Can Gallstones Break the Heart? Pancreatitis‐Induced Takotsubo Cardiomyopathy Mimicking Acute Myocardial Infarction

To the Editor: Takotsubo, or apical ballooning cardiomyopathy, accounts for a small but significant number of acute coronary syndrome presentations. Clinical consideration of this entity is essential when evaluating suspected myocardial infarctions in the setting of significant adrenergic stress. Herein is reported an individual with Takotsubo cardiomyopathy developing soon after the onset of gallstone pancreatitis. A 76-year-old woman with a medical history of hypertension, hyperlipidemia, and diabetes mellitus presented to the emergency department with 1 day of epigastric pain, nausea, and vomiting. She had reported severe, nonradiating pain not associated with meals. She also reported diaphoresis and new-onset shortness of breath. She denied drug or alcohol use. On examination, she was afebrile and had an oxygen saturation of 97% on 4 L through a nasal cannula; her other vital signs were normal. Her examination was significant for bibasilar crackles and epigastric tenderness. Laboratory analysis revealed mild leukocytosis, high troponin, and markedly high lipase in the presence of a mild transaminitis. A chest X-ray demonstrated left lower lobe consolidation, bilateral pleural effusion, and mild diffuse interstitial edema. Abdominal ultrasound demonstrated common bile duct dilation with numerous echogenic foci but no wall thickening. Electrocardiogram demonstrated sinus rhythm and a new 10-mm ST segment elevation in the anteroseptal leads. Transesophageal echocardiogram showed anteroseptal segment hypokinesis with a preserved ejection fraction of 50–55%. Subsequent left heart catheterization showed no coronary disease but a hypokinetic apical left ventricle with an ejection fraction of 30–35%, consistent with acute nonischemic cardiomyopathy (Figure 1). Pancreatitis-related fluid loss was corrected cautiously given her cardiomyopathy and pulmonary edema. Her pain improved over the course of 3 days, with serial troponin rising to a maximum of 9.94 ng/mL. Upon resolution of her pulmonary edema, she underwent laparoscopic cholecystectomy. After recovery from a postoperative biloma, endoscopic retrograde cholangiopancreatography (ERCP) revealed choledocholithiasis, which was treated with a sphincterotomy, and she was discharged to a skilled nursing facility for rehabilitation. Takotsubo cardiomyopathy accounts for 1–2% of cases of acute coronary syndrome.1 Acute physical or emotional stress in elderly women is thought to precipitate the majority of cases through catecholamine cardiotoxicity. Transient myocardial stunning occurs with an apical predilection.2 The Mayo Criteria are the most widely accepted for this condition: electrocardiographic changes indicative of acute myocardial infarction, transient hypokinesia of the left ventricle, nonobstructed coronary arteries, and absence of several exclusion criteria (intracranial hemorrhage, pheochromocytoma, hypertrophic cardiomyopathy, myocarditis).3 Treatment is based on expert opinion and is generally symptomatic in nature, determined by subsequent complications. The prognosis is generally favorable, with in-hospital mortality of 0–12%, and recurrence is rare.2 An extensive literature review yielded only four cases of Takotsubo cardiomyopathy documented in association with acute pancreatitis. Of these, only one occurred in close temporal association with a nonalcoholic pancreatitis.4 The other three episodes ranged from 1 to 7 days after onset of acute pancreatitis, with one case occurring after alcohol-mediated pancreatitis,5 another after ERCP subsequent to a resolved case of gallstone pancreatitis,6 and the third after a resolving case of pancreatitis of unspecified etiology.7 This case highlights the importance of considering Takotsubo cardiomyopathy when evaluating apparent acute coronary syndrome. Management of associated medical conditions such as pancreatitis requires careful attention to cardiac function and fluid status. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Case management: Leubner, Ortiz, Drake. Preparation of manuscript: Leubner, Ortiz, Wolfrey, Drake. Critical review of manuscript: Leubner, Ortiz, Wolfrey, Drake. Sponsor's Role: No sponsors involved.