{"id":71375,"date":"2023-04-27T09:36:53","date_gmt":"2023-04-27T07:36:53","guid":{"rendered":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/?p=71375"},"modified":"2024-02-28T10:13:41","modified_gmt":"2024-02-28T09:13:41","slug":"dolor-toracico-tipico-que-acude-a-urgencias-sindrome-de-tako-tsubo","status":"publish","type":"post","link":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/dolor-toracico-tipico-que-acude-a-urgencias-sindrome-de-tako-tsubo\/","title":{"rendered":"Dolor tor\u00e1cico t\u00edpico que acude a urgencias. S\u00edndrome de Tako-Tsubo"},"content":{"rendered":"

Dolor tor\u00e1cico t\u00edpico que acude a urgencias. S\u00edndrome de Tako-Tsubo<\/strong><\/p>\n

Autora principal: Alba Mart\u00ednez de la Horra<\/p>\n

Vol. XVIII; n\u00ba 8; 376<\/p>\n

Typical chest pain that goes to the emergency. Tako-Tsubo Syndrome<\/strong><\/p>\n

Fecha de recepci\u00f3n: 27\/03\/2023<\/p>\n

Fecha de aceptaci\u00f3n: 21\/04\/2023<\/p>\n

Incluido en Revista Electr\u00f3nica de PortalesMedicos.com Volumen XVIII. N\u00famero 8 Segunda quincena de Abril de 2023 \u2013 P\u00e1gina inicial: Vol. XVIII; n\u00ba 8; 376<\/p>\n

AUTORES: Alba Mart\u00ednez de la Horra. Enfermera en 061 Cantabria y servicios de urgencia<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Mar\u00eda Casuso Ruiz, enfermera en HUMV unidad de consultas hospitalarias<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Marta Arenal Osorno, enfermer\u00eda 061 Cantabria y servicios de urgencia<\/p>\n

PALABRAS CLAVE: dolor tor\u00e1cico, infarto, tako-tsubo<\/p>\n

KEYWORDS: chest pain, heart attack, tako-tsubo<\/p>\n

CASO CLINICO<\/strong><\/p>\n

Mujer de 65 a\u00f1os que acude a urgencias por dolor tor\u00e1cico de aparici\u00f3n s\u00fabita tras discusi\u00f3n con su marido esta ma\u00f1ana. Sin antecedentes cardiacos previos, intolerancia digestiva a los corticoides, sin alergias farmacol\u00f3gicas conocidas y con hipertensi\u00f3n arterial en tratamiento con losartan. El dolor es centro tor\u00e1cico, opresivo, que no se modifica con los movimientos posturales ni respiratorios y con irradiaci\u00f3n a regi\u00f3n dorsal y extremidades superiores. Tambi\u00e9n refiere sudoraci\u00f3n profusa, mareo y sensaci\u00f3n de falta de aire. La exploraci\u00f3n f\u00edsica no aporta datos relevantes. En urgencias se procede a la realizaci\u00f3n de un electrocardiograma, anal\u00edtica con enzimas card\u00edacas y ecocardiograf\u00eda.<\/p>\n

CTES: TA:145\/87 FC:78X1 Sat 02: 98%<\/p>\n

ANALITICA: se le realiza hemograma y bioqu\u00edmica con resultado de leucocitosis (13.670) y un incremento de Troponina T 0,43 ng\/dl.<\/p>\n

ECG: ritmo sinusal entorno a 80x\u2019 con aplanamiento de onda T en V3-V4-V5.<\/p>\n

En la radiograf\u00eda de t\u00f3rax no se muestran im\u00e1genes patol\u00f3gicas.<\/p>\n

ECOCARDIO: Inicialmente muestra una discinesia o acinesia del \u00e1pex del VI, con normo o hipocinesia basal.<\/p>\n

Con estos datos se llega al diagn\u00f3stico probable de SCASEST, instaurando tratamiento con nitroglicerina, doble antiagregaci\u00f3n, anticoagulaci\u00f3n, antihipertensivo, beta-bloqueante y estatina e ingresada en la Unidad de Cuidados Intensivos a la espera de la realizaci\u00f3n de cronograf\u00eda.<\/p>\n

