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023H Takotsubo and a Police Visit

TAKOTSUBO CARDIOMYOPATHY –

59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house.

She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)

3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.

THE SCREAM by Edvard Munch

 

DAY 1

On admission

EKG showed ST elevation in V4 and V5.

CXR showed LAE and LVE mild congestion, and left lower lung nodule.

CARINA WIDENED
Ashley Davidoff MD
CXR – CHF and LVE
Ashley Davidoff MD

Echo showed EF of 50% and apical hypokinesis.

PLEURAL BASED LUNG NODULES (red arrows)
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
CENTRILOBULAR NODULE (green arrow) PARENCHYMAL NODULE (yellow) and FISSURAL NODULE (red arrow)
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
NODULES IN THE INTRALOBULAR SEPTA and a SINGLE CENTRILOBULAR NODULE (green oval). with BRONCHOVASCULAR PROMINENCE (green oval). FISSURAL NODULE (red arrow)
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
CENTRILOBULAR NODULE (green arrow) PARENCHYMAL NODULE (yellow) and FISSURAL NODULE (red arrow)
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
PAWNBROKER or 1,2,3 SIGN
MEDIASTINAL AND HILAR ADENOPATHY
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
CORONARY CALCIFICATION including L MAIN
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
NORMAL SIZED CARDIAC CHAMBERS
SARCOIDOSIS and TAKOTSUBO CARDIOMYOPATHY –
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD
59-year-old female with a history of 1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house. EKG showed ST elevation in V4 and V5.
CXR showed LAE and LVE mild congestion, and left lower lung nodule.
Elevated troponin necessitated cardiac cath which showed normal coronaries and apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%
Echo showed EF of 50% and apical hypokinesis.
Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present
MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.
She has a past history of similar chest pain 2 years ago with negative cardiac workup. She has a history sarcoidosis (cutaneous, ocular and pulmonary). ACE level was 89 (normal 8-53)
3 years prior a CT showed hilar adenopathy and skin biopsy showed sarcoidosis. A CT 2 years prior to admission showed increasing hilar adenopathy and bronchiolectasis in the RUL and multiple upper lobe pulmonary nodules. Exercise tolerance test was negative 2 years ago.
Ashley Davidoff MD

DAY 3

Elevated troponin necessitated cardiac cath which showed normal coronaries.

AP – NORMAL LEFT MAIN LAD and CIRCUMFLEX
Ashley Davidoff MD
AP – NORMAL LEFT MAIN LAD and CIRCUMFLEX
Ashley Davidoff MD
NORMAL LAD and SEPTAL
Ashley Davidoff MD
LAO – NORMAL CIRCUMFLEX
Ashley Davidoff MD
RAO – NORMAL LAD AND CIRCUMFLEX
Ashley Davidoff MD

LAO – NORMAL RCA

RAO – NORMAL RCA
Ashley Davidoff MD

LV ventriculography showed  apical hypokinesis/dyskinesis consistent with Takotsubo heart. EF was 40%

Takotsubo Heart gif file

 

CXR – IMPROVING CHF
Ashley Davidoff MD

Chest CT showed multiple non calcified nodules, increased since prior studies, and increase in mediastinal and hilar adenopathy, as well as abdominal adenopathy. Coronary calcification was present

 

MRI showed normal EF, with apical hypokinesis, findings consistent with Takotsubo heart.

LV APICAL EDEMA
TAKOTSUBO CARDIOMYOPATHY –
Ashley Davidoff MD
?BALLOONING OF THE LV APEX
TAKOTSUBO CARDIOMYOPATHY –
Ashley Davidoff MD
MRI TAKOTSUBO
SHORT AXIS – LGE
Suboptimal study but no obvious ischemic disease
Ashley Davidoff MD

Thus this lady has a diagnosis of sarcoidosis (ocular skin and likely pulmonary)and Takotsubo cardiomyopathy precipitated by an acute emotional stress when the policE visited her home looking for men in her basement.

She presented with acute coronary syndrome, ST segment changes on EKG, mildly elevated troponins, CHF on CXR, with normal  coronary arteriography and LV gram characteristic of Takotsubo cardiomyopathy

 

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