Myocardial injury triggered by combination of emotional stress and carbon monoxide poisoning

Abstract

Introduction: Carbon monoxide (CO) is a leading cause of poisoning worldwide.Central nervous systems and the heart have the highest demand for oxygen and may be severely injured in CO poisoning. Case report: A patient was referred to the emergency department after exposure to CO and strong emotional stress. On admission she was comatose with elevated lactate 14,62, metHgb 0,3% and carboxyhemoglobin 12,9%. Electrocardiogram showed sinus rhythm, 100 beats/min, poor R wave progression with inverted T waves in V1-V3 leads, biphasic T waves in V5 and V6. Transthoracic echocardioography showed left ventricle with akinetic apex and all apical segments of the left ventricle with reduced systolic function. Cardiac troponin was significantly elevated; coronary angiography showed normal coronary arteries without culprit lesion. Takotsubo syndrome was diagnosed. She was treated with high flow oxygen on mechanical ventilation, antiplatelet, angi-otenzinconvertase inhibitors, beta blockers and statin therapy with complete recovery. After one month ehocardiography showed left ventricle normal in size and function. Conclusion: CO poisoning hasn't yet been described as a trigger for Takotsubo syndrome. We propose that two risk factors CO poisoning and stress by may have initiated a catecholamine surge and caused the development of this specific condition.