Lombardi Marco, Vergallo Rocco, Liuzzo Giovanna, Crea Filippo
Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8-00168 Rome, Italy.
Eur Heart J Case Rep. 2020 Dec 11;5(1):ytaa477. doi: 10.1093/ehjcr/ytaa477. eCollection 2021 Jan.
Takotsubo syndrome (TTS) is a disease characterized by an acute and reversible myocardial injury typically precipitated by stressful and/or emotional triggers. Despite extensive research, its pathogenesis remains incompletely understood. Spasm of epicardial coronary arteries has been proposed as a potential pathogenic factor in TTS.
Herein, we report the case of a 68-year-old female admitted to the emergency department after developing chest pain in concomitance with an intense emotional stress. A diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) was made. Coronary angiography disclosed normal coronary arteries, and left ventriculography showed an inferior focal akinesia with basal and apical hyperkinesis, so that a diagnosis of 'focal TTS' was made. Two months later, the patient was re-admitted with NSTEMI, and repeat coronary angiography showed an irregular subocclusive stenosis of a well-developed first obtuse marginal branch. After intracoronary nitroglycerine infusion, a complete recover of the vessel patency was noted, and a diagnosis of epicardial spasm was made. Intracoronary optical coherence tomography was performed to assess a residual 'hazy' region, which confirmed a normal vessel morphology and a residual focal area of spasm without signs of instability.
Whether TTS and coronary artery spasm are two expressions of the same disease, or rather two separate entities with overlapping mechanisms remains unknown, and further research is warranted to solve this issue. Meanwhile, the opportunity of performing provocative tests for coronary spasm in patients with suspected TTS might be considered to gain more insights into this hypothesis.
应激性心肌病（TTS）是一种以急性可逆性心肌损伤为特征的疾病，通常由压力和/或情绪触发因素诱发。尽管进行了广泛研究，但其发病机制仍未完全明确。心外膜冠状动脉痉挛已被提出作为TTS的一个潜在致病因素。
在此，我们报告一例68岁女性病例，该患者在经历强烈情绪应激后出现胸痛，被收入急诊科。诊断为非ST段抬高型心肌梗死（NSTEMI）。冠状动脉造影显示冠状动脉正常，左心室造影显示下壁局部运动减弱，基底段和心尖段运动增强，因此诊断为“局灶性TTS”。两个月后，患者因NSTEMI再次入院，重复冠状动脉造影显示一支发育良好的第一钝缘支存在不规则的亚闭塞性狭窄。冠状动脉内注入硝酸甘油后，血管通畅完全恢复，诊断为心外膜痉挛。进行了冠状动脉内光学相干断层扫描以评估残留的“模糊”区域，结果证实血管形态正常，存在残留的局灶性痉挛区域且无不稳定迹象。
TTS和冠状动脉痉挛是同一疾病的两种表现，还是具有重叠机制的两个独立实体，目前尚不清楚，需要进一步研究来解决这个问题。同时，可以考虑对疑似TTS患者进行冠状动脉痉挛激发试验，以更深入地了解这一假设。
