PP049 FALL INTO THE TRAP WITH STREPTOKINASE

Abstract

Introduction

Takotsubo cardiomyopathy (TC) mimics ST elevated acute myocardial infarction (STEMI) clinically. It is generally triggered by stress in elderly or postmenopausal females and has a good prognosis.

Case presentation

A 46 years old Malay lady presented to Emergency Department after 4 hours of postprandial chest discomfort associated with dizziness and vomiting. Electrocardiogram (ECG) on arrival showed normal sinus rhythm. She developed worsening chest discomfort 4 hours later. Repeated ECG showed marked ST segment elevation over leads V2-V4. Troponin T level was elevated. Patient was immediately treated as acute anterior STEMI. However, she developed stroke and was intubated, 90min after completion of streptokinase. Bedside echocardiogram done in coronary care unit revealed left ventricle apical ballooning with regional apical hypokinesia. Coronary angiogram on the succeeding day showed absence of significant coronary artery stenosis. Hence, the diagnosis of Takotsubo cardiomyopathy was made.

Discussion

It is a great challenge for clinician to differentiate anterior STEMI and TC as clinical similarities of both diseases are almost identical. Highly specific ECG criteria to differentiate TC from anterior STEMI have been published in few recent articles. It would be valuable to distinguish those using ECG criteria in view of profound differences in immediate treatment between TC and STEMI. Ability to perform focused cardiac ultrasound plays a pivotal role in early diagnosis of TC. Coronary angiogram remained the gold standard method to exclude STEMI.

Conclusion

1) Knowledge of ECG criteria is important to differentiate STEMI and TC.

2) Bedside echocardiogram provides additional input to diagnose TC.

3) Early activation of cathetherization lab will avoid misdiagnosis as STEMI and unnecessary exposure to possible complications from thrombolysis therapy.