A TAKOTSUBO SYNDROME TRIGGERED BY HYPOCALCEMIA: THE IMPORTANCE OF ELECTROLYTE BALANCE IN CANCER PATIENTS

Introduction: Takotsubo Syndrome (TTS) is characterized by a transient left ventricle (LV) systolic dysfunction usually occurring in postmenopausal women after intense physical or emotional stress. Case Report: A 75 year old female patient without a history of heart disease was admitted to our hospital for sudden onset of painful muscle spasms associated with a burning sensation in hands and feet. She also reported peri–oral numbness, dysphagia and nausea. She received, at the age of 68, a diagnosis of metastatic serous ovarian cancer BRCA wild–type at IV stage, treated with surgery and chemotherapy and actually receiving palliative care. On arrival, physical examination revealed Chvostek ’s sign and Trousseau’s sign. Laboratory exams displayed a severe hypocalcemia without any other electrolyte derangement and a normal cardiac troponin. Thefirst ECG showed sinus tachycardia with a reduced R–wave progression from lead V1 to V4 and no QT prolongation. Therefore, a treatment with intravenous magnesium and calcium gluconate was immediately started. Subsequently, a marked increase of cardiac troponin was observed, without evidence of chest pain or dyspnea. The transthoracic echocardiography was highly suggestive for TTS with a severe LV systolic dysfunction and an apical ballooning shape. When transferred to our ward, the ECG revealed diffuse ST–segment elevation with concomitant ST – segment depression in leads aVR and V1, requiring an urgent coronary angiography, which found normal coronary arteries. Thus, a guideline directed medical heart failure (HF) therapy was initiated, going forward to correct the serum calcium. Patient’s conditions improved rapidly, and systolic function completely recovered after the restoration of the calcium levels. Discussion: Among the potentials TTS–triggers, electrolyte impairment is rarely described. Specifically, hypocalcemia is rare and its occurrence in cancer patients may have several causes, from chemotherapy to malnutrition. Moreover, the chronic inflammatory state associated with malignancies may increase cardiac adrenoceptor sensitivity, predisposing frail patients to TTS. Heart involvement and hospitalization can suddenly worsen prognosis especially in end –stage cancer. Therefore, an accurate monitoring of serum electrolytes should be provided in this setting. Calcium replacement and HF therapy are pivotal in this scenario.