Download Intractable Ventricular Tachycardia Associated With Stress

ECG & EP Cases
Intractable Ventricular Tachycardia
Associated With Stress Cardiomyopathy
경희대학교 의과대학 내과학교실
진은선
Eun-Sun Jin, MD, PhD
Cardiovascular Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea
Abstract
A 75-year-old woman presented with medically intractable wide QRS tachycardia. She had experienced chest
discomfort during a vertebral procedure and was transferred to our hospital. Electrocardiography showed
sustained wide QRS tachycardia, which persisted in various QRS axes despite the repeated administration of
electrical shock. Through amiodarone infusion and repeated shock delivery, the cardiac rhythm was stabilized
to a sinus rhythm. Thereafter, the sustained ventricular tachycardia, for which electrical shock was necessary,
occurred repeatedly for 12 hours, but then decreased in frequency and disappeared in 3 days. Echocardiography revealed akinesia of the entire left ventricular apical segment, and coronary angiography showed minimal coronary disease, which was compatible with a diagnosis of stress-induced cardiomyopathy. The patient
recovered with general supportive care. Follow-up echocardiography revealed normalized left ventricular wall
motion and systolic function.
Key Words: ■ Takotsubo cardiomyopathy ■ tachycardia ■ ventricular
Introduction
malities of the left ventricular wall. However,
the coronary arteries appear normal in such
Stress cardiomyopathy (SCM)—also known as
cases and the prognosis is good. Patients with
Takotsubo cardiomyopathy—is a common clini-
SCM also present with QT prolongation on ECG.
cal condition with a clinical presentation that
However, only a few cases of SCM presenting
similar to acute myocardial infarction. Such pa-
with ventricular tachycardia (VT) associated with
tients may present with chest pain, ST changes
long QT have been reported. In the present re-
on electrocardiography (ECG), elevated cardiac
port, we describe a case of a 75-year-old patient
enzyme levels, and regional wall motion abnor-
with medically intractable monomorphic VT associated with SCM.
Received: 14 August, 2014
Revision Received: September 11, 2014
Accepted: September 14, 2014
Correspondence: Eun-Sun Jin, MD, PhD, Cardiovascular Center,
Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro,
Gangdong-gu, Seoul, Korea.
Tel: +82-2-440-6109, Fax: +82-2-440-7242
E-mail: [email protected] Ko, MD, PhD, Division of Cardiology
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The Official Journal of Korean Heart Rhythm Society
Case
A 75-year-old woman was transferred to the
emergency room of our hospital for chest dis-
ECG & EP Cases
Figure 1. Sustained wide QRS tachycardia even after an electrical shock. Occasionally, the QRS axis changed after an electrical shock.
Figure 2. Spontaneous QRS axis changes during wide QRS tachycardia.
comfort that developed during neuroplasty for
QRS axis changed, but the wide QRS tachycardia
lumbar spinal stenosis. She was receiving medi-
persisted (Figure 1). Most of the VTs were mono-
cation for diabetes mellitus and hypertension.
morphic, but occasionally, the QRS axis changed
Upon arrival to the emergency room, her ECG
spontaneously (Figure 2). The patient underwent
showed a sustained wide QRS tachycardia of 150
electrical shock more than 30 times within 12
bpm. Her blood pressure was 90/50 mmHg. We
hours to terminate the recurrent VT. Because the
suspected the presence of monomorphic VT, and
QT interval of the sinus rhythm was normal (Fig-
hence, electrical shock was delivered. After re-
ure 3), amiodarone was infused for the recurrent
peated administration of electrical shock, the
VT. Subsequently, VT changed to the nonsus-
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ECG & EP Cases
A
B
Figure 3. Electrocardiography in sinus rhythm showed no QT prolongation (A). 1 month later, ECG showed better R wave progression
and T wave change without QT prolongation in precordial leads (B).
Figure 4. Coronary angiography showing no significant stenosis.
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The Official Journal of Korean Heart Rhythm Society
ECG & EP Cases
tained form and then gradually resolved.
level was 3.5 mmol/L. Although prolonged QT
Thereafter, echocardiography showed akinesia
with polymorphic VT is a common ECG finding
of the middle and apical wholesegments. Ex-
in cases of SCM, monomorphic VT may also de-
tensive ischemia of the left anterior descending
velop. Because the proposed mechanism of SCM
artery was suspected, but the findings were also
involves microvascular myocardial ischemia.4,5
compatible with stress-induced cardiomyopathy.
Medical treatment for sustained VT can be ad-
In addition, coronary angiography indicated no
justed according to the VT mechanism. Amio-
significant stenosis (Figure 4).
darone infusion is not used for treating cases of
Amiodarone administration was discontinued
torsades de pointes with long QT, but can be used
because of the development of QT prolongation
for treating cases of monomorphic VT with no QT
during drug infusion. With supportive treatment,
prolongation that may be associated with micro-
the left ventricular function and wall motion nor-
vascular myocardial ischemia.
malized, and VT did not recur. The patient was
Although a patient may experience life-threat-
discharged without any medication. ECG which
ening sustained VT resulting from SCM, place-
was taken 1 month after discharge showed better
ment of an implantable cardioverter-defibrillator
R wave progression with T wave change without
is not recommended because SCM is considered a
QT prolongation in precordial leads (Figure 3B).
reversible, self-limited disease. Nevertheless, 11%
of patients experience symptom recurrence after a
Discussion
4-year follow-up period.6 Thus, large-scale, longterm follow-up data are needed to estimate the re-
SCM is a commonly encountered disease, char-
currence of life-threatening VT caused by SCM.
acterized by its initially severe presentation, followed by a mild clinical course. On presentation,
it is often misdiagnosed as myocardial infarction.
References
The most distinguishable clinical aspects of this
disease are the absence of coronary artery stenosis and a good prognosis. Although myocardial
infarction is the most common cause of sudden
cardiac death, the mortality rate of SCM in hospitals ranges from 1% to 2%.1,2
A potentially dangerous clinical presentation
of SCM is torsades de pointes coinciding with
QT prolongation, which is often accompanied by
hypokalemia.3 However, cases of sustained VT
causing cardiac death are uncommon.
In the present case, the patient showed recurrent, sustained VT of both the monomorphic and
polymorphic forms, with the monomorphic form
occurring more frequently. In the sinus rhythm,
QT was not prolonged and the serum potassium
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Takotsubo Syndrome. Eur Heart J. 2010;31:1319-1327.
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6. Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Fouryear recurrence rate and prognosis of the apical ballooning syndrome.
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