Pires Inês, Mapelli Massimo, Amelotti Nicola, Salvioni Elisabetta, Ferrari Cristina, Baggiano Andrea, Conte Edoardo, Mattavelli Irene, Agostoni Piergiuseppe
Cardiology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal.
Centro Cardiologico Monzino, IRCCs, Milan, Italy.
Front Psychiatry. 2022 May 2;13:882870. doi: 10.3389/fpsyt.2022.882870. eCollection 2022.
Takayasu's arteritis (TA) is a systemic inflammatory disease that affects aorta and its major branches. There are several cardiac manifestations of TA and an association with Takotsubo syndrome (TTS) - but not coronary vasospasm - has been previously reported. The role of emotional stress in this context is unknown.
A 58-year-old Caucasian female elementary school teacher, with a history of generalized anxiety disorder (GAD), severe asymptomatic aortic regurgitation (AR), and TA in remission under corticosteroids, was admitted in the emergency department with worsening chest pain and dyspnea, initiated after a period of intense emotional stress (increased workload during COVID-19 pandemic). Physical examination revealed signs of heart failure (HF) with hemodynamic stability and an early diastolic heart murmur. The electrocardiogram showed sinus tachycardia, T wave inversion in left precordial and lateral leads, and a corrected QT of 487 ms. Laboratorial evaluation presented high values of high-sensitivity troponin I (3494 ng/L) and B-type natriuretic peptide (4759 pg/mL). The transthoracic echocardiogram revealed severe dilation of left ventricle (LV) with moderate systolic dysfunction, due to apical and midventricular akinesia, and severe AR. The coronary angiography showed normal coronary arteries. An acetylcholine provocative test induced spasm of both the left anterior descending and circumflex arteries, accompanied by chest pain and ST depression, completely reverted after intracoronary nitrates administration. The patient was switched to diltiazem and a drug multitherapy for HF was started. A cardiac magnetic resonance revealed severe dilation of the LV, mild apical hypokinesia, improvement of ejection fraction to 53%, signs of myocardial edema and increased extracellular volume in apical and mid-ventricular anterior and anterolateral walls, and absence of myocardial late gadolinium enhancement, compatible with TTS. At discharge, the patient was clinically stable, without signs of HF, and a progressive reduction of troponin and BNP levels was observed. A final diagnosis of TTS and coronary vasospasm in a patient with GAD and TA was done.
We present the first case of acute HF showing coexistence of TA, TTS and coronary vasospasm. TA is a rare inflammatory disease that can be associated with TTS and coronary vasospasm. Besides that, coronary vasospasm may also be involved in TTS pathophysiology, suggesting a complex interplay between these diseases. Mood disorders and anxiety influence the response to stress, through a gain of the hypothalamic-pituitary-adrenal axis and an increased cardiovascular system sensitivity to catecholamines. Therefore, although the mechanisms behind these three pathologies are not yet fully studied, this case supports the role of inflammatory and psychiatric diseases in TTS and coronary vasospasm.
大动脉炎（TA）是一种影响主动脉及其主要分支的全身性炎症性疾病。TA有多种心脏表现，此前有报道称其与应激性心肌病（TTS）有关——但与冠状动脉痉挛无关。在这种情况下，情绪应激的作用尚不清楚。
一名58岁的白人女性小学教师，有广泛性焦虑症（GAD）、严重无症状主动脉瓣反流（AR）病史，在使用皮质类固醇治疗下TA处于缓解期，因在一段强烈情绪应激（新冠疫情期间工作量增加）后出现胸痛和呼吸困难加重而入住急诊科。体格检查发现心力衰竭（HF）体征，血流动力学稳定，有舒张早期心脏杂音。心电图显示窦性心动过速，左胸前导联和侧壁导联T波倒置，校正QT间期为487毫秒。实验室检查显示高敏肌钙蛋白I（3494纳克/升）和B型利钠肽（4759皮克/毫升）值升高。经胸超声心动图显示左心室（LV）严重扩张，伴有中度收缩功能障碍，原因是心尖和心室中部运动减弱，以及严重AR。冠状动脉造影显示冠状动脉正常。乙酰胆碱激发试验诱发左前降支和回旋支动脉痉挛，伴有胸痛和ST段压低，冠状动脉内给予硝酸盐后完全缓解。患者改用维拉帕米，并开始使用多种药物治疗HF。心脏磁共振显示LV严重扩张，心尖轻度运动减弱，射血分数提高到53%，心尖和心室中部前壁及前侧壁有心肌水肿迹象和细胞外容积增加，且无心肌晚期钆增强，符合TTS。出院时，患者临床稳定，无HF体征，肌钙蛋白和BNP水平逐渐降低。最终诊断为一名患有GAD和TA的患者出现TTS和冠状动脉痉挛。
我们报告了首例急性HF病例，显示TA、TTS和冠状动脉痉挛并存。TA是一种罕见的炎症性疾病，可与TTS和冠状动脉痉挛相关。除此之外，冠状动脉痉挛可能也参与了TTS的病理生理过程，提示这些疾病之间存在复杂的相互作用。情绪障碍和焦虑通过下丘脑 - 垂体 - 肾上腺轴的亢进和心血管系统对儿茶酚胺敏感性的增加影响对应激的反应。因此，尽管这三种病症背后的机制尚未完全研究清楚，但该病例支持炎症性疾病和精神疾病在TTS和冠状动脉痉挛中的作用。
