Article

Takotsubo cardiomyopathy after anti-influenza vaccination: catecholaminergic effects of immune system

Unlabelled imageAmerican Journal of Emergency Medicine 31 (2013) 1627.e1-1627.e4

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American Journal of Emergency Medicine

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Case Report

Takotsubo cardiomyopathy after anti-influenza vaccination: catecholaminergic effects of immune system?,??

Abstract

Takotsubo cardiomyopathy is a well-known condition, which leads to sudden transient regional systolic dysfunction. It mostly affects aging women and is usually precipitated by emotional or physical stress. Despite the tremendous amount of literature on TTC, cardiac Sympathetic hyperactivity is the only thing known to be associated with pathogenesis. In our case, an Elderly woman presented with an acute episode of TTC 24 hours after anti-influenza vaccination without any obvious stressor for sudden rise in the catecholamine level. Sudden postvaccination change in the cardiac sympathetic discharge is the most likely precipitant of TTC in this case.

Takotsubo cardiomyopathy (TTC), also known as stress cardio- myopathy, was first described in Japan in 1991 [1]. Takotsubo cardiomyopathy can be defined based on transient left ventricular (LV) systolic dysfunction that presents as an acute coronary syndrome in the absence of any significant coronary artery disease. Takotsubo cardiomyopathy predominantly affects aging women and is usually preceded by an emotional or physical stress [2]. It is postulated that catecholamine-mediated Myocardial stunning in- duces TTC [3]. However, why an increase in catecholamines affects some individuals and not others, why mostly women, and why the LV apex is predominantly affected are some of the many questions that are currently unanswered.

An 86-year-old woman with history of paroxysmal atrial fibrilla- tion and bronchiectasis presented to hospital with central chest pain and shortness of breath. She could not identify any antecedent emotional or physical stressors; however, she did receive an influenza vaccination 24 hours before the onset of pain. Her electrocardiogram demonstrated anterolateral ST-segment elevation with reciprocal inferior ST depression. Based on these findings, she was taken for an emergency coronary angiogram, which showed Normal coronary arteries without evidence of acute Plaque rupture. Contrast left ventriculogram revealed apical ballooning classic of apical form of TTC (Fig. 1) (Video 1).

On the day of admission, Cardiac troponin T was elevated at 114 ng/L as was creatine kinase at 210 U/L, and N-Terminal prohormone of brain nartiuretic peptide was 1375 pg/mL (normal b 100 pg/mL). Plasma metanephrine and normetanephrine were raised at 570 pmol/L (normal b 200 pmol/L) and 1080 pmol/L (normal b 660 pmol/L), respectively. transthoracic echocardiogram on the day of presentation

? Conflict of interest: None of the authors has any disclosure or conflict of interest.

?? All the authors had access to data and role in writing the manuscript.

confirmed LV dyskinesia of the mid-distal walls and apical ballooning. Left ventricular ejection fraction, estimated using Simpson’s biplane method, was 33% (Fig. 2A) (Video 2). Mean longitudinal strain was – 8.5% (normal, -20% to -25%) with highest strain derangement in apical segments (Fig. 2B). cardiac magnetic resonance imaging extended the coronary angiogram and transthoracic echocardiogram finding demonstrating apical hypokinesis (Fig. 3). No late gadolinium enhancement evident.

Classic precipitating emotional or physical stressors are found in almost 80% of patients with TTC [4]. The cause of sudden rise of catecholamines in rest of the patients is uncertain. In our case, was the sudden rise of catecholamines because of vaccination?

Although the utility of influenza vaccination in high-risk in- dividuals such as the elderly is well established [5], there have been several reports of myopericarditis because of influenza vaccination [6], and it is possible that this mechanism applied to the current case. Although it can be suspected that myocarditis in such cases is caused by virus infection, in the previous reports, virus antigen was not found in the patient’s serum. Moreover, the complication of myocarditis after vaccination is not only limited to influenza vaccination but has been found after various other disease vaccina- tions such as diphtheria, tetanus and polio [7], anticattarh [8], and hepatitis B vaccination [9]. Occurrence of myocarditis from any of the aforementioned vaccine disapproves the theory of Influenza infection as the cause of myocarditis.

Although influenza vaccination-induced myocarditis is a possible differential diagnosis, the clinical and investigative features of this case were strongly suggestive of TTC. However, there is no previous distinctive evidence linking vaccination of any sort with emergence of TTC.

If it is postulated that vaccination induced TTC, a component of the association must be either increased release of or myocardial sensitization to catecholamines. Akashi et al [10] demonstrated cardiac sympathetic hyperactivity in patients with TTC by using

(123) I-metaiodobenzlguanidine myocardial scintigraphy. Influenza vaccination or vaccination in general causes a systemic inflammatory reaction, which can be measured by a rise in the C-reactive protein and body temperature post vaccination [11]. These changes by the vaccination along with subclinical inflammation lead to imbalance in the cardiosympathetic system, with increase in sympathetic discharge that have been demonstrated by the reduction in Heart rate variability post vaccination [11].

Patients with TTC require Close monitoring of patients for the first 48 hours in the hospital to treat any Life-threatening complications such as long QT interval-related ventricular tachycardia [12]. A second reason for close monitoring is potential for early hemodynamic instability. Although the bases remain uncertain, a proportion of

0735-6757/$ – see front matter (C) 2013

1627.e2 K. Singh et al. / American Journal of Emergency Medicine 31 (2013) 1627.e11627.e4

perindopril 2.5 mg oral daily and bisoprolol 1.25 mg, although neither of these therapies is currently evidence based.

Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2013.06.039.

Kuljit Singh MD

Department of Cardiology, Queen Elizabeth Hospital

Woodville South, SA, Australia E-mail address: [email protected]

Tina Marinelli MBBS Department of Medicine, Queen Elizabeth Hospital Woodville South, SA 5011 Australia

John D Horowitz MD

Department of Cardiology, Queen Elizabeth Hospital

Woodville South, SA, Australia

http://dx.doi.org/10.1016/j.ajem.2013.06.039

Fig. 1. A and B, Contrast left ventriculogram during diastole and systole. Left ventricular dyskinesis and contraction of the basal segment can be seen during systole giving the typical appearance of “Octopus Trap” (Japanese meaning of takotsubo).

patients with TTC can develop shock in the first 48 hours and need close observation [13]. A further important step in the management of TTC is avoidance of medications that can raise Catecholamine levels

[14] and thus increase the myocardial injury. Hence, norepinephrine, epinephrine, and dopamine use for hypotension should be avoided. Thus, intra-aortic balloon pump insertion is frequently appropriate for shocked TTC patients. In this case, the patient was treated with

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    Fig. 2. A, Longitudinal strain measurement on Apical 4-chamber view of transthoracic echocardiography. The strain is highest (most abnormal) in the apical segment of the LV illustrating the most affected segment of the LV in TTC. B, Average longitudinal strain obtained from apical 4-chamber, apical 2-chamber, and apical long-axis view of transthoracic echocardiography. Seventeen segments of the LV can be seen in the above picture showing the most abnormal strain in the apical segments.

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    Fig. 3. Cardiac magnetic resonance imaging of the LV showing apical long-axis view in diastole (upper left) and systole (upper right) and apical 4-chamber view in diastole (lower left) and systole (lower right). In both the apical views, in systole, only basal segment can be seen contracting while the apex is akinetic.

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