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Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?

INTRODUCTION: Takayasu's arteritis (TA) is a systemic inflammatory disease that affects aorta and its major branches. There are several cardiac manifestations of TA and an association with Takotsubo syndrome (TTS) – but not coronary vasospasm - has been previously reported. The role of emotiona...

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Autores principales: Pires, Inês, Mapelli, Massimo, Amelotti, Nicola, Salvioni, Elisabetta, Ferrari, Cristina, Baggiano, Andrea, Conte, Edoardo, Mattavelli, Irene, Agostoni, Piergiuseppe
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9108163/
https://www.ncbi.nlm.nih.gov/pubmed/35586412
http://dx.doi.org/10.3389/fpsyt.2022.882870
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author Pires, Inês
Mapelli, Massimo
Amelotti, Nicola
Salvioni, Elisabetta
Ferrari, Cristina
Baggiano, Andrea
Conte, Edoardo
Mattavelli, Irene
Agostoni, Piergiuseppe
author_facet Pires, Inês
Mapelli, Massimo
Amelotti, Nicola
Salvioni, Elisabetta
Ferrari, Cristina
Baggiano, Andrea
Conte, Edoardo
Mattavelli, Irene
Agostoni, Piergiuseppe
author_sort Pires, Inês
collection PubMed
description INTRODUCTION: Takayasu's arteritis (TA) is a systemic inflammatory disease that affects aorta and its major branches. There are several cardiac manifestations of TA and an association with Takotsubo syndrome (TTS) – but not coronary vasospasm - has been previously reported. The role of emotional stress in this context is unknown. CASE PRESENTATION: A 58-year-old Caucasian female elementary school teacher, with a history of generalized anxiety disorder (GAD), severe asymptomatic aortic regurgitation (AR), and TA in remission under corticosteroids, was admitted in the emergency department with worsening chest pain and dyspnea, initiated after a period of intense emotional stress (increased workload during COVID-19 pandemic). Physical examination revealed signs of heart failure (HF) with hemodynamic stability and an early diastolic heart murmur. The electrocardiogram showed sinus tachycardia, T wave inversion in left precordial and lateral leads, and a corrected QT of 487 ms. Laboratorial evaluation presented high values of high-sensitivity troponin I (3494 ng/L) and B-type natriuretic peptide (4759 pg/mL). The transthoracic echocardiogram revealed severe dilation of left ventricle (LV) with moderate systolic dysfunction, due to apical and midventricular akinesia, and severe AR. The coronary angiography showed normal coronary arteries. An acetylcholine provocative test induced spasm of both the left anterior descending and circumflex arteries, accompanied by chest pain and ST depression, completely reverted after intracoronary nitrates administration. The patient was switched to diltiazem and a drug multitherapy for HF was started. A cardiac magnetic resonance revealed severe dilation of the LV, mild apical hypokinesia, improvement of ejection fraction to 53%, signs of myocardial edema and increased extracellular volume in apical and mid-ventricular anterior and anterolateral walls, and absence of myocardial late gadolinium enhancement, compatible with TTS. At discharge, the patient was clinically stable, without signs of HF, and a progressive reduction of troponin and BNP levels was observed. A final diagnosis of TTS and coronary vasospasm in a patient with GAD and TA was done. DISCUSSION: We present the first case of acute HF showing coexistence of TA, TTS and coronary vasospasm. TA is a rare inflammatory disease that can be associated with TTS and coronary vasospasm. Besides that, coronary vasospasm may also be involved in TTS pathophysiology, suggesting a complex interplay between these diseases. Mood disorders and anxiety influence the response to stress, through a gain of the hypothalamic-pituitary-adrenal axis and an increased cardiovascular system sensitivity to catecholamines. Therefore, although the mechanisms behind these three pathologies are not yet fully studied, this case supports the role of inflammatory and psychiatric diseases in TTS and coronary vasospasm.
