Spectrum of radionuclide perfusion study abnormalities in takotsubo cardiomyopathy
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Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, UT University of Utah School of Medicine, Salt Lake City, UT Stanford University School of Medicine, Stanford, CA Rocky Mountain University of Health Professions, Provo, UT
Received Jul 14, 2020; accepted Aug 29, 2020 doi:10.1007/s12350-020-02385-w
Background. Takotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized. Methods and Results. Intermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11. Conclusions. Despite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation. (J Nucl Cardiol 2020) Key Words: Positron emission tomography Æ radionuclide perfusion study Æ stress-induced cardiomyopathy Æ takotsubo cardiomyopathy Æ takotsubo syndrome The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarizes the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com. The authors have also provided an audio summary of the article, which is available to download as ESM, or to listen to via the JNC/ASNC Podcast. All editorial decisions for this article, including selection of reviewers and the final decision, were made by Guest Editor Nagara Tamaki, MD. Funding The study was funded by internal departmental support.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12350-020-02385-w) contains supplementary material, which is available to author
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