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Takotsubo syndrome and complete heart block, which came first? A case report
Mohammad Khurram Nadeem1, Jason Leo Walsh1, Simon Davies1
1Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK.
Insights
Takotsubo syndrome (TTS) can cause complete heart block (CHB). In a case study, emotional stress triggered TTS, which then likely caused CHB, clarifying the causal relationship.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- Recent consensus documents highlight takotsubo syndrome (TTS) diagnosis and management.
- The association between TTS and complete heart block (CHB) is recognized but poorly understood, with causation often unclear.
Observation:
- An 89-year-old woman presented with symptoms of TTS, including chest pain and dyspnea, following a significant emotional stressor.
- Electrocardiogram revealed CHB with a broad QRS, and echocardiography showed apical akinesis and ballooning consistent with TTS.
- Coronary angiography excluded significant coronary artery disease.
Findings:
- The case suggests that TTS, triggered by emotional stress, may precipitate CHB.
- A dual-chamber pacemaker was implanted, and ventricular function normalized during follow-up.
Implications:
- This case provides evidence for TTS precipitating CHB, challenging the notion that CHB is always the primary event.
- Understanding the causal link between TTS and CHB is crucial for appropriate patient management and treatment strategies.
Background:
In 2018, the European Society of Cardiology published two consensus documents on takotsubo syndrome (TTS), which include the current consensus on nomenclature, diagnosis, management, and complications. However, little is mentioned on the association with complete heart block (CHB), except that 'AV block [occurs in] 2.9% of cases'. Complete heart block is a recognized rare association of TTS, but causation is often unclear. Does CHB trigger TTS or vice-versa? Here, we present a case of TTS associated with CHB.
Case Summary:
An 89-year-old woman presented with a transient loss of consciousness, acute chest pain, and dyspnoea. A few days prior to this her daughter died suddenly of a myocardial infarction. On presentation, troponin levels were elevated, the electrocardiogram showed CHB with a broad QRS and an echo showed apical akinesis and ballooning. Angiographic investigation excluded significant coronary artery disease. A dual-chamber pacemaker was implanted after a brief period of temporary pacing. Ventricular function normalized during follow-up and her underlying rhythm remained CHB.
Discussion:
Takotsubo syndrome may be triggered by both emotional and physical stressors. Complete heart block is recognized association, but causation is often unclear. In our case, a clear emotional trigger was identified suggesting the TTS may have precipitated CHB not vice versa.
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