Point of Care Ultrasound Utility in the Setting of Chest Pain: A Case of Takotsubo Cardiomyopathy

Ramzi Ibrahim MD, Chelsea Takamatsu MD, João Paulo Ferreira MD

Department of Medicine, University of Arizona - Tucson and Banner University MedicalCenter, Tucson

Tucson, AZ USA

Abstract 

Chest pain is a frequently encountered chief complaint in the Emergency Department and entails a broad differential. Point-of-care ultrasound (POCUS) can be utilized to guide diagnostic decision making and initial triaging. Takotsubo cardiomyopathy presents similarly to acute coronary syndrome and has characteristic findings on echocardiogram. This case presentation details a scenario of ST segment elevation on electrocardiogram and elevated high sensitivity troponin levels, worrisome for a ST elevation myocardial infarction (STEMI). Apical hypokinesis to akinesis and apical ballooning were appreciated on echocardiogram, raising suspicion for Takotsubo cardiomyopathy, subsequently confirmed by coronary angiogram. A cardiac focused point-of-care ultrasound assessment can provide valuable information to aid in diagnostic accuracy. 

Case Presentation 

A 72-year-old woman with a known history of chronic obstructive pulmonary disease (COPD) presented to the hospital for progressively worsening dyspnea in the previous few days along with new onset chest discomfort in the past one day. Patient was found to have an oxygen saturation of 87% on room air, pH of 7.25 and a pCO2 of 98 on venous blood gas, and was admitted for acute on chronic hypoxic and hypercapnic respiratory failure in the setting of a COPD exacerbation. Patient was intubated for respiratory distress and worsening acuteencephalopathy. Chest radiograph was grossly unremarkable for consolidations or

opacities. A bedside point-of-care ultrasound (POCUS) assessment revealed clear lung zones bilaterally without apparent B lines; however, minimal pleural sliding was appreciated on the left anterior lung zones. Cardiac focused assessment identified marked hypokinesis to akinesis of the entire mid-distal left ventricle with apical ballooning, raising the suspicion of Takotsubo cardiomyopathy (Videos 1-2).

 

Video 1. Subcostal view with identification of a hyperkinetic basal segment and hypokinetic apex. Apical ballooning is also clearly identifiable in this view. (Click here to view the video in a separate window)

Video 2. Parasternal short axis identifying a hyperkinetic basal segment near the level of the mitral valve with subsequent hypokinetic apical view. The image plane is being panned from base to apex and back. (Click here to view the video in a separate window).

High sensitivity troponin level was elevated at 42 ng/L with an increase to 540 ng/L on repeat testing. Electrocardiogram (ECG) was initially grossly unremarkable for signs of acute ischemic changes, however, repeat ECG revealed ST elevation in the anterior leads. The patient was taken urgently to the catheterization lab where intervention identified mild non-obstructive disease in a right dominant circulation and the diagnosis of Takotsubo cardiomyopathy was confirmed. 

Discussion 

Chest pain is among the most common chief complaints of patients presenting to the Emergency Department. The differential diagnoses of chest pain remain broad which includes a variety of pathological processes. POCUS has emerged as an indispensable tool for diagnostic accuracy and for aid with initial triaging before considering further confirmatory testing. An emerging consideration is its utility in the acute setting, specifically when trying to differentiate between cardiac and non-cardiac chest pain. Comprehensive echocardiography, usually completed in a formal setting upon request, provides valuable information that can be indicative of ischemic states, including regional wall motion abnormalities, decreased systolic movement, decreased myocardial thickening, valvular function abnormalities, inter-ventricular shunts, and acute papillary muscle dysfunction (1). Alternatively, bedside POCUS in acute settings for assessment of cardiac function and structural abnormalities provides timely objective data but holds greater limitations mainly due to inferior ultrasound quality, variable operator skillsets, and time constraints. of

In our case, we utilized POCUS in an unresponsive, intubated patient, noting discrete regions of hypokinesis-akinesis the left ventricle with apical ballooning, prior to ECG showing elevated ST segments in the anterior leads and a rising troponin level on serial lab tests. Our initial impression based on the POCUS findings was concerning for Takotsubo cardiomyopathy. Given the urgency of the troponin and ECG abnormalities, a Code STEMI was called. Cardiology urgently took the patient to the catheterization lab which confirmed the diagnosis of Takotsubo cardiomyopathy after identifying no obstructive coronary artery disease.

Takotsubo cardiomyopathy often presents very similarly to acute coronary syndrome with elevated markers of myocardial ischemia and ST changes on ECG (2). Hallmarks of this clinical entity include apical hypokinesia and basal segment hyperkinesia on echocardiogram and no obstructive coronary artery disease on coronary angiography. Given the acuity of these findings, this case presentation portrays the importance of utilizing a cardiac focused POCUS assessment to help tailor differential diagnoses and raise index of suspicion not only to acute coronary syndromes, but also to mimicking clinical diseases. 

