Case Presentation: As physicians, we frequently engage patients and families in goals of care discussions in the context of advanced serious illnesses. These discussions can be challenging for numerous reasons. We present an atypical case of a woman, who experienced acute onset of confusion, numbness, pre-syncope, chest pain, and abdominal pain, after initiating a discussion on her husband’s prognosis.A 70 y/o female with HTN, fibromyalgia, and anxiety, developed sudden onset of confusion, headache, upper extremity weakness, lightheadedness, substernal and epigastric pain after initiating a discussion on the prognosis of her terminally ill husband. She was sent to the ED for suspicion of having a TIA or CVA. On evaluation, she was afebrile and hemodynamically stable. Her confusion was transient and resolved within an hour. Physical exam was without focal deficits. CT of the head revealed no acute intracranial abnormalities and no evidence of perfusion or flow limiting defects. EKG revealed no abnormalities indicative of ischemia. Serologic workup was remarkable for a troponin that increased from 0.05 ng/mL to 1.57 ng/mL over 6 hours. She was admitted and treated with an NSTEMI protocol. An echocardiogram revealed normal LV size and thickness but a mid-distal septal, apical akinesis without thrombus and an estimated LVEF of 30-35%. The following day, a left heart catheterization revealed mild nonobstructive coronary disease and an abnormal left ventricular wall motion with elevated left ventricular end-diastolic pressure consistent with stress cardiomyopathy. She was stabilized and discharged with metoprolol and grief counseling support.
Discussion: Stress cardiomyopathy is associated with severe emotional or physical stress that can cause rapid weakness of the heart muscle. This case highlights a unique yet rare complication of having goals of care and prognostication discussions with patients’ families. Delivering bad news is very challenging itself, and when compiled with physical manifestations of symptoms, it can be even more so.
Conclusions: Our patient developed a constellation of symptoms that manifested from a “broken heart” or stress cardiomyopathy, that after investigation, was attributed to hearing about the terminal state of her husband’s illness. Although its mechanism of myocardial stunning is still unknown, it should remain a possible complication of discussing goals of care or delivering news to loved ones of a patient.