La coronariograf\u00eda dio como resultado arterias coronarias epic\u00e1rdicas sin estenosis angiogr\u00e1ficas significativas, disquinesia de segmentos mediales en caras anterior, lateral, septal y diafragm\u00e1tico, con una reducci\u00f3n de la fracci\u00f3n de eyecci\u00f3n de ventr\u00edculo izquierdo (FEVI) 40-45%, con diagn\u00f3stico probable de S\u00edndrome de Takotsubo.<\/p>\n

La evoluci\u00f3n fue favorable y el ecocardiograma de control a los 5 d\u00edas despu\u00e9s del primero, mostr\u00f3 una hipertrofia ventricular conc\u00e9ntrica ligera con alteraci\u00f3n de la relajaci\u00f3n, siendo el resto de la exploraci\u00f3n normal, por lo que se procede al alta hospitalaria con tratamiento ansiol\u00edtico.<\/p>\n

DISCUSION<\/strong><\/p>\n

Distinguir, en urgencias, con la cl\u00ednica y el ECG, un s\u00edndrome de Tako-Tsubo de un s\u00edndrome coronario agudo por trombosis coronaria puede ser dif\u00edcil.<\/p>\n

El s\u00edndrome tako-tsubo o sindrome del coraz\u00f3n roto fue descrito por primera vez en los a\u00f1os 90 en Jap\u00f3n. Se le denomin\u00f3 Tako-Tsubo porque as\u00ed se llama una vasija, abombada y con el cuello estrecho, usada tradicionalmente entre los pescadores Japoneses para atrapar pulpos (posee la misma forma que la que adopta el ventr\u00edculo izquierdo en la ventriculograf\u00eda). En 2006, la American Heart Association incorpora el s\u00edndrome de Tako-Tsubo como miocardiopat\u00eda primaria adquirida en su clasificaci\u00f3n de las miocardiopat\u00edas<\/p>\n

Suele afectar mayoritariamente a mujeres posmenop\u00e1usicas con pocos factores de riesgo cardiovascular y suele estar precedido de un estr\u00e9s f\u00edsico o ps\u00edquico que act\u00faa como desencadenante. Se caracteriza por dolor precordial anginoso, cambios electrocardiogr\u00e1ficos, elevaci\u00f3n de enzimas de da\u00f1o mioc\u00e1rdico, ausencia de obstrucci\u00f3n coronaria en la angiograf\u00eda y una caracter\u00edstica discinesia anteroapical del ventr\u00edculo izquierdo que se normaliza en unos pocos d\u00edas. La disfunci\u00f3n apical transitoria se caracteriza por la morfolog\u00eda que adopta el ventr\u00edculo izquierdo, con el \u00e1pex redondeado y el cuello estrecho, originada por la hipocinesia, acinesia o discinesia de los segmentos apicales, e hipercontractilidad de los segmentos basales. El diagn\u00f3stico suele darse tras descartar enfermedad aterotromb\u00f3tica en las arterias coronarias durante la realizaci\u00f3n de una coronograf\u00eda.<\/p>\n

La etiopatogenia del Sindrome Tako.Tsubo es a\u00fan desconocida. Se han indicado varios criterios diagn\u00f3sticos, siendo los m\u00e1s utilizados aquellos propuestos por la Cl\u00ednica Mayo. Deben estar presentes los 4 criterios para que se pueda establecer el diagn\u00f3stico.<\/p>\n

Criterios diagn\u00f3sticos de la Cl\u00ednica Mayo para el s\u00edndrome de takotsubo<\/p>\n\n\n\n\n\n\n
1. Hipoquinesia, aquinesia o disquinesia transitoria de los segmentos medios del VI con o sin afectaci\u00f3n apical. Las anormalidades en la motilidad de la pared ventricular se extienden m\u00e1s all\u00e1 del territorio de irrigaci\u00f3n de una \u00fanica arteria coronaria epic\u00e1rdica. A menudo, aunque no siempre, existe un evento estresante desencadenante.<\/td>\n<\/tr>\n
2. Ausencia de enfermedad coronaria obstructiva o de evidencia angiogr\u00e1fica de rotura aguda de una placa\u00a0.<\/td>\n<\/tr>\n
3. Alteraciones ECG nuevas (elevaci\u00f3n del segmento ST y\/o inversi\u00f3n de la onda T) o elevaci\u00f3n discreta de las troponinas card\u00edaca.<\/td>\n<\/tr>\n
4. Ausencia de feocromocitoma y miocarditis. \u00a0El feocromocitoma es un \u00a0tumor, generalmente benigno y adrenal, productor de catecolaminas.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

El pron\u00f3stico suele ser bueno, pero pueden existir complicaciones como arritmias, insuficiencia card\u00edaca, estenosis suba\u00f3rtica din\u00e1mica, shock cardiog\u00e9nico, accidente cerebrovascular de origen emb\u00f3lico e incluso muerte. Con su r\u00e1pido reconocimiento se puede evitar la administraci\u00f3n de fibrinol\u00edticos y la realizaci\u00f3n de cateterismo en la fase aguda. El tratamiento con bloqueadores beta o con agonistas alfa-adren\u00e9rgicos, a\u00f1adidos a inhibidores de la enzima conversora de angiotensina (IECA) son de gran utilidad para disminuir o anular el gradiente din\u00e1mico que se genera durante la fase aguda. A los dos o tres d\u00edas de la fase aguda comienza la recuperaci\u00f3n cl\u00ednica y hemodin\u00e1mica. Las alteraciones del ECG y de la ecocardiograf\u00eda pueden durar d\u00edas o semanas y en algunos pacientes se ha observado la existencia de una disfunci\u00f3n ventricular izquierda residual.<\/p>\n

Conflicto de intereses<\/p>\n

Los autores declaran no tener ning\u00fan conflicto de intereses<\/p>\n

CLINICAL CASE<\/strong><\/p>\n

A 65-year-old woman came to the emergency department due to sudden onset of chest pain after an argument with her husband this morning. No previous cardiac history, digestive intolerance to corticosteroids, no known drug allergies, and arterial hypertension being treated with losartan. The pain is oppressive in the thoracic center, which does not change with postural or respiratory movements and irradiates to the dorsal region and upper extremities. She also reports profuse sweating, dizziness, and feeling short of breath. Physical examination does not provide relevant data. In the emergency department, an electrocardiogram, cardiac enzyme analysis, and echocardiography were performed.<\/p>\n

CTES: TA:145\/87 FC:78X1 Sat 02: 98%<\/p>\n

ANALYTICAL: A complete blood count and biochemistry were performed, with the result of leukocytosis (13,670) and an increase in Troponin T 0.43 ng\/dl. ECG: sinus rhythm around 80x’ with flattening of the T wave in V3-V4-V5.<\/p>\n

Chest radiography does not show pathological images.<\/p>\n

ECHOCARDIO: Initially it shows dyskinesia or akinesia of the LV apex, with normal or basal hypokinesia.<\/p>\n

With these data, a probable diagnosis of NSTE-ACS was reached, establishing treatment with nitroglycerin, double antiplatelet therapy, anticoagulation, antihypertensive, beta-blocker, and statin, and she was admitted to the Intensive Care Unit awaiting coronography.<\/p>\n

The evolution was favorable and the control echocardiogram 5 days after the first showed mild concentric ventricular hypertrophy with impaired relaxation, the rest of the examination being normal, for which reason he was discharged from the hospital with anxiolytic treatment.<\/p>\n

DISCUSSION<\/strong><\/p>\n

Distinguishing Tako-Tsubo syndrome from acute coronary syndrome due to coronary thrombosis based on symptoms and ECG in the emergency department can be difficult.<\/p>\n

Tako-tsubo syndrome or broken heart syndrome was first described in the 1990s in Japan. It was called Tako-Tsubo because that is the name of a bowl, convex and with a narrow neck, traditionally used among Japanese fishermen to catch octopuses (it has the same shape as the one adopted by the left ventricle in ventriculography). In 2006, the American Heart Association incorporated Tako-Tsubo syndrome as a primary acquired cardiomyopathy in its classification of cardiomyopathies.<\/p>\n

It tends to mainly affect postmenopausal women with few cardiovascular risk factors and is usually preceded by physical or psychological stress that acts as a trigger. It is characterized by anginal chest pain, electrocardiographic changes, elevated myocardial damage enzymes, absence of coronary obstruction on angiography, and characteristic left ventricular anteroapical dyskinesia that normalizes within a few days. Transient apical dysfunction is characterized by the morphology adopted by the left ventricle, with a rounded apex and a narrow neck, caused by hypokinesia, akinesia, or dyskinesia of the apical segments, and hypercontractility of the basal segments. The diagnosis is usually made after ruling out atherothrombotic disease in the coronary arteries during coronography.<\/p>\n