References

1. Leischik R, Dworrak B, Sanchis-Gomar F, Lucia A, Buck T, Erbel R. Echocardiographic assessment of myocardial ischemia. Ann Transl Med. 2016 Jul;4(13):259. [CrossRef] [PubMed]
2. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008 Mar;155(3):408-17. [CrossRef] [PubMed]

Cite as: Ibrahim R, Takamatsu C, Ferreira JP. Point of Care Ultrasound Utility in the Setting of Chest Pain: A Case of Takotsubo Cardiomyopathy. Southwest J Pulm Crit Care Sleep. 2022;25(2):30-33. doi: https://doi.org/10.13175/swjpccs035-22 PDF  

December 2017 Critical Care Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale AZ USA

Clinical History: A 57-year-old man with no known previous medical history was brought to the emergency room via ambulance and admitted to the intensive care unit with a compliant of severe chest pain in the substernal region and epigastrium. The patient was awake and alert and did not complain of shortness of breath.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. The patient’s vital signs revealed tachycardia (105 bpm) and his blood pressure was 108 mmHg / 60 mmHg.

Laboratory evaluation showed a slightly elevated white blood cell count (13 x 10⁹ cells/L), but his hemoglobin and hematocrit values were with within normal limits, as was his platelet count. 

Which of the following diagnoses are appropriate considerations for this patient’s condition? (Click on the correct answer to proceed to the second of nine pages)

1. Acute pericarditis
2. Aortic dissection
3. Community-acquired pneumonia
4. Myocardial infarction
5. All of the above

Cite as: Gotway MB. December 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(6):241-52. doi: https://doi.org/10.13175/swjpcc145-17 PDF 

February 2016 Critical Care Case of the Month

Thomas M. Stewart, MD

Bhargavi Gali, MD 

Department of Anesthesiology

Mayo Clinic Minnesota

Rochester, MN USA

Case Presentation

A 32 year-old, previously healthy, female hospital visitor had been participating in a family care conference regarding her critically ill grandmother admitted to the cardiac intensive care unit. During the care conference, she felt unwell and had some mild chest discomfort; she collapsed and cardiopulmonary resuscitation (CPR) was initiated (1). Upon arrival of the code team, she was attached to the monitor and mask ventilation was initiated. Her initial rhythm is shown in Figure 1.

Figure 1. Initial rhythm strip.

In addition to DC cardioversion which of the following should be administered immediately? (Click on the correct answer to proceed to the second of four panels)

1. Lidocaine
2. Magnesium sulfate
3. Procainamide
4. 1 and 3
5. All of the above

Cite as: Stewart TM, Gali B. February 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;12(2):41-5. doi: http://dx.doi.org/10.13175/swjpcc011-16 PDF 

June 2015 Critical Care Case of the Month: Just Ask the Nurse

Robert A. Raschke, MD

Banner University Medical Center

Phoenix, AZ

 History of Present Illness

A 61-year-old police officer had just finished delivering a speech at a law enforcement conference in Phoenix when he briefly complained of chest pain or chest tingling before lapsing into a mute state. He became diaphoretic cyanotic, and vomited. Emergency medical services was called. They noted a blood pressure of 80/50 mm Hg, a pulse of 45, temperature of 95º F, a respiratory rate of 12, and widely dilated pupils. He was transported to the emergency room.

PMH, SH, FH, Medications

Unknown.

Physical Examination

Vital signs: blood pressure 120/75 mm Hg by oscillometric thigh cuff, pulse 43 and irregular, temperature 96º F, respiratory rate 10, SpO2 96% on O2 @ 5L/min by nasal cannula

Neck: No JVD.

Lungs: Poor inspiratory effort

Heart: Irregular rhythm without a murmur

Neurological:

• Delirious – mute – won’t obey commands or track with his eyes
• Pupils 3 mm reactive
• Withdrew 3 extremities to nail bed pressure – he will defend his left arm with his right arm

He suddenly became asystolic and cardiopulmonary resuscitation was begun. After about a minute a femoral pulse could be felt.

Which of the following are indicated at this time? (Click on the correct answer to proceed to the second of five panels)

1. Arterial blood gas
2. Chest x-ray
3. Electrocardiogram
4. Electrolytes
5. All of the above

Reference as: Raschke RA. June 2015 critical care case of the month: just ask the nurse. Southwest J Pulm Crit Care. 2015;10(6):323-9. doi: http://dx.doi.org/10.13175/swjpcc077-15 PDF