Tako Tsubo Cardiomyopathy Secondary to Seizures

Tako Tsubo cardiomyopathy was first described in Japan in 1990 by Satoh et al. 1 This syndrome of transient left ventricular dysfunction in response to severe emotional stress or illness occurs in the setting of normal epicardial coronary arteries.Patients are most commonly females without prior history of cardiac disease.The syndrome consists of chest pain, EKG abnormalities and elevation of cardiac markers.The resulting left ventricular dysfunction primarily affects the anterior and apical segments, creating an image of apical ballooning on left ventriculogram.The term Tako Tsubo is Japanese for octopus trap, which the left ventriculogram appearance resembles.This letter highlights presentation of Tako Tsubo cardiomyopathy secondary to a seizure.A 64-year-old right-handed female was brought to the emergency department after being found experiencing a generalized tonic-clonic seizure.Significant medical history included: seizure disorder of undetermined etiology since age nine, current smoker, hypertension, depression, possible asthma, and bilateral mastectomies for fibrosystic breast diease.The day prior to admission, the patient described a vague sensation of being "unwell".The seizure leading to admission was of unknown duration but felt to be typical of her prior events.The patient received 2.5 mg of midazolam from paramedics with seizure resolution.However, she experienced a subsequent seizure in the emergency department.Initial vital signs were: BP 160/66, HR 116, RR 18, 100% oxygen saturation on 3L by nasal drip.The patient appeared dyspneic to emergency staff.Initial EKG was abnormal with minor ST elevation in leads V2 and V3 (Figure 1).Chest x-ray revealed pulmonary edema.An echocardiogram was performed in the emergency department confirming antero-lateral papillary muscle dysfunction, mild mitral regurgitation, and slightly dilated left ventricle with moderate-severe systolic dysfunction secondary to antero-apical akinesis (Figure 2).Cardiac markers were elevated (Troponin T peak 1.54 µg/L).A CT head scan revealed a remote left caudate lacunar infarct.Carbamazepine level was in the low therapeutic range (20-50 umol/L) at 23.9.The patient was admitted to the coronary care unit for management of suspected acute coronary syndrome and congestive heart failure.Her initial therapy included: ASA, atorvastatin, topical nitrates, IV heparin, ace-inhibitor, phenytoin and carbamazepine.She improved clinically and underwent cardiac catheterization within a week of presentation.Left ventricular end-diastolic pressure was 14 mm Hg with severe anterolateral and apical systolic impairment.Ejection fraction

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