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Macroscopic T-wave alternans in a patient with takotsubo cardiomyopathy and QT prolongation Haider J. Warraich, MD, Alfred E. Buxton, MD, Robb D. Kociol, MD, MS From the Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Figure 1 (A) Electrocardiogram demonstrates macroscopic t-wave alternans and profound QT prolongation. Note the deep T-wave inversions on alternate beats. (B) Electrocardiogram 10 days after initial presentation demonstrates resolution of T-wave alternans but shows persistently prolonged QT segment and t wave inversions
KEYWORDS Takotsubo cardiomyopathy; Torsades de pointes; T-Wave alternans ABBREVIATIONS TCM ¼ takotsubo cardiomyopathy; TWA ¼ T-wave alternans (Heart Rhythm 2014;0:1–2) Address reprint requests and correspondence: Dr Haider J. Warraich, Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Rd, Boston, MA 02215. E-mail address: [email protected].
1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.
A 61-year-old woman presented with intermittent diarrhea and acute onset of dyspnea. She had arrived from Ecuador few days ago. An electrocardiogram revealed macroscopic T-wave alternans (TWA) with QT prolongation (Figure 1A). Her potassium was 3.1 mEq/L and magnesium was 1.8 mg/dL. She had no family history of sudden cardiac death and arrhythmias and had no history of syncope. Her N http://dx.doi.org/10.1016/j.hrthm.2014.03.005
2
Heart Rhythm, Vol 0, No 0, Month 2014
Figure 2 Real time three-dimensional volumetric mapping of the left ventricle demonstrates ballooning and dyskinesis of the left ventricular apex consistent with Takotsubo’s cardiomyopathy.
terminal pro brain natriuretic peptide (NT-proBNP) was 15,000. Serological tests for Chagas disease were negative. An echocardiogram revealed an ejection fraction of 25%, with apical ballooning and hypokinesis suggestive of Takotsubo cardiomyopathy (TCM; Figure 2 and Online Video 1). Cardiac catheterization revealed no obstructive coronary lesions. The patient was given intravenous supplements of potassium and magnesium, and her ejection fraction improved to 45% after 3 days. She had resolution of TWA after 10 days but continued to have prolonged corrected QT interval (Figure 1B). She never experienced tachyarrhythmias. While macroscopic TWA has been reported in the setting of QT prolongation, we believe this is the first published report of TWA in a patient with TCM. Macroscopic TWA is ominous for impending torsades de pointes; therefore, it is important for physicians to recognize this classic electrocardiographic pattern.1 QT prolongation associated with TCM was first reported in 2007.2 Management principles include aggressive electrolyte repletion, particularly magnesium and potassium, telemonitoring, and avoidance of QT prolonging medications. This patient did not develop any ventricular arrhythmia, reflecting data that suggest female patients with TCM and QT prolongation experience torsades de pointes less frequently than do male patients.3 A recent study reported higher TP-e dispersion (largest difference
between t-peak and t-end intervals among precordial leads) in patients with TCM who developed tachyarrhythmias compared to controls.4 Our case had higher TP-e dispersion compared to patients with TCM in the study who developed tachyarrhythmias (80 ⫾ 16 ms vs 36 ⫾ 16 ms), although none of those patients had TWA.
Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.hrthm. 2014.03.005.
References 1. Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, Philippides GJ, Roden DM, Zareba W. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation 2010;121:1047–1060. 2. Nault MA, Baranchuk A, Simpson CS, Redfearn DP. Takotsubo cardiomyopathy: a novel “proarrhythmic” disease. Anadolu Kardiyol Derg 2007;7:101–103. 3. Samuelov-Kinori L, Kinori M, Kogan Y, et al. Takotsubo cardiomyopathy and QT interval prolongation: who are the patients at risk for torsades de pointes? J Electrocardiol 2009;42(353–357):e1. 4. Streitner F, Hamm K, Wittstein IS, Baranchuk A, Akashi YJ, Nef HM, Bonello L, Wolpert C, Borggrefe M, Haghi D. Is abnormal myocardial repolarization associated with the occurrence of malignant tachyarrhythmias in takotsubo cardiomyopathy? Cardiol J 2013;20:633–638.