The etiopathogenesis of Tako-Tsubo Syndrome is still unknown. Various diagnostic criteria have been indicated, the most widely used being those proposed by the Mayo Clinic. All 4 criteria must be present for the diagnosis to be established.<\/p>\n

Mayo Clinic diagnostic criteria for takotsubo syndrome:<\/p>\n

    \n
  1. Transient hypokinesia, akinesia, or dyskinesia of the middle LV segments with or without apical involvement. Abnormalities in ventricular wall motion extend beyond the supply territory of a single epicardial coronary artery. Often, though not always, there is a triggering stressful event.<\/li>\n
  2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture.<\/li>\n
  3. New ECG changes (ST segment elevation and\/or T wave inversion) or mild elevation of cardiac troponins.<\/li>\n
  4. Absence of pheochromocytoma and myocarditis. Pheochromocytoma is a tumor, generally benign and adrenal, that produces catecholamines.<\/li>\n<\/ol>\n

    The prognosis is usually good, but there may be complications such as arrhythmias, heart failure, dynamic subaortic stenosis, cardiogenic shock, embolic stroke, and even death. With its rapid recognition, the administration of fibrinolytics and catheterization in the acute phase can be avoided. Treatment with beta-blockers or alpha-adrenergic agonists, added to angiotensin-converting enzyme (ACE) inhibitors, are very useful to reduce or cancel the dynamic gradient that is generated during the acute phase. Two or three days after the acute phase, clinical and hemodynamic recovery begins. ECG and echocardiographic abnormalities may last days or weeks, and residual left ventricular dysfunction has been observed in some patients.<\/p>\n

    Conflict of interests<\/p>\n

    The authors declare they have no conflict of interest<\/p>\n

    Ver anexo<\/strong><\/a><\/h2>\n

    BIBLIOGRAFIA<\/strong><\/p>\n

      \n
    1. Da Costa A, Isaaz K, Faure E, Mourot A, Cerisier A, Lamaud M. Clinical characteristics, aetiological factorsand long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram. Eur Heart J 2001; 22: 1459-1465. ]<\/li>\n
    2. Del Nogal S\u00e1ez et al. S\u00edndrome de tako-tsubo. Discinesia transitoria del ventr\u00edculo izquierdo. Presentaci\u00f3nde nuestra casu\u00edstica. Med Intensiva. 2011;35(5):307-311.<\/li>\n
    3. Sato et al. Stunnes myocardium with speciphic (Takotsubo-type) left ventriculographic configuration due tomultivessel spasm. Clinical aspect of myocardial injury. From ischemia to heart failure. Kodama K. Hori M. Eds Kagakuhyyouronsya Co. Tokio. 1990; 56:-64.<\/li>\n
    4. Tsuchihashi K, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 2001;38:11-8.<\/li>\n
    5. Kurisu S. et al. Time course of electrocardiographic changes in patients with Takotsubo syndrome: comparison with acute myocardial infarction with minimal enzymatic release. Cir J. 2004;68:77-81.<\/li>\n
    6. Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, et al. Angina Pectoris-Myocardial Infarction Investigations in Japan. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001;38:11-8.<\/li>\n
    7. Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. 2004;94:343-6.<\/li>\n
    8. Auer J, Porodko M, Berent R, Punzengruber C, Weber T, Lamm G, et al. Transient left ventricular apical ballooning mimicking acute coronary syndrome in four patients from central europe. Croat Med J. 2005;46:942-9.<\/li>\n
    9. Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol. 2003;4:737-42.<\/li>\n
    10. Sato, H. Tateishi, T. Uchida. Tako-tsubo-type cardiomyopathy due to multivessel spasm. Clinical aspect of myocardial injury; from ischemia to heart failure, pp. 56-64<\/li>\n
    11. J. Maron, J.A. Towbin, G. Thiene, C. Antzelevitch, D. Corrado, D. Arnett, et al<\/em>. American Heart Association contemporary definitions and classification of the cardiomyopathies. Circulation, 113 (2006), pp. 1807-1816<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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