Acute Pancreatitis-Induced Takotsubo Cardiomyopathy in an African American Male

Abstract

LEARNING OBJECTIVE #1: Recognize acute pancreatitis as a rare trigger for Takotsubo's cardiomyopathy and highlight appropriate management LEARNING OBJECTIVE #2: Report the first male case and second African-American male presenting with this unique association CASE: A 55-year old African-American male with a history of recurrent episodes of alcohol-induced acute pancreatitis and alcoholic steatohepatitis, and essential hypertension was admitted to the hospital after several hours of severe, sharp, stabbing, 10/10, nonradiating pain in the epigastrium and left lower sternal border. The pain was associated with diaphoresis, nausea, and yellow, non-bilious, non-bloody vomiting. He reported a 2- week alcohol binge prior to the intensity of the pain restricting his ability to drink alcohol the morning of admission. Abdominal examination revealed epigastric distension, involuntary guarding, and diffuse abdominal tenderness to palpation. Electrocardiogram(EKG) showed normal sinus rhythm with QT-segment prolongation and ST-Tsegment depression (STTSD) and T-wave inversions (TWI). Initial cardiac biomarkers i.e. troponin-I (TnI) and NT pro-beta natriuretic polypeptide were elevated at 0.29 ng/mL and 4420 pg/mL respectively. Additionally, laboratory parameters revealed elevated serum lipase and amylase at 773 IU/L and 97 IU/L respectively, and metabolic profile demonstrated elevated anion-gap metabolic acidosis with elevated serum lactate and ketones. Serial TnI was trended with peak level of 0.658 ng/mL. Transthoracic echocardiogram (TTE) showed decreased left ventricular (LV) systolic function with LV ejection fraction (EF) 30-35 %. Dilated and dyskinetic apex and hypokinetic segments in mid- and apicalanterior wall, apical lateral wall, mid- and apical-septum and apical inferolateral walls of the LV were noted. Compensatory hyperkinesia of basal segments was noted. Computerized tomographic scan of the abdomen revealed peripancreatic edema and infiltration without necrosis or fluid collections and hepatobiliary ultrasound was negative for obstructive pathology. Emergent coronary angiogram after stabilization demonstrated insignificant mild irregularities in left circumflex and right coronary arteries without obstructive coronary artery disease (CAD). Contrast left ventriculography demonstrated reduced LVEF (25 %) with apical ballooning and hyper-contractile basal segments, consistent with Takotsubo cardiomyopathy (TCM). The patient was medically stabilized on aspirin, metoprolol, and lisinopril. Due to concern for apical mural thrombus formation, the patient was started on warfarin with goal international normalized ratio of 2.0-3.0. Subsequently 3 weeks later, a repeat TTE demonstrated complete recovery of LVEF (60- 65%) with no akinetic or hypokinetic segments. His anticoagulation was stopped since no LV thrombus was noted. He continues to remain sober and is on regular follow-up with substance dependency services. DISCUSSION: TCM, also variedly known as LV apical ballooning, broken heart syndrome and stress cardiomyopathy, is characterized by LVapical ballooning and has been called that due to its resemblance of a Japanese octopus trap, a tako tsubo. Typically reported triggers include emotional stress, pheochromocytoma and sub-arachnoid hemorrhage. It has been hypothesized that the pathophysiology of TCM is related to coronary micro vascular dysfunction, coronary artery spasm, catecholamine-induced myocardial stunning, reperfusion injury following acute coronary syndrome, myocardial micro infarction and abnormalities in cardiac fatty acid metabolism. The Mayo Criteria is the most widely accepted diagnostic criteria, where all four criteria must be met to make the diagnosis: (a) transient hypokinesis, akinesis, or dyskinesis of the LV mid segments with or without apical involvement, (b) absence of obstructive CAD or angiographic evidence of acute plaque rupture, (c) new electrocardiogram abnormalities (either STTS elevation or TWI) or modest elevation in cardiac troponin, (d) absence of pheochromocytoma or myocarditis. Ninety percent of patients diagnosed with TCM are postmenopausal women aged 61-76 years. This is hypothesized to be due to estrogen deficiency. Consistent with the same; the five reported cases of pancreatitis-induced TCMare females over the age of 40 years old. Alcoholic pancreatitis was first implicated as an antecedent physical stressor in a case of 'inverted' TCM in 2006. Since that time, two cases of acute gallstone, a postendoscopic retrograde cholangiopacreatography study, and an unspecified pancreatitisinduced TCM have been described. In our case report, we described what we believe to be the first reported case of pancreatitis-induced TCM in an African-American male.