Macroscopic T-wave alternans in a patient with takotsubo cardiomyopathy and QT prolongation Haider J. Warraich, MD, Alfred E. Buxton, MD, Robb D. Kociol, MD, MS From the Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Figure 1 (A) Electrocardiogram demonstrates macroscopic t-wave alternans and profound QT prolongation. Note the deep T-wave inversions on alternate beats. (B) Electrocardiogram 10 days after initial presentation demonstrates resolution of T-wave alternans but shows persistently prolonged QT segment and t wave inversions
KEYWORDS Takotsubo cardiomyopathy; Torsades de pointes; T-Wave alternans ABBREVIATIONS TCM ¼ takotsubo cardiomyopathy; TWA ¼ T-wave alternans (Heart Rhythm 2014;0:1–2) Address reprint requests and correspondence: Dr Haider J. Warraich, Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Rd, Boston, MA 02215. E-mail address: [email protected].
1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.
A 61-year-old woman presented with intermittent diarrhea and acute onset of dyspnea. She had arrived from Ecuador few days ago. An electrocardiogram revealed macroscopic T-wave alternans (TWA) with QT prolongation (Figure 1A). Her potassium was 3.1 mEq/L and magnesium was 1.8 mg/dL. She had no family history of sudden cardiac death and arrhythmias and had no history of syncope. Her N http://dx.doi.org/10.1016/j.hrthm.2014.03.005
2
Heart Rhythm, Vol 0, No 0, Month 2014
Figure 2 Real time three-dimensional volumetric mapping of the left ventricle demonstrates ballooning and dyskinesis of the left ventricular apex consistent with Takotsubo’s cardiomyopathy.
terminal pro brain natriuretic peptide (NT-proBNP) was 15,000. Serological tests for Chagas disease were negative. An echocardiogram revealed an ejection fraction of 25%, with apical ballooning and hypokinesis suggestive of Takotsubo cardiomyopathy (TCM; Figure 2 and Online Video 1). Cardiac catheterization revealed no obstructive coronary lesions. The patient was given intravenous supplements of potassium and magnesium, and her ejection fraction improved to 45% after 3 days. She had resolution of TWA after 10 days but continued to have prolonged corrected QT interval (Figure 1B). She never experienced tachyarrhythmias. While macroscopic TWA has been reported in the setting of QT prolongation, we believe this is the first published report of TWA in a patient with TCM. Macroscopic TWA is ominous for impending torsades de pointes; therefore, it is important for physicians to recognize this classic electrocardiographic pattern.1 QT prolongation associated with TCM was first reported in 2007.2 Management principles include aggressive electrolyte repletion, particularly magnesium and potassium, telemonitoring, and avoidance of QT prolonging medications. This patient did not develop any ventricular arrhythmia, reflecting data that suggest female patients with TCM and QT prolongation experience torsades de pointes less frequently than do male patients.3 A recent study reported higher TP-e dispersion (largest difference
between t-peak and t-end intervals among precordial leads) in patients with TCM who developed tachyarrhythmias compared to controls.4 Our case had higher TP-e dispersion compared to patients with TCM in the study who developed tachyarrhythmias (80 ⫾ 16 ms vs 36 ⫾ 16 ms), although none of those patients had TWA.
Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.hrthm. 2014.03.005.
References 1. Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, Philippides GJ, Roden DM, Zareba W. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation 2010;121:1047–1060. 2. Nault MA, Baranchuk A, Simpson CS, Redfearn DP. Takotsubo cardiomyopathy: a novel “proarrhythmic” disease. Anadolu Kardiyol Derg 2007;7:101–103. 3. Samuelov-Kinori L, Kinori M, Kogan Y, et al. Takotsubo cardiomyopathy and QT interval prolongation: who are the patients at risk for torsades de pointes? J Electrocardiol 2009;42(353–357):e1. 4. Streitner F, Hamm K, Wittstein IS, Baranchuk A, Akashi YJ, Nef HM, Bonello L, Wolpert C, Borggrefe M, Haghi D. Is abnormal myocardial repolarization associated with the occurrence of malignant tachyarrhythmias in takotsubo cardiomyopathy? Cardiol J 2013;20:633–638.
