Токсическое поражение миокарда, спровоцированное острым отравлением газообразным хлором, у пациента с коронарным атеросклерозом

Острое отравление газообразным хлором приводит к активации симпатической нервной системы и, как следствие, дисфункции сердечно-сосудистой системы (ССС).  Представлен клинический случай токсического поражения миокарда — газообразным хлором. У мужчины с ишемической болезнью сердца и полипатией токсическое поражение миокарда имитировало острый коронарный  синдром (ОКС) и сопровождалось большой площадью  микрососудистой дисфункции левого желудочка, не совпадающей с зонами кровоснабжения измененных  коронарных артерий; динамика электрокардиографических  изменений напоминала оглушение миокарда при синдроме такоцубо (СТ). Обсуждаются воздействие хлора на ССС,  особенности клинико-инструментальной диагностики и дифференциации первичного/вторичного СТ и ОКС. 

1. Kose A, Kose B, Açikalin A, Gunay N, Yildirim C. Myocardial infarction, acute ischemic stroke, and hyperglycemia triggered by acute chlorine gas inhalation. Am J Emerg Med. 2009;27(8):1022.e1–4. PMID: 19857438 https://doi.org/10.1016/j.ajem.2008.12.029

2. Mohan A, Naveen Kumar S, Rao MH, Bollineni S, Manohar C. Acute accidental exposure to chlorine gas: Clinical presentation, pulmonary functions and outcome. Indian J Chest Dis Allied Sci. 2010;52(3):149–152. PMID: 20949733

3. Medina de Chazal H, de Buono MG, Keyser-Marcus L, Ma L, Moeller FG, Berrocal D, et al. Stress cardiomyopathy diagnosis and treatment: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72(16):1955–1971. PMID: 30309474 https://doi.org/10.1016/j.jacc.2018.07.072

4. Sato H, Tateishi H, Uchida T, Kodama K, Haze K, Hon M, et al. Tako-Tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K., Haze K., Hori M. (eds.) Clinical aspect of myocardial injury: from ischemia to heart failure (in Japanese). Tokyo: Kagakuhyoronsha Publishing Co; 1990. р. 56–64.

5. Maron BJ, Towbin JA, Thiene G, Antzelevitch C, Corrado D, Arnett D, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association scientific statement from the council on clinical cardiology, heart failure and transplantation committee; quality of care and outcomes research and functional genomics and translational biology interdisciplinary working groups; and council on epidemiology and prevention. Circulation. 2006;113(14):1807–1816. PMID: 16567565 https://doi.org/10.1161/circulationaha.106.174287

6. Lyon AR, Bossone E, Schneider B, Sechtem U, Citro R, Underwood SR, et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology: Current state of knowledge on Takotsubo syndrome. Eur J Heart Fail. 2016;18(1):8–27. PMID: 26548803 https://doi.org/10.1002/ejhf.424

7. Dias A, Gil IJ, Santoro F, Madias JE, Pelliccia F, Brunetti ND, et al. Takotsubo syndrome: state-of-the-art review by an expert panel–part 1. Cardiovasc Rev Med. 2019;20(1):70–79. PMID: 30528096 https://doi.org/10.1016/j.carrev.2018.11.015

8. Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo syndrome. Circulation. 2017;135(24):2426–2441. PMID: 28606950 https://doi.org/10.1161/CIRCULATIONAHA.116.027121

9. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation. 2008;118(25):2754–2762. PMID: 19106400 https://doi.org/10.1161/CIRCULATIONAHA.108.767012

10. Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. New Engl J Med. 2005;352(6):539–548. PMID: 15703419 https://doi.org/10.1056/NEJMoa043046

11. Zhong-qun Z, Chong-quan W, Nikus KC, Sclarovsky S. Correlation between ECG presentation and cardiovascular magnetic resonance imaging in Takotsubo cardiomyopathy. J Electrocardiol. 2013;46(4):343–345. PMID: 23578660 https://doi.org/10.1016/j.jelectrocard.2013.02.005

12. Paur H, Wright PT, Sikkel MB, Tranter MH. High levels of circulating epinephrine trigger apical cardiodepression in a 2-adrenergic receptor/Gi-dependent manner: a new model of takotsubo cardiomyopathy. Circulation. 2012;126(6):697–706. PMID: 22732314 https://doi.org/10.1161/CIRCULATIONAHA.112.111591

13. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Int Med. 2004;141(11):858–865. PMID: 15583228 https://doi.org/10.7326/0003-4819-141-11-200412070-00010

14. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155(3):408–417. PMID: 18294473 https://doi.org/10.1016/j.ahj.2007.11.008

15. Ajam M, Elmoghrabi A, Ashraf S, Yassin A, Shokr M. Apical Ballooning of Takotsubo Cardiomyopathy in a Patient with Non-ST Elevation Myocardial Infarction Due to Right Coronary Artery Stenosis: The Trapped Octopus Got a Heart Attack. Cureus. 2019;11(4):e4415. PMID: 31245203 https://doi.org/10.7759/cureus.4415

16. Bill V, El-Battrawy I, Schramm K, Ansari U, Hoffmann U, Haghi D, et al. Coincidental coronary artery disease impairs outcome in patients with takotsubo cardiomyopathy. QJM. 2017;110(8):483–488. PMID: 28340038 https://doi.org/10.1093/qjmed/hcx035

17. Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. New Eng J Med. 2015;373(10):929–938. PMID: 26332547 https://doi.org/10.1056/NEJMoa1406761

18. Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, et al. International expert consensus document on Takotsubo syndrome (part II): diagnostic workup, outcome, and management. Eur Heart J. 2018;39(22):2047–2062. PMID: 29850820 https://doi.org/10.1093/eurheartj/ehy077

19. Almendro-Delia M, Núñez-Gil IJ, Lobo M, Andrés M, Vedia O, Sionis A, et al. Short-and long-term prognostic relevance of cardiogenic shock in takotsubo syndrome: results from the RETAKO registry. JACC Heart Fail. 2018;6(11):928–936. PMID: 30316938 https://doi.org/10.1016/j.jchf.2018.05.015

20. Stiermaier T, Moeller C, Oehler K, Desch S, Graf T, Eitel C, et al. Long-term excess mortality in takotsubo cardiomyopathy: predictors, causes and clinical consequences. Eur J Heart Fail. 2016;18(6):650-656. PMID: 26990821 https://doi.org/10.1002/ejhf.494

21. Napp LC, Bauersachs J. Takotsubo syndrome: between evidence, myths, and misunderstandings. Herz. 2020;45(3):252–266. PMID: 32206851 https://doi.org/10.1007/s00059-020-04906-2

22. Murakami T, Yoshikawa T, Maekawa Y, Ueda T, Isogai T, Konishi Y, et al. Characterization of predictors of in-hospital cardiac complications of Takotsubo cardiomyopathy: multi-center registry from Tokyo CCU Network. J Cardiol. 2014;63(4):269–273. PMID: 24139869 https://doi.org/10.1016/j.jjcc.2013.09.003

23. Муксинова М.Д., Шилова А.С., Гиляров М.Ю., Константинова Е.В., Нестеров А.П., Удовиченко А.Е., и др. Может ли кардиомиопатия такоцубо возникнуть вследствие инфаркта миокарда? Кардиология. 2017;57(12):97–104. https://doi.org/10.18087/cardio.2017.12.10071

24. Алехин М.Н. Синдром такоцубо: значение эхокардиографии. Кардиология. 2017;57(7):80–89. https://doi.org/10.18087/cardio.2017.7.10009

25. Minhas AS, Scheel P, Garibaldi B, Liu G, Horton M, Jennings M, et al. Takotsubo Syndrome in the Setting of COVID-19 Infection. JACC: Case Reports. 2020;2(9):1321–1325. PMID: 32363351 https://doi.org/10.1016/j.jaccas.2020.04.023

26. Шустов С.Б., Барсуков А.В. Стресс-индуцированная кардиомиопатия (синдром takotsubo) у пациентки с артериальной гипертензией. Артериальная гипертензия. 2006;12(4):325-333.

27. Geisler BP, Raad RA, Esaian D, Sharon E, Schwartz DR. Apical ballooning and cardiomyopathy in a melanoma patient treated with ipilimumab: a case of takotsubo-like syndrome. J Immunother Cancer. 2015;3(1):4. PMID: 25705383 https://doi.org/10.1186/s40425-015-0048-2 eCollection 2015.

28. Moscatelli S, Montecucco F, Carbone F, Valbusa A, Massobrio L, Porto I, et al. An Emerging Cardiovascular Disease: Takotsubo Syndrome. Biomed Res Int. 2019;2019:6571045. PMID: 31781633 https://doi.org/10.1155/2019/6571045 eCollection 2019.

