Case Series of Triathletes with Takotsubo Cardiomyopathy Presenting with Swimming-Induced Pulmonary Edema

Table 1

A summary of cases presentation, investigation, and management.

	Case 1	Case 2	Case 3
Gender	Male	Female	Female
Age	53	57	60
Race distance	Sprint distance	Sprint distance	Sprint distance
Wetsuit	Yes	Yes	Yes
Initial presentation	Acute dyspnoea	Acute dyspnoea	Severe dyspnoea
	Chest pain (band-like)	Chest pain	Haemoptysis
	Haemoptysis
Field investigations	SpO2: 95% on RA	SpO2: 78% on RA	SpO2: 88% on RA
	BP: 114/74	BP: 144/80	BP: 112/85
	RR: 26	RR: 34	RR: 20
	HR: 122	HR: 124	HR: 105
Observations at ED	Sats: 97% on 4 L O2	Sats: 94% on RA	Sats: 92% on RA and 95% on 1 L O2
	BP: 124/86	BP: 111/74	BP: 101/67
	RR: 17	RR: 14	RR: 19
	HR 54	HR: 82	HR: 106
Examination	Bilateral coarse crackles	Bibasal crepitus	Bibasal coarse crackles/creps
	No peripheral oedema		No peripheral oedema
Management at ED	Aspirin 300 mg	Admitted to medical team	1 L O2 via nasal cannulae
	Clopidogrel	300 mg oral clopidogrel	30 mg IV furosemide + further 40 mg oral
	GTN 400 mg (sublingual)		DAPT (until normal angiogram confirmed)
	Admitted to medical team
CXR	Bilateral pulmonary oedema in the hilar region	Pulmonary oedema with upper zone diversion	Bilateral pulmonary oedema with upper zone diversion
Relevant laboratory blood tests:	Troponin: 0.11 ug/L initially and 0.15 at 4 hrs	Troponin: 0.26 ug/L initially and peaked at 1.12 ug/L	Troponin: 1118 ng/L and 2241 ng/L on repeat
	D-Dimer: 1.949 ng/mL	No D-dimer undertaken	No D-dimer undertaken
ECG	T wave inversion in V4-6 (nondynamic)	T Wave inversion V4-6	T Wave inversion in V1-4 (anterior)
			Partial left bundle branch block?
CTPA	No evidence of PE	Not performed	Not performed
TTE	Apical anterior hypokinesia	LV apical ballooning with significant akinesis	Anterior and anterioseptal akinesis
	“Good biventricular function”	Good RV function	Mild LV dilation
			LVED 35%
			Mild mitral regurg
			Good RV function
CMR	N/A	N/A	Classical TCM features (see figure).
			LVEF 43%.
Angiogram	Mild nonobstructive atheroma in mid-LAD	Normal coronary arteries	Normal coronary arteries
Management admission-onwards:	GTN administered	Started on aspirin, ramipril 1.25 mg qd bisoprolol 1.25 mg qd	Started on:
	Started on:		Ramipril 1.25 mg qd
	Aspirin 75 mg,		Bisoprolol 2.5 mg qd
	Atorvastatin 40 mg,
	Ramipril 1.25 mg qd
Lifestyle advice	No exercise for 6 weeks	Refrain from strenuous activities for the next 3 months	Slow and gradual return to activity

ED, emergency department; CXR, chest radiograph; ECG, electrocardiogram; CTPA, CT pulmonary angiography; TTE, transthoracic echocardiogram.