A 73-year-old woman comes to the emergency department because of chest discomfort. She was involved in a low velocity motor vehicle accident earlier in the day in which she backed into another car in the parking lot. She was wearing a seatbelt at the time and suffered no injuries. This is her second accident in the last three months, and she is very worried that her children will take away her car as a result. Approximately one hour after returning home, she noted the onset of substernal chest pressure, described as a "heaviness" which radiates to the jaw bilaterally and shortness of breath. She has never experienced these symptoms before. Her other medical problems include hypertension and hypothyroidism. Her medications include lisinopril, hydrochlorothiazide, levothyroxine, and aspirin. Her temperature is 36.7 C (98 F), blood pressure is 145/75 mm Hg, and pulse is 104/min. Her BMI is 24 kg/m². The patient is in mild distress. The estimated jugular venous pressure is 8 mm H₂O. There is a 2/6 systolic ejection murmur at the right upper sternal border, which radiates to the carotids bilaterally. Her lungs are clear on auscultation. Her peripheral pulses are 2+ and no peripheral edema is present. An electrocardiogram demonstrates sinus tachycardia and 2 mm of ST elevation in leads V1 to V4 with T wave inversions. No prior EKG is available for comparison. Emergent coronary angiography is performed, which demonstrates no obstructive coronary artery disease. Echocardiogram shows dyskinesis of the mid and apical left ventricle with hyperkinesis of the base and an overall left ventricular ejection fraction of 25%. Which of the following best explains this patient's symptoms?

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11ec193a_95bd_960c_853d_875edffd2307_MD0002_00 This patient's presentation is consistent with stress cardiomyopathy (Takotsubo cardiomyopathy), defined as chest pain with ischemic appearing EKG changes in the absence of obstructive coronary disease. It is typically seen in post-menopausal women (average age is late 60s) after a very stressful emotional or physical situation. The syndrome is likely due to excessive sympathetic stimulation causing myocardial stunning and microvascular dysfunction. Diagnosis is based on clinical criteria (as described in the above table). Treatment is largely supportive with hydration, treatment of complications, and clinical monitoring as the stressful situation resolves. However, many clinicians prescribe beta-blockers indefinitely. Patients recover left ventricular function within 1-4 weeks in most cases, but can sometimes take up to 2-3 months. (Choice A) Significant aortic stenosis usually presents with chest pain, syncope, occasional dyspnea, and decreased aortic valve area on echocardiogram. This patient's murmur is likely due to aortic sclerosis. (Choice B) Cardiac contusion occurring after significant blunt trauma (e.g., motor vehicle accident) typically presents with chest pain, low level elevations in cardiac markers, and regional wall motion abnormalities in the affected area. This patient's low velocity impact and the large area of affected myocardium make a contusion less likely. (Choice C) Demand ischemia is a mismatch between cardiac oxygen supply and demand due to a primary coronary event or critical illness (e.g., coronary artery spasm, anemia, arrhythmia, coronary embolism, or significant hypertