老年女性患者以广泛前壁心梗心电图为表现的脓毒症性章鱼壶心肌病1例

Sepsis-Induced Takotsubo Cardiomyopathy Mimicking Acute Anterior STEMI in a Geriatric Female: A Diagnostic Dilemma

摘要: 脓毒症诱发Takotsubo心肌病，是指在脓毒症基础上发展出的具有Takotsubo心肌病特征的临床情况，表现为短暂的左心室节段性收缩功能障碍，常伴有心电图异常和心肌酶升高，但无明显冠状动脉病变。本文报道了一例76岁女性患者，因“发热伴寒战1天，突发意识丧失20小时”入院。患者既往有高血压、糖尿病史，且近期停用阿司匹林。入院时心电图提示急性广泛前壁心肌梗死，肌钙蛋白I显著升高，初步诊断为急性心肌梗死并心源性休克。急诊冠脉造影显示冠状动脉仅存在轻中度狭窄，血流正常，与典型心肌梗死表现不符。随后在重症监护病房中，结合患者白细胞计数、降钙素原显著升高及血培养证实的肺炎克雷伯菌感染，明确脓毒症诊断。超声心动图显示左心室心尖部及中间段室壁运动消失，基底部运动正常，呈典型“心尖球样改变”。尽管最初考虑急性ST段抬高型心肌梗死，但冠脉造影和超声心动图的异常发现促使重新评估，最终诊断为脓毒症诱发的Takotsubo心肌病。通过调整血管活性药物并使用糖皮质激素，患者血流动力学稳定，心功能逐渐恢复。本病例强调，对于临床表现疑似急性冠脉综合征，尤其是老年绝经后女性患者，若冠脉造影结果与临床严重程度不符，应高度警惕脓毒症诱发Takotsubo心肌病的可能。及时识别并避免使用大剂量儿茶酚胺类药物，对改善预后至关重要。

Abstract: Sepsis-induced Takotsubo cardiomyopathy refers to a clinical condition characterized by the development of Takotsubo cardiomyopathy features on the basis of sepsis. It manifests as transient left ventricular segmental systolic dysfunction, often accompanied by ECG abnormalities and elevated cardiac biomarkers, but without significant coronary artery pathology. This report describes a 76-year-old female patient who was admitted with “fever and chills for 1 day, and sudden loss of consciousness for 20 hours”. The patient had a medical history of hypertension and diabetes mellitus, and had recently discontinued aspirin use. On admission, the electrocardiogram (ECG) showed findings suggestive of acute extensive anterior wall myocardial infarction, with markedly elevated troponin I, and she was initially diagnosed with acute myocardial infarction and cardiogenic shock. Emergency coronary angiography revealed only mild to moderate coronary stenosis with preserved TIMI flow, which was inconsistent with the typical presentation of acute myocardial infarction. Subsequently, in the intensive care unit (ICU), the diagnosis of sepsis was confirmed based on significantly elevated white blood cell count, procalcitonin levels, and blood culture positive for Klebsiella pneumoniae. Echocardiography demonstrated akinesis of the left ventricular apical and mid-segments with preserved basal function, exhibiting the classic “apical ballooning” pattern. Although an initial diagnosis of acute ST-segment elevation myocardial infarction (STEMI) was considered, the discordance between the coronary angiography findings and the clinical severity prompted further evaluation. Ultimately, the diagnosis of sepsis-induced Takotsubo cardiomyopathy was established. Following adjustments in vasopressor therapy and the administration of corticosteroids, the patient’s hemodynamics stabilized and cardiac function gradually improved. This case underscores that in patients—particularly postmenopausal elderly females—with clinical presentations suggestive of acute coronary syndrome, a high index of suspicion for sepsis-induced Takotsubo cardiomyopathy should be maintained when coronary angiography findings are disproportionate to the clinical severity. Early recognition and avoidance of high-dose catecholamine therapy are crucial for improving patient outcomes.