TAKO‐TSUBO LEFT VENTRICULAR DYSFUNCTION CAUSED BY A FALL (2005)

To the Editor: We read with interest the systematic review of the psychological outcomes of falling by Jorstad et al.1 Most of the physical complications resulting from falls are head injuries and fractures.2,3 In addition, psychological problems sometimes induce physical complications. Falls can induce chest pain and heart failure. There have been some reports of patients with transient left ventricular dysfunction after emotional or physical stress, mostly in older women.4–6 Here, we present a case of transient heart failure that occurred in an elderly woman after a fall. An 85-year-old Japanese woman was referred to the University of Tokyo Hospital in July 2004 with gait disturbance, bradykinesia, anorexia, weakness, and dyspnea. Her daughter claimed that her gait disturbance had appeared a few months before and gradually worsened. She had fallen in her bedroom 2 days before and was not able to get up until the care worker visited her house the next morning. Fortunately, she had no fractures. She exhibited stiffness and slowness of movement, stooped posture, and a mask-like facial expression and was disabled because of rigidity and slight tremor that were more marked in the right upper extremity. She had no dementia. Brain computed tomography revealed several small infarctions in the thalamus and basal nuclei, suggesting that her parkinsonism was due to multiple cerebral infarctions. Chest radiograph showed right pleural effusion but no cardiomegaly, and electrocardiogram (ECG) showed deep negative T-waves in leads I, AVL, AVF, and V2−6 (Figure 1A). Echocardiography revealed akinesis of the apical wall of the left ventricle, although the rest of the left ventricle was normokinetic (Figure 1C). Myocardial infarction was suspected, but there was no increase in creatine kinase, troponin T, or myosin light chain. Thallium scintigraphy was performed, but no evidence of myocardial ischemia was detected. Her dyspnea improved, and the pleural effusion had disappeared by the third day without any medication. A. Initial electrocardiogram (ECG) showing deep negative T-waves in I, AVL, AVF, and V2−6. B. ECG showing improvement of T-waves 6 months later. C and D. Echocardiography showing akinesis of the apical wall and normokinesis of the basal region of the left ventricle (C. systolic; D. diastolic). Two weeks later, the echocardiography showed normal ventricular wall motion, although negative T-waves on the ECG remained unchanged. Finally, the ECG recovered to normal (Figure 1B) 6 months later, although she did not have any further cardiovascular medications. After excluding drug-related cardiomyopathy, myocarditis, and myocardial infarction, based on her medical history, laboratory data, and scintigram, “tako-tsubo” (which means an octopus trap in Japanese) left ventricular dysfunction5 was diagnosed. Transient left ventricular apical ballooning, or tako-tsubo left ventricular dysfunction, is a transient reversible cardiomyopathy with the unique feature of being induced by physical or emotional stress. The patient felt desperate when she fell and could not get up by herself, so her emotional stress may have induced this transient heart failure. Elderly women are reported to be susceptible to this disorder.4–6 Its symptoms are similar to those of myocardial infarction, although sometimes there are none. In most cases, cardiac dysfunction is transient and recovers rapidly, although cardiogenic shock due to ventricular septal perforation7 has been reported. Its mechanism is still unknown, although some reports suggest that reversible coronary microvascular impairment8 or sudden surges in circulating catecholamine levels4 are involved in this disease. The incidence of this disease is unknown, but it is likely to be more common than generally thought. In this case, a fall resulting from parkinsonism was the cause of psychological distress, which was considered the only possible cause of tako-tsubo left ventricular dysfunction. Falls could cause psychological difficulties in older people and could be the trigger for this disorder. Fortunately the patient's heart failure was mild and did not need medical attention, but falls might cause chest pain or heart failure, as well as head injuries and fractures. Financial Disclosure: None of the authors had any financial support for research, consultantships, and speakers' forums or any company holdings (e.g., stocks) or patents. Author's Contributions: Taro Kojima was the attending physician and prepared this manuscript. Masato Eto, Kiyoshi Yamaguchi, Koichi Kozaki, and Masahiro Akishita cared for the patient with Taro Kojima. Yasuhiro Yamaguchi followed the patient at the outpatient clinic. Yasuyoshi Ouchi supervised this case report. Sponsor's Role: Not applicable.