Cardiovascular Journal of Africa: Vol 27 No 3 (May/June 2016)

94 / 102

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016 e12 AFRICA
Case Report
Short-term warfarin treatment for apical thrombus in a
patient with Takotsubo cardiomyopathy
Abdullah İcli, Hakan Akilli, Mehmet Kayrak, Alpay Aribas, Kurtulus Ozdemir
Abstract
Takotsubo cardiomyopathy (TCMP) is characterised by a
temporary aneurysm of the left ventricular apex in individu-
als without significant stenosis of the coronary arteries. It is
extremely rare to see it combined with a thrombus. In this case
report, we present a 57-year-old female patient with TCMP in
whom apical thrombus was treated with short-term warfarin
use.
Keywords: Takotsubo cardiomyopathy, apical thrombus,
warfarin
Submitted 20/10/15, accepted 17/2/16
Published online 19/5/16
Cardiovasc J Afr 2016; 27: e12–e14
DOI: 10.5830/CVJA-2016-011
Takotsubo cardiomyopathy (TCMP) is characterised by a
temporary aneurysm of the left ventricular apex in individuals
without significant stenosis of the coronary arteries. Mostly
seen in postmenopausal women, it is also called ampulla
cardiomyopathy, human stress cardiomyopathy or broken heart
syndrome.1 It is extremely rare to see it combined with a
thrombus.
The Mayo Clinic diagnostic criteria for TCMP include
reversible left ventricular dysfunction, newly emerging
ECG changes and/or increased troponin levels, intracranial
haemorrhage, pheochromocytoma and hypertrophic
cardiomyopathy, absence of head trauma, and angiographic
exclusion of occlusive coronary artery disease or plaque rupture.2
In this case report, we present a 57-year-old female patient with
TCMP in whom apical thrombus was treated with short-term
warfarin use.
Case report
A 57-year-old postmenopausal female patient was admitted to
the emergency department with a four-day history of chest pain
and dyspnoea. Her past medical history included hypertension.
Electrocardiography performed in the emergency department
showed symmetrical T-wave negativity in V1–V6 and DI–avL
(Fig. 1). With ongoing chest pain, the patient underwent
coronary angiography, which detected normal coronary anatomy
(Fig. 2). During the follow up, the troponin level was 0.83 ng/
ml. Transthoracic echocardiography revealed a dyskinetic left
ventricular apex, with an ejection fraction of 35% and a 2.3 ×
3.3-cm thrombus (Fig. 3).
In the light of the typical ECG, coronary angiography and
echocardiography findings, the patient was diagnosed with
TCMP. The patient was informed about the risks and benefits
of anticoagulation with warfarin, surgical thrombectomy and
other treatment options, including beta-blockers and angiotensin
converting enzyme inhibitor. Warfarin was commenced. The
patient was discharged with a recommendation to visit a week
later for measurement of the prothrombin time international
normalised ratio (PT-INR) and warfarin dose arrangement.
Fifteen days later, the patient was admitted with bruising on
her body, and her PT-INR level was 6.5. The echocardiographic
examination was repeated, which showed that the apical
dyskinesia and thrombus in the left ventricle had disappeared,
and the ejection fraction was normal (Fig. 4).
Discussion
The vast majority (90%) of patients with TCMP are hypertensive
postmenopausal women.3 In addition to ST-segment elevation,
otherECGchanges suchasT-wave inversionandQTprolongation
may be seen. Cardiac enzymes are generally moderately elevated.
For these reasons, TCMP is often misdiagnosed as myocardial
infarction with ST elevation.
A definitive diagnosis is made with the detection of
hypokinetic and aneurysmal images of the left ventricular
apex in echocardiography or ventriculography, with coronary
angiography showing an absence of stenosis in the coronary
arteries.4 Cardiac magnetic resonance imaging may be
highly beneficial in differentiating between various types of
cardiomyopathy and myocarditis.5
Diverse factors have been proposed for the pathophysiology
of TCMP, including stress, increased adrenergic activity,
prolonged stunned myocardium, hypertension, chronic
obstructive lung disease, decreased oestrogen levels, small-vessel
disease, myocarditis and insufficient fatty acid metabolism in
Department of Cardiology, Meram School of Medicine,
Necmettin Erbakan University, Konya, Turkey
Abdullah İcli, MD, ,
Hakan Akilli, MD
Mehmet Kayrak, MD
Alpay Aribas, MD
Kurtulus Ozdemir, MD