IJCS | Volume 32, Nº2, March/April 2019

DOI: 10.5935/2359-4802.20190006 197 CASE REPORT International Journal of Cardiovascular Sciences. 2019;32(2)197-200 Mailing Address: Roberto Ramos Barbosa Rua Dr. Jairo de Matos Pereira, 780, ap. 1001. Postal Code: 29101-310, Praia da Costa, Vila Velha, ES - Brazil. E-mail: roberto.rb@cardiol.br, beto.cardio@yahoo.com.br Variant Type of Stress Cardiomyopathy: Inverted Takotsubo Syndrome Roberto Ramos Barbosa, 1, 2 M ayara da Silva, 1 M arceloVaz de Mello Demian, 2 L uiz Fernando Machado Barbosa 1 Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), 1 ES - Brazil Hospital Unimed Vitória, 2 ES - Brazil Manuscript received December 25, 2017; revised manuscript February 15, 2018; accepted March 27, 2018. Takotsubo Cardiomyopathy/complications; Takotsubo Cardiomyopathy/physiopathology; Tako t subo Ca r d i omyopa t hy/d r ug t he r apy ; Psychological Stress; Heart Ventricles/diagnostic imaging; Echocardiography. Keywords Introduction Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is a rare condition characterized by transient systolic and diastolic LV dysfunction, with akinesia of the apex and compensatory basal hyperkinesia, giving the heart the aspect of “apical ballooning”, described for the first time in 1990 in Japan. 1 Its clinical presentationmainly includes chest pain, which often has typical angina characteristics, and dyspnea, 2 being an important differential diagnosis from a classic acute coronary syndrome (ACS). TTS isobservedpredominantlyamongpostmenopausal women, and the emotional stress is considered a precipitating factor in most studies. Its etiology is still controversial, and the excess of circulating catecholamine is the most acceptable mechanism. 2-5 Variant forms of TTS have been increasingly reported, 6 among which are described the apical, mid-ventricular, basal, and focal types 7 or the inverted Takotsubo syndrome (ITS), characterized by hyperdynamic apex and akinesia of the base; a morphological pattern opposite to the most common clinical manifestation of the disease. In this case report, we present the diagnosis and the evolution of a rare variant formof stress cardiomyopathy: inverted Takotsubo syndrome. Case report A physically active female aged 70 years of age, with no cardiovascular risk factors, was admitted to the cardiac emergency department, on 04/19/17, complaining of chest pain with angina characteristics, with two hours of evolution, which started after emotional stress within her family. Her physical examination did not show significant alterations, with arterial oxygen saturation of 97%, blood pressure of 142/74 mmHg and a heart rate of 78 beats per minute. The ECG demonstrated sinus rhythm, a heart rate of 76 beats perminute and absence of ST-T segment changes. First troponin I dosage was 3.97 mg/dl (reference: < 0.4) and CK-MB mass of 9.38 mg/dl (reference: < 5.4). The diagnosis at admission was myocardial acute infarction (MAI) without ST segment elevation. She was medicated with bisoprolol, enalapril, aspirin, ticagrelor, enoxaparin and pantoprazole, with improvement in chest pain. On 04/20/17, she was submitted to a coronary coronary angiography, which revealed angiographically normal coronary arteries with no obstructive lesions (Figure 1). Left ventriculography showed systolic dysfunction with basal akinesia and apical hyperkinesia consistent with ITS (variant contractile pattern of stress cardiomyopathy) (Figure 2). Transthoracic echocardiography revealed akinesia of mid portion of anterior, septal, inferior and lateral LV walls, with hyperkinesis of the other walls, and estimated ejection fraction at 39%, calculated with the Simpson’s method. Maintained in clinical treatment, the patient presented satisfactory intra-hospital evolution, without new episodes of angina or clinical instability. She was discharged on 04/22/17, under use of aspirin and carvedilol, and remained asymptomatic during the 30-day clinical follow-up.