Case Presentation:
A 63 year old female with a history of anxiety disorder presented with acute chest pain and shortness of breath. Physical examination revealed an anxious appearing woman with tachycardia and hypertension (180/95). An ECG showed ST‐segment elevation in leads V2‐V6. Troponin levels and creatinine kinase‐MB fraction were elevated. Diagnosed with a probable ST‐segment elevation myocardial infarction an emergent cardiac catheterization was performed. However, the angiogram demonstrated only mild atherosclerosis in the coronary vessels. A left ventriculogram revealed an ejection fraction of 34% with moderate hypokinesis of the apical septal and apical segments.
The patient was admitted to the cardiac care unit for continuous cardiac monitoring, received beta‐blocker therapy, and was seen by psychiatry for further management of her anxiety disorder. In follow up three months later she reported no cardiac symptoms and an echocardiogram revealed a ejection fraction of 70%. Discussion: Known as takotsubo cardiomyopathy, after a round‐bottomed narrow‐necked Japanese fishing pot used for trapping octopus, left ventricular apical ballooning syndrome was first described in Japan over a decade ago. It is a novel acute coronary syndrome whose clinical presentation mimics that of an acute myocardial infarction. A number of case series have shown consistent clinical characteristics including ischemic‐like chest pain, ST‐segment elevation, mildly elevated cardiac biomarker levels, and transient apical and mid‐ventricular regional wall motion abnormalities. However, these findings occur in the absence of obstructive coronary atherothrombosis.
Reports show predominance in postmenopausal women and most episodes occur after an acute increase in physiologic or emotional stress. The characteristic wall motion abnormalities and decreased systolic function typically resolve in a matter of days to weeks. The overall prognosis for this syndrome is favorable; however several isolated deaths have been reported.
The optimal treatment has not been well characterized due to limited clinical data. After the initial acute presentation, appropriate management is primarily supportive including aspirin, diuretics, beta‐blockers, and angiotensin‐converting enzyme inhibitors.
The exact cause of this acute stress induced cardiac dysfunction is unknown. While the precise mechanism is unclear, exaggerated sympathetic stimulation is thought to be a central cause of this syndrome.
Conclusion:
Transient Apical Ballooning Syndrome is an uncommon cause of acute coronary syndrome.
Diagnosis requires ST‐segment elevation, elevated cardiac biomarkers, absence of obstructive coronary disease, and specific wall motion abnormalities.
Treatment is supportive and full recovery occurs in most.
Seen most commonly in middle aged women experiencing a stressful event in life.
Author Disclosure Block:
A. Reyburn, None.