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spelling pubmed-91081632022-05-17 Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19? Pires, Inês Mapelli, Massimo Amelotti, Nicola Salvioni, Elisabetta Ferrari, Cristina Baggiano, Andrea Conte, Edoardo Mattavelli, Irene Agostoni, Piergiuseppe Front Psychiatry Psychiatry INTRODUCTION: Takayasu's arteritis (TA) is a systemic inflammatory disease that affects aorta and its major branches. There are several cardiac manifestations of TA and an association with Takotsubo syndrome (TTS) – but not coronary vasospasm - has been previously reported. The role of emotional stress in this context is unknown. CASE PRESENTATION: A 58-year-old Caucasian female elementary school teacher, with a history of generalized anxiety disorder (GAD), severe asymptomatic aortic regurgitation (AR), and TA in remission under corticosteroids, was admitted in the emergency department with worsening chest pain and dyspnea, initiated after a period of intense emotional stress (increased workload during COVID-19 pandemic). Physical examination revealed signs of heart failure (HF) with hemodynamic stability and an early diastolic heart murmur. The electrocardiogram showed sinus tachycardia, T wave inversion in left precordial and lateral leads, and a corrected QT of 487 ms. Laboratorial evaluation presented high values of high-sensitivity troponin I (3494 ng/L) and B-type natriuretic peptide (4759 pg/mL). The transthoracic echocardiogram revealed severe dilation of left ventricle (LV) with moderate systolic dysfunction, due to apical and midventricular akinesia, and severe AR. The coronary angiography showed normal coronary arteries. An acetylcholine provocative test induced spasm of both the left anterior descending and circumflex arteries, accompanied by chest pain and ST depression, completely reverted after intracoronary nitrates administration. The patient was switched to diltiazem and a drug multitherapy for HF was started. A cardiac magnetic resonance revealed severe dilation of the LV, mild apical hypokinesia, improvement of ejection fraction to 53%, signs of myocardial edema and increased extracellular volume in apical and mid-ventricular anterior and anterolateral walls, and absence of myocardial late gadolinium enhancement, compatible with TTS. At discharge, the patient was clinically stable, without signs of HF, and a progressive reduction of troponin and BNP levels was observed. A final diagnosis of TTS and coronary vasospasm in a patient with GAD and TA was done. DISCUSSION: We present the first case of acute HF showing coexistence of TA, TTS and coronary vasospasm. TA is a rare inflammatory disease that can be associated with TTS and coronary vasospasm. Besides that, coronary vasospasm may also be involved in TTS pathophysiology, suggesting a complex interplay between these diseases. Mood disorders and anxiety influence the response to stress, through a gain of the hypothalamic-pituitary-adrenal axis and an increased cardiovascular system sensitivity to catecholamines. Therefore, although the mechanisms behind these three pathologies are not yet fully studied, this case supports the role of inflammatory and psychiatric diseases in TTS and coronary vasospasm. Frontiers Media S.A. 2022-05-02 /pmc/articles/PMC9108163/ /pubmed/35586412 http://dx.doi.org/10.3389/fpsyt.2022.882870 Text en Copyright © 2022 Pires, Mapelli, Amelotti, Salvioni, Ferrari, Baggiano, Conte, Mattavelli and Agostoni. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Psychiatry
Pires, Inês
Mapelli, Massimo
Amelotti, Nicola
Salvioni, Elisabetta
Ferrari, Cristina
Baggiano, Andrea
Conte, Edoardo
Mattavelli, Irene
Agostoni, Piergiuseppe
Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?
title Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?
title_full Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?
title_fullStr Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?
title_full_unstemmed Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?
title_short Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?
title_sort case report: acute heart failure induced by the combination of takayasu's, takotsubo and coronary vasospasm in an elementary school teacher–a reaction to return-to-work stress after covid-19?
topic Psychiatry
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9108163/
https://www.ncbi.nlm.nih.gov/pubmed/35586412
http://dx.doi.org/10.3389/fpsyt.2022.882870
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