29. Дорошенко Д.А., Ефременко С.В., Швыдкой Ю.Г., Антоник Е.Ю., Гиляревский С.Р. Развитие неврогенной стрессовой кардиомиопатии после хирургического вмешательства по поводу опухоли IV желудочка мозга. Клиницист. 2012;(3-4):53–58.

30. Vančata R, Lhotský J, Beránek V, Krištof J, Rokyta R. Myocardial injury after carbon monoxide intoxication in suicide attempt, with features of both toxic and tako-tsubo cardiomyopathy: case report. Vnitr lek. 2018;64(7–8):797–801. PMID: 30441985

31. Champion S, Malissin I, Cleophax C, Vodovar D, Deye N, Mégarbane B, et al. Chloroquine poisoning-associated inverted Takotsubo cardiomyopathy. Clin Toxicol. 2012;50(7):721–722. PMID: 22800504 https://doi.org/10.3109/15563650.2012.711477

32. Jeon U, Park S, Park S, Lee EY, Gil HW. Clinical characteristics of stress cardiomyopathy in patients with acute poisoning. Sci Rep. 2018;8(1):1–6. PMID: 29317766 https://doi.org/10.1038/s41598-017-18478-5

33. Zhang X, Szeto C, Gao E, Tang M, Jin J, Fu Q, et al. Cardiotoxic and cardioprotective features of chronic -adrenergic signaling. Circ Res. 2013;112(3):498–509. PMID: 23104882 https://doi.org/10.1161/CIRCRESAHA.112.273896

34. Jaguszewski M, Osipova J, Ghadri JR, Napp LC, Widera C, Franke J, et al. A signature of circulating microRNAs differentiates takotsubo cardiomyopathy from acute myocardial infarction. Eur Heart J. 2014;35(15):999–1006. PMID: 24046434 https://doi.org/10.1093/eurheartj/eht392

35. Rivero F, Cuesta J, García-Guimaraes M, Bastante T, Alvarado T, Antuña P, et al. Time-related microcirculatory dysfunction in patients with Takotsubo cardiomyopathy. JAMA Cardiology. 2017;2(6):699–700. PMID: 28273298 https://doi.org/10.1001/jamacardio.2016.5993

36. Wang X, Pei J, Hu X. The Brain-Heart Connection in Takotsubo Syndrome: The Central Nervous System, Sympathetic Nervous System, and Catecholamine Overload. Cardio Res Pract. 2020;2020:4150291. PMID: 32211202 https://doi.org/10.1155/2020/4150291 eCollection 2020.

37. Amin HZ, Amin LZ, Pradipta A. Takotsubo Cardiomyopathy: A Brief Review. J Med Life. 2020;13(1):3–7. PMID: 32341693 https://doi.org/10.25122/jml-2018-0067

38. Khalid N, Ahmad SA, Shlofmitz E, Chhabra L. Pathophysiology of Takotsubo Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. PMID: 30844187

39. Núñez-Gil IJ, Almendro-Delia M, Andrés M, Sionis A, Martin A, Bastante T, et al. Secondary forms of Takotsubo cardiomyopathy: a whole different prognosis. Eur Heart J Acute Cardiovasc Care. 2016;5(4):308–316. PMID: 26045512 https://doi.org/10.1177/2048872615589512

40. Prasitlumkum N, Kittipibul V, Limpruttidham N, Rattanawong P, Chongsathidkiet P, Boondarikpornpant T. The presence of atrial fibrillation in Takotsubo cardiomyopathy is predictive of mortality: Systematic review and meta-analysis. Ann Noninvasive Electrocardiol. 2019;24(1):e12566. PMID: 29938868 https://doi.org/10.1111/anec.12566

41. Scally C, Abbas H, Ahearn T, Srinivasan J, Mezincescu A, Rudd A, et al. Myocardial and systemic inflammation in acute stress-induced (Takotsubo) cardiomyopathy. Circulation. 2019;139(13):1581–1592. PMID: 30586731 https://doi.org/10.1161/CIRCULATIONAHA.118.037975

42. Namgung J. Electrocardiographic findings in takotsubo cardiomyopathy: ECG evolution and its difference from the ECG of acute coronary syndrome. Clin Med Insights: Cardiol. 2014;8:29–34. PMID: 24653650 https://doi.org/10.4137/CMC.S14086

43. Inoue M, Shimizu M, Ino H, Yamaguchi M, Terai H, Fujino N, et al. Differentiation between patients with takotsubo cardiomyopathy and those with anterior acute myocardial infarction. Circ J. 2005;69(1):89–94. PMID: 15635210 https://doi.org/10.1253/circj.69.89

44. Ogura R, Hiasa Y, Takahashi T, Yamaguchi K, Fujiwara K, Ohara Y, et al. Specific findings of the standard 12-lead ECG in patients with “takotsubo” cardiomyopathy. Circ J. 2003;67(8):687–690. PMID: 12890911 https://doi.org/10.1253/circj.67.687

45. Looi JL, Wong CW, Lee M, Khan A, Webster M, Kerr AJ. Usefulness of ECG to differentiate Takotsubo cardiomyopathy from acute coronary syndrome. Int J Cardiol. 2015;199:132–140. PMID: 26188834 https://doi.org/10.1016/j.ijcard.2015.07.046

46. Syed FF, Asirvatham SJ, Francis J. Arrhythmia occurrence with takotsubo cardiomyopathy: a literature review. Europace. 2011;13(6):780–788. PMID: 21131373 https://doi.org/10.1093/europace/euq435

47. Yoshida T, Hibino T, Kako N, Murai S, Oguri M, Kato K, et al. A pathophysiologic study of takotsubo cardiomyopathy with F-18 fluorodeoxyglucose positron emission tomography. Eur Heart J. 2007;28(21):2598–2604. PMID: 17921529 https://doi.org/10.1093/eurheartj/ehm401

48. Hurst RT, Prasad A, Askew JW, Sengupta PP, Tajik AJ. Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology. JACC Cardiovasc Imaging. 2010;3(6):641–649. PMID: 20541719 https://doi.org/10.1016/j.jcmg.2010.01.009

49. Citro R, Rigo F, Ciampi Q, D’Andrea A, Provenza G, Mirra M, et al. Echocardiographic assessment of regional left ventricular wall motion abnormalities in patients with takotsubo cardiomyopathy: comparison with anterior myocardial infarction. Eur J Echocardiogr. 2011;12(7):542–549. PMID: 21606046 https://doi.org/10.1093/ejechocard/jer059

50. Frangieh AH, Obeid S, Ghadri JR, Imori Y, D’Ascenzo F, Kovac M, et al. ECG criteria to differentiate between Takotsubo (stress) cardiomyopathy and myocardial infarction. J Am Heart Assoc. 2016;5(6):e003418. PMID: 27412903 https://doi.org/10.1161/JAHA.116.003418

51. Sharkey SW. Electrocardiogram mimics of acute ST-segment elevation myocardial infarction: insights from cardiac magnetic resonance imaging in patients with takotsubo (stress) cardiomyopathy. J Electrocardiol. 2008;41(6):621–625. PMID: 18790504 https://doi.org/10.1016/j.jelectrocard.2008.06.015

52. Shlofmitz E, Kuku KO, Waksman R, Garcia-Garcia HM. Intravascular ultrasound-guided drug-eluting stent implantation. Minerva Cardioangiol. 2019;67(4):306–317. PMID: 30845795 https://doi.org/10.23736/S0026-4725.19.04895-3

53. Arcari L, Limite LR, Cacciotti L, Alonzo A, Musumeci MB, Passaseo I, et al. Tortuosity, recurrent segments, and bridging of the epicardial coronary arteries in patients with the takotsubo syndrome. Am J Cardiol. 2017; 119(2):243–248. PMID: 27866652 https://doi.org/10.1016/j.amjcard.2016.09.055

54. Martinez TT, Long C. Explosion risk from swimming pool chlorinators and review of chlorine toxicity. J Toxicol Clin Toxicol. 1995;33(4):349–354. PMID: 7629902 https://doi.org/10.3109/15563659509028921

55. Bill V, El-Battrawy I, Behnes M, Baumann S, Becher T, Elmas E, et al. “Diabetes paradox” in Takotsubo cardiomyopathy. Int J Cardiol. 2016;224:88–89. PMID: 27636833 https://doi.org/10.1016/j.ijcard.2016.08.136

56. Sharkey SW. A Clinical Perspective of the Takotsubo Syndrome. Heart Fail Clin. 2016;12(4):507–520. PMID: 27638021 https://doi.org/10.1016/j.hfc.2016.06.003

57. Kato K, di Vece D, Cammann VL, Micek J, Szawan KA, Bacchi B, et al. Takotsubo recurrence: morphological types and triggers and identification of risk factors. J Am Coll Cardiol. 2019;73(8):982–984. PMID: 30819368 https://doi.org/10.1016/j.jacc.2018.12.033

58. Stiermaier T, Santoro F, El-Battrawy I, Möller C, Graf T, Novo G, et al. Prevalence and prognostic impact of diabetes in Takotsubo syndrome: insights from the international, multicenter GEIST registry. Diabetes Care. 2018;41(5):1084–1088. PMID: 29449312 https://doi.org/10.2337/dci18-0016

59. Khalid N, Ahmad SA, Umer A, Chhabra L. Role of microcirculatory disturbances and diabetic autonomic neuropathy in Takotsubo cardiomyopathy. Crit Care Med. 2015;43(11):e527. PMID: 26468716 https://doi.org/10.1097/CCM.0000000000001183

60. Spinelli L, Trimarco V, Di Marino S, Marino M, Iaccarino G, Trimarco B. L41Q polymorphism of the G protein coupled receptor kinase 5 is associated with left ventricular apical ballooning syndrome. Eur J Heart Fail. 2010;12(1):13–16. PMID: 20023040 https://doi.org/10.1093/eurjhf/hfp173

61. Limongelli G, D’Alessandro R, Masarone D, Maddaloni V, Vriz O, Minisini R, et al. Takotsubo cardiomyopathy: do the genetics matter? Heart Fail Clin. 2013;9(2):207–216, ix. PMID: 23562121 https://doi.org/10.1016/j.hfc.2012.12.008

62. Eitel I, Moeller C, Munz M, Stiermaier T, Meitinger T, Thiele H, et al. Genome-wide association study in takotsubo syndrome – Preliminary results and future directions. Int J Cardiol. 2017;236:335–339. PMID: 28108127 https://doi.org/10.1016/j.ijcard.2017.01.093

63. Himmel HM. Mechanisms involved in cardiac sensitization by volatile anesthetics: general applicability to halogenated hydrocarbons? Crit Rev Toxicol. 2008;38(9):773-803. PMID: 18941968 https://doi.org/10.1080/10408440802237664

64. Giordano FJ. Oxygen, oxidative stress, hypoxia and heart failure. J Clin Invest. 2005;115(3):500–508. PMID: 15765131 https://doi.org/10.1172/JCI24408

65. Luo M, Anderson ME. Mechanisms of altered Ca² handling in heart failure. Circ Res. 2013;113(6):690–708. PMID: 23989713 https://doi.org/10.1161/CIRCRESAHA.113.301651

66. Dogan Y, Soylu A, Dogan SN, Sahin A, Eren GA. Acute Atrial Fibrillation Developed by the Inhalation of Chlorine Gas. J Clinic Toxicol. 2011;1(3):113–118. https://doi.org/10.4172/2161-0495.1000113

67. Mangat HS, Stewart TL, Dibden L, Tredget EE. Complications of chlorine inhalation in a pediatric chemical burn patient: a case report. J Burn Care Res. 2012;33(4):e216–221. PMID: 22665132 https://doi.org/10.1097/BCR.0b013e318254d1c8

68. Van Sickle D, Wenck MA, Belflower A, Drociuk D, Ferdinands J, Holguin F, et al. Acute health effects after exposure to chlorine gas released after a train derailment. Am J Emerg Med. 2009;27(1):1–7. PMID: 19041527 https://doi.org/10.1016/j.ajem.2007.12.006

69. Carlisle M, Lam A, Svendsen ER, Aggarwal S, Matalon S. Chlorine-induced cardiopulmonary injury. Ann N Y Acad Sci. 2016;1374(1):159. PMID: 27303906 https://doi.org/10.1111/nyas.13091

70. Squadrito GL, Postlethwait EM, Matalon S. Elucidating mechanisms of chlorine toxicity: reaction kinetics, thermodynamics, and physiological implications. Am J Physiol Lung Cell Mol Physiol. 2010;299(3):L289–300. PMID: 20525917 https://doi.org/10.1152/ajplung.00077.2010