Glycoprotein IIb/IIIa antagonists in Takotsubo cardiomyopathy
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bo cardiomyopathy (TC) is an under-recognized clinical entity mimicking acute coronary syndrome. Glycoprotein IIb/IIIa (GP IIb/IIIa) antagonists are not indicated in TC; however, in some instances, TC masquerades as ST-segment elevation myocardial infarction (STEMI) when chest pain, ST-segment elevation, and troponin leak coexist. ST-segment elevation is the commonest finding on the admission electrocardiogram (ECG) in patients with TC and is seen in 46–100% of patients [1]. Prior to confirming the diagnosis, these patients are usually managed with an initial working diagnosis of myocardial infarction with aspirin, beta blockers, intravenous heparin, GP IIb/IIIa antagonists, or even thrombolytic therapy. In developing countries, thrombolytic therapy is the mainstay of reperfusion for STEMI, either because it is cheaper or due to the lack of widespread availability of catheterization suites, and can be unnecessarily given in cases with suspected TC presenting with chest pain and ST-segment elevation. The diagnosis of TC is only confirmed when occlusive coronary artery disease is absent on coronary angiography and the characteristic apical ballooning is evident on left ventriculogram. This highlights the importance of recognizing the distinguishing ECG features that can—to a great extent—differentiate TC from STEMI. Recently, Akpinar and colleagues [2] described an interesting observation of the rapid recovery of TC following tirofiban administration. A main concern
H.R. Omar Internal Medicine Department, Mercy Hospital and Medical Center, Chicago, Illinois
Glycoprotein IIb/IIIa antagonists in Takotsubo cardiomyopathy
Fig. 1 9 a ECG of a patient diagnosed with takotsubo cardiomyopathy (TC) revealing diffuse ST-segment elevation and PR-segment depression (except in leads aVR and V1) consistent with acute pericarditis. (Adapted from [17], copyright 2012 by the Texas Heart Institute, Houston). b ECG of another case of TC demonstrating the classic ECG features of acute pericarditis. (Adapted from [9] with permission from Elsevier) Herz 2013
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Image of the month with GP IIb/IIIa antagonists in TC is the potential for the devastating complication of cardiac tamponade if pericarditis is present. TC with ECG evidence of pericarditis is well known in the literature [3, 4, 5, 6, 7, 8, 9]. I have previously elaborated on the coexistence of both pathologies and provided possible explanations for this association [10, 11]. The increased incidence of pericardial effusion in patients with TC has been illustrated by Eitel et al. [12] using cardiac magnetic resonance imaging. Yeh et al. [13] previously demonstrated the development of cardiac tamponade in a patient with TC after administration of intravenous heparin and the GP IIb/IIIa antagonist, eptifibatide. In addition to its pivotal role in evaluating patients with suspected TC, echocardiography is crucial to rule out pericardial effusion, which if present should avert the use of GP IIb/ IIIa antagonists. More obviously, these drugs will clearly be avoided in instances whe
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