Takotsubo syndrome in the context of severe hypoglycemia

Simón Frapolli, Víctor José; López Medina, José Antonio; Tinahones Madueño, Francisco José

doi:10.1016/j.medcle.2021.05.013

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Classic TTS is characterized by apical akinesia of the left ventricle with compensatory hyperkinesis of the rest of the myocardial regions, in the absence of coronary artery stenosis or atheromatous plaque rupture. TTS generally occurs more frequently in women than in men (9:1), especially in postmenopausal women, and is mainly triggered by physical or emotional stress, resulting in exaggerated myocardial exposure to catecholamines<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.Far from being a benign disease, TTS has high short- and long-term morbidity rates (fatal arrhythmias) and a high mortality rate, of up to 8%. Approximately 95% of patients recover fully, with a recurrence rate of up to 11% if stressors recur<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>.We report the clinical case of a 39-year-old male, type 1 diabetic with poor adherence to treatment, who was rushed to hospital due to a low level of consciousness, with severe hypoglycaemia and a capillary measurement of 13 mg/dl. Physical examination: weight 69 kg, height 188 cm (BMI: 19.5 kg/m2), blood pressure 112/84 mmHg, heart rate 112 lpm, basal oxygen saturation 97% and capillary glycaemia 33 mg/dl, requiring treatment with intravenous glucose. Complementary tests: glucose 67 mg/dl, creatinine 0.86 mg/dl, sodium 141 mEq/l, potassium 2.8 mEq/l, lactate 3.8 U/l, creatinine kinase 179 U/l, aspartate transaminase 152 U/l, alanine transaminase 77 U/l, C-reactive protein <1 mg/dl, undetectable ethanol and leucocytosis of 23. 760/mL (21,870 neutrophils/mL). Venous blood gases: metabolic alkalosis with pH 7,473 and HCO 331.8 mmol/l. Negative toxicity urinalysis Emergency department electrocardiogram: sinus tachycardia with prolonged QTc. Chest X-ray and head CT without pathological findings.Subsequently, his hemodynamic status worsened, and a transthoracic echocardiogram and Swan-Ganz catheter placement were performed, observing severe left ventricular dysfunction with morphology compatible with TTS (Fig. A.1), with reduced ejection fraction and cardiac output < 2 l/min despite support with vasoactive drugs, so an intra-aortic balloon was implanted and ventricular support by means of veno-arterial extracorporeal membrane oxygenation was provided, which was removed after 72 h. Echocardiographic findings returned to normal during follow-up. The electrocardiogram on the second day progressed to a diffuse flattening of T waves, followed by diffuse inversion of T waves that returned to normal on the fourth day. Troponin I values increased since admission with a peak of 1,042.67 ng/l on the second day, returning to normal on the ninth day. Angiography without significant changes.CBC: albumin 2.2 g/dl, prealbumin 19.5 mg/dl. IgA 559 mg/dl (normal: 40–350), IgM 134 mg/dl (normal: 50–300), IgG 2,109 mg/dl (normal: 650–1,600) with subclasses G1 1,430 mg/dl (normal: 278–822) and G4 836 mg/dl (normal: 3–132). Anti-glutamate decarboxylase 10.26 U/mL (normal: < 5), anti-tyrosine phosphatase 1.59 U/mL (normal: <7.5) and anti-insulin antibodies negative. Thyroid hormone and autoimmune profile, celiac profile, complement and normal systemic autoimmunity parameters.Diabetes mellitus (DM) is the most common endocrine disorder in the general population, and hypoglycaemia is its most common complication. However, few cases of TTS associated with hypoglycaemia have been described.This clinical case is atypical since it is a relatively young male, when TTS usually develops in postmenopausal women<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. In addition, although severe hypoglycaemia is the most important factor in the onset of the condition, protein-calorie malnutrition may also have played a role.Hypoglycaemia is a complication of DM that entails significant adverse effects. It is well known that tight metabolic control in the diabetic patient leading to hypoglycaemia can increase mortality<a class="elsevierStyleCrossRef" href="#bib0020">4</a>. Hypoglycaemia is common in the emergency department, but myocardial abnormalities secondary to hypoglycaemia are rarely explored at present, so TTS may go undetected and undiagnosed if its haemodynamic course is benign. Therefore, we should pay more attention to cardiac function in patients with impaired carbohydrate metabolism, considering echocardiography, if necessary, as hypoglycaemia-associated STT may be one of the key factors in the increased cardiovascular morbidity and mortality observed in previous studies focusing on diabetic patients<a class="elsevierStyleCrossRef" href="#bib0025">5</a>." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Simón Frapolli VJ, López Medina JA, Tinahones Madueño FJ. Síndrome de Takotsubo en el contexto de hipoglucemia grave. Med Clin (Barc). 2022;158:192." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Takotsubo-type cardiomyopathy due to multivessel spasm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. Sato" 1 => "H. Tateishi" 2 => "T. 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Genuth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0802743" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2008" "volumen" => "358" "paginaInicial" => "2545" "paginaFinal" => "2559" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18539917" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015800000004/v1_202202170636/S2387020622000390/v1_202202170636/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015800000004/v1_202202170636/S2387020622000390/v1_202202170636/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622000390?idApp=UINPBA00004N"]

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2.6

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3.1

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0.371

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