heart disease mimicking acute coronary syndrome. The mid–ventricular variant is almost rare (15% of TTS cases). A 62 years old woman was referred to our hospital for oppressive chest pain radiating to the jaw lasting at least 30 minutes after an attempted strangulation by a family member. She denied any conventional cardiovascular risk factor; she was taking beta–blockers (BB) to reduce symptomatic and idiopathic premature ventricular complexes (PVCs) burden. On arrival, the patient was hemodynamically stable, reporting only swallowing difficulties. Physical examination revealed neck bruising and irregular pulse. The initial ECG showed sinus rhythm with a heart rate of 62 bpm, PVCs and a biphasic T wave in lead aVL. Hs–cTnI first dosage was 145 pg/mL. Transthoracic echocardiography (TTE) found moderate left ventricular (LV) dysfunction and severe hypokinesis of mid septal and mid inferior segments. Coronary angiography revealed normal coronary arteries. Left ventriculogram showed hypokinesis of the midventricular section with a hyperdynamic base and apex suggestive of mid–ventricular variant of TTS. After a few hours, she experienced a lipothymic episode and telemetry showed marked sinus bradycardia followed by multiple sinus pauses. A TTE was immediately performed, demonstrating a worsening LV ejection fraction with new development of severe symmetrical akinesia of the LV apex. Successively, psychotherapy was started. Wall motion abnormalities and LV systolic function completely recovered over a few days. At present the patient is in good health status. Discussion domestic violence against women is prevalent, but it is often omitted as a potential stress trigger that affects their hearts. In Italy, it’s reported that 32% of women had experienced physical violence. Strangulation is very uncommon as cause of TTS and psychotherapy may prevent recurrences and recover in a shorter time. Bradycardia due to atrioventricular block and asystole has been described in the acute phase of TTS and it is often attributed to BB therapy. Although BB have been proposed to add further benefit of blunting the effect of catecholamine excess, their use should be used cautiously in the acute phase of TTS. Moreover, beta–adrenoceptor hypersensitivity may generate a parasympathetic drive when on BB infusion, provoking a worsening LV dysfunction and a transient sick sinus syndrome as we described.
ISSN:1520-765X
1554-2815
DOI:10.1093/eurheartjsupp/suae036.287