Cardioembolic Stroke Secondary to Massive Stress-Induced Apical Thrombosis: A Clinical Conundrum Relating to Anticoagulation Initiation

Overview

Journal J Community Hosp Intern Med Perspect

Date 2023 Oct 23

PMID 37868237

Authors

Siva N S Yarrarapu

Parth Shah

Vikramaditya S Venkata

Jayasree Ravilla

Gaurav Mohan

Poorva Bhide

David Anwar

Affiliations

Soon will be listed here.

Abstract

Takotsubo cardiomyopathy or stress cardiomyopathy is a condition characterized by acute and transient left ventricular systolic dysfunction in the absence of coronary heart disease, occurring after an acute emotional or physical stressful event. Cardiac dysfunction in these patients is suspected to be secondary to catecholamine induced cardiac myocyte injury via cyclic AMP-mediated calcium overload or due to endothelial dysfunction. Even though left ventricular dysfunction in takotsubo cardiomyopathy is transient, it can lead to acute complications. Left ventricular thrombus formation is a widely reported complication and has an incidence of around 5-14% in Takotsubo cardiomyopathy patients and can lead to thromboembolic events like stroke. We report a case of takotsubo cardiomyopathy with an apical LV thrombus, complicated by a large cardioembolic stroke. This case constitutes a clinical conundrum, as LV thrombus would warrant prompt initiation of anticoagulation, while the severe ischemic stroke would be a contraindication for immediate anticoagulation.

References

Dalia T, Lahan S, Ranka S, Goyal A, Zoubek S, Gupta K . Warfarin versus direct oral anticoagulants for treating left ventricular thrombus: a systematic review and meta-analysis. Thromb J. 2021; 19(1):7. PMC: 7849079. DOI: 10.1186/s12959-021-00259-w. View

Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H . Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J. 2006; 27(20):2433-9. DOI: 10.1093/eurheartj/ehl274. View

Bossone E, Savarese G, Ferrara F, Citro R, Mosca S, Musella F . Takotsubo cardiomyopathy: overview. Heart Fail Clin. 2013; 9(2):249-66, x. DOI: 10.1016/j.hfc.2012.12.015. View

Mitsuma W, Kodama M, Ito M, Kimura S, Tanaka K, Hoyano M . Thromboembolism in Takotsubo cardiomyopathy. Int J Cardiol. 2008; 139(1):98-100. DOI: 10.1016/j.ijcard.2008.06.089. View

Mann D, Kent R, Parsons B, Cooper 4th G . Adrenergic effects on the biology of the adult mammalian cardiocyte. Circulation. 1992; 85(2):790-804. DOI: 10.1161/01.cir.85.2.790. View

Kim S, Aikat S, Bailey A, White M . Takotsubo cardiomyopathy as a source of cardioembolic cerebral infarction. BMJ Case Rep. 2012; 2012. PMC: 4543685. DOI: 10.1136/bcr-2012-006835. View

Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B . 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016; 37(38):2893-2962. DOI: 10.1093/eurheartj/ehw210. View

Medina DE Chazal H, Del Buono M, Keyser-Marcus L, Ma L, Moeller F, Berrocal D . Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018; 72(16):1955-1971. PMC: 7058348. DOI: 10.1016/j.jacc.2018.07.072. View

Lyon A, Rees P, Prasad S, Poole-Wilson P, Harding S . Stress (Takotsubo) cardiomyopathy--a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med. 2007; 5(1):22-9. DOI: 10.1038/ncpcardio1066. View

10.

Templin C, Ghadri J, Diekmann J, Napp L, Bataiosu D, Jaguszewski M . Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015; 373(10):929-38. DOI: 10.1056/NEJMoa1406761. View

11.

de Gregorio C, Grimaldi P, Lentini C . Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review. Int J Cardiol. 2008; 131(1):18-24. DOI: 10.1016/j.ijcard.2008.05.060. View

12.

Dawson D . Acute stress-induced (takotsubo) cardiomyopathy. Heart. 2017; 104(2):96-102. DOI: 10.1136/heartjnl-2017-311579. View

13.

Bontioti E, Kanje M, Lundborg G, Dahlin L . End-to-side nerve repair in the upper extremity of rat. J Peripher Nerv Syst. 2005; 10(1):58-68. DOI: 10.1111/j.1085-9489.2005.10109.x. View

14.

Taylor J . The National Standards Guidelines for Prehospital Nursing Curriculum: a job well done. J Emerg Nurs. 1992; 18(1):5-6. View

15.

Gianni M, Dentali F, Grandi A, Sumner G, Hiralal R, Lonn E . Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 2006; 27(13):1523-9. DOI: 10.1093/eurheartj/ehl032. View

16.

Santoro F, Stiermaier T, Tarantino N, De Gennaro L, Moeller C, Guastafierro F . Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry. J Am Heart Assoc. 2017; 6(12). PMC: 5779019. DOI: 10.1161/JAHA.117.006990. View

17.

Haghi D, Papavassiliu T, Heggemann F, Kaden J, Borggrefe M, Suselbeck T . Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography. QJM. 2008; 101(5):381-6. DOI: 10.1093/qjmed/hcn017. View

18.

Kida K, Akashi Y, Fazio G, Novo S . Takotsubo cardiomyopathy. Curr Pharm Des. 2010; 16(26):2910-7. DOI: 10.2174/138161210793176509. View

19.

de Gregorio C . Cardioembolic outcomes in stress-related cardiomyopathy complicated by ventricular thrombus: a systematic review of 26 clinical studies. Int J Cardiol. 2009; 141(1):11-7. DOI: 10.1016/j.ijcard.2009.09.468. View

20.

Tornvall P, Collste O, Ehrenborg E, Jarnbert-Petterson H . A Case-Control Study of Risk Markers and Mortality in Takotsubo Stress Cardiomyopathy. J Am Coll Cardiol. 2016; 67(16):1931-6. DOI: 10.1016/j.jacc.2016.02.029. View