2022-01-04 21:47:45
الاجابه
B. Give intravenous fluid
This patient has stress-induced cardiomyopathy, also
referred to as Takotsubo cardiomyopathy or broken-heart
syndrome. This was first described in Japan in 1990, and was
characterized by chest pain with electrocardiographic evi-
dence of ischemia, usually deep symmetrical T-wave
inversions, transient apical ballooning with hypokinesis or
regional wall motion abnormality in a noncoronary distri-
bution, and absence of angiographic evidence of signifi-
cant obstructive coronary artery disease or acute plaque
rupture.23,109,110 Patients also typically have recovery of their
left ventricular systolic function within 3 to 6 months. It
should be noted that this is a diagnosis of exclusion, and
patients need to have an ischemia evaluation prior to defini-
tive diagnosis of Takotsubo cardiomyopathy. The pathogen-
esis is not well understood and there is a myriad of proposed
mechanisms for this phenomenon; however, the prevailing
mechanism seems to be a catecholamine-mediated myocar-
dial dysfunction.110 In this patient, there is evidence of left
ventricular outflow tract (LVOT) obstruction, given the
hyperdynamic motion of the basal segments. Patients with
LVOT gradients are susceptible to volume depletion, which
can lead to hypotension. Administering IV fluids is the first
option for management of hypotension with evidence of
dynamic LVOT obstruction (choice B). Additional inotro-
pic agents such as dobutamine (choice A) and norepineph-
rine (choice C) will increase the hypercontractility of the
basal segments. This will worsen the dynamic LVOT
obstruction. This is the same rationale for the cautionary
use of inotropic agents in hypertrophic obstructive cardio-
myopathy (HOCM) with systolic anterior motion of mitral
valve (SAM). Inotropic agents will cause SAM to come
closer to septum; therefore worsening the dynamic LVOT
obstruction. Intra-aotic balloon pump (choice D) will
decrease afterload and can worsen symptoms, particularly
if there is SAM. It is not the first line of treatment for hypo-
tension from LVOT.
317 views18:47
I
