Swimming into "the octopus trap": an unusual etiology of st-segment elevation

SESSION TITLE: Cardiovascular Disease Case Report Posters 9 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Takotsubo cardiomyopathy (TCM) is an uncommon reversible form of cardiomyopathy that is often precipitated by extreme psychological or physical stress. It is prevalent in 1-2% of patients presenting with acute coronary syndrome [1]. While some cases of exercise-induced TCM have been reported in the literature, associated mitral regurgitation (MR), mid-left ventricle involvement and reduced ejection fraction (EF) are rare findings. CASE PRESENTATION: A 64-year-old female with a past medical history of hyperlipidemia, tongue cancer status post reconstructive surgery, lichen planus of the mucous membranes & esophagus and anxiety initially presented to a nearby hospital with complaints of retrosternal chest pain that began 5-10 minutes prior while swimming at the gym. Pain was 10/10 in severity, radiating to the left arm and jaw, pressure-like in quality, and associated with nausea, vomiting, and diaphoresis. An emergent electrocardiogram revealed ST elevation myocardial infarction (STEMI) in anterolateral and inferior leads. She was given aspirin 324 mg, ticagrelor 180 mg, metoprolol tartrate 25 mg, and low dose heparin. STEMI alert was called and she was immediately transferred to our hospital for an emergent cardiac catheterization. On arrival, her vitals revealed blood pressure 116/94 mmHg, heart rate 86 beats per minute, respiratory rate 23 breaths per minute, afebrile and saturating 96% on ambient air. Initial troponin was 0.37 ng/mL (ref: <0.04 ng/mL). Coronary arteries were angiographically normal. The ventriculogram revealed akinesis of the entire mid-distal anterior wall, apex, apical inferior and mid-inferior walls. Also, a hyperkinetic base and 3+ mitral regurgitation were noted. The left ventricular EF was estimated to be 20% with an LVEDP of 24 mmHg (ref: 4-12 mmHg). She was diagnosed with Takotsubo cardiomyopathy with mitral regurgitation induced by exercise. She was placed on metoprolol 12.5 mg twice daily and discharged to home. DISCUSSION: While TCM has been a commonly identified phenomenon in literature, our patient had rare findings of mid-distal and inferior ventricular wall involvement with a reduction in EF in addition to MR making this case unique. The pathophysiology of TCM has been suspected to be due to catecholamine surges in response to stress, however, the exact mechanism remains poorly understood and requires further studies [2]. CONCLUSIONS: Various stress related causes of TCM are known; however, identifying MR and reduced EF as possible clinical findings is vital for patient outcomes. REFERENCE #1: Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo Syndrome. Circulation. 2017 Jun 13;135(24):2426-2441. doi: 10.1161/CIRCULATIONAHA.116.027121. PMID: 28606950. REFERENCE #2: Cantor G, Teressa G. Mid-Left Ventricular Ballooning Variant Takotsubo Syndrome Induced by Treadmill Exercise Stress Testing. Case Rep Cardiol. 2018;2018:5282747. doi:10.1155/2018/5282747 DISCLOSURES: No relevant relationships by Hira Akhlaq No relevant relationships by Ghadier Al Saoudi No relevant relationships by Aubin Attila No relevant relationships by Alejandro Cruz Ponce No relevant relationships by Steven Imburgio No relevant relationships by Anmol Johal No relevant relationships by Viraaj Pannu No relevant relationships by Helen Pozdniakova No relevant relationships by Matthew Saybolt No relevant relationships by Ndausung Udongwo