A 61-year-old woman is hospitalized due to chest pressure and shortness of breath. Two days ago her husband died in a car accident. The patient's medical history is significant for hypertension, hyperlipidemia, and gout. Five years ago, she was diagnosed with breast cancer and treated with surgery and chemotherapy. Blood pressure is 165/90 mm Hg and pulse is 95/min and regular. Physical examination is unremarkable. ECG shows normal sinus rhythm with T-wave inversions in the anterior leads. Echocardiogram shows hypokinesis of the apical wall with decreased left ventricular ejection fraction. Diagnostic coronary angiography shows no evidence of obstructive coronary artery disease. The patient is treated medically and discharged home. Four weeks later, she is seen in the office and has no symptoms. Repeat echocardiography demonstrates normal left ventricular wall motion and ejection fraction. Which of the following is the likely cause of this patient's initial presentation?

Question

A 61-year-old woman is hospitalized due to chest pressure and shortness of breath.  Two days ago her husband died in a car accident.  The patient's medical history is significant for hypertension, hyperlipidemia, and gout.  Five years ago, she was diagnosed with breast cancer and treated with surgery and chemotherapy.  Blood pressure is 165/90 mm Hg and pulse is 95/min and regular.  Physical examination is unremarkable.  ECG shows normal sinus rhythm with T-wave inversions in the anterior leads.  Echocardiogram shows hypokinesis of the apical wall with decreased left ventricular ejection fraction.  Diagnostic coronary angiography shows no evidence of obstructive coronary artery disease.  The patient is treated medically and discharged home.  Four weeks later, she is seen in the office and has no symptoms.  Repeat echocardiography demonstrates normal left ventricular wall motion and ejection fraction.  Which of the following is the likely cause of this patient's initial presentation?

Quizplus · Accepted Answer

11ec160b_38ea_6771_9249_7d84c441c40e_MD0001_00 This patient likely has stress-induced (takotsubo) cardiomyopathy, which is characterized by hypokinesis of the mid and apical segments and hyperkinesis of the basal segments of the left ventricle (LV), leading to systolic dysfunction and reduced ejection fraction. The condition is likely caused by a catecholamine surge in the setting of physical or emotional stress (eg, death of a loved one). Catecholamines may cause microvascular spasm leading to ischemia and myocardial stunning or they may cause direct myocardial dysfunction. The resulting segmental LV dysfunction creates a characteristic balloon shape on echocardiogram that mimics that of an octopus trap (takotsubo means "octopus trap" in Japanese). Stress-induced cardiomyopathy most commonly affects postmenopausal women. Patients typically have chest pain that can mimic a myocardial infarction and may also have symptoms of heart failure (eg, dyspnea, lower extremity swelling). ECG often shows evidence of ischemia (eg, ST elevation, T-wave inversion) in the anterior precordial leads; however, coronary angiography typically reveals an absence of obstructive coronary artery disease. The condition usually resolves within several weeks with supportive treatment only. (Choice B) Ischemia-induced transmural myocardial necrosis is seen in patients with acute myocardial infarction, which is unlikely in this patient with no evidence of obstructive coronary artery disease on coronary angiography. (Choice C) LV hypertrophy due to uncontrolled hypertension typically leads to diastolic dysfunction without systolic wall motion abnormalities. (Choices D and E) Myocardial infiltration with lymphocytes is seen in patients with acute viral myocarditis. Toxin-induced myocardial injury can occur with exposure to a variety of agents, including alcohol, cocaine, and certain chemotherapy drugs (eg, anthracyclines). These myocardial insults typically lead to dilated cardiomyopathy with global (rather than segmental) LV systolic dysfunction. Educational objective: Stress-induced (takotsubo) cardiomyopathy is characterized by hypokinesis of the mid and apical segments and hyperkinesis of the basal segments of the left ventricle, resulting in systolic dysfunction. The condition is likely caused by a surge of catecholamines in the setting of physical or emotional stress. It usually affects postmenopausal women and resolves on its own within several weeks. __________ References: Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/16720686) Neurohumoral features of myocardial stunning due to sudden emotional stress. (http://www.ncbi.nlm.nih.gov/pubmed/15703419)

A 61-Year-Old Woman Is Hospitalized Due to Chest Pressure and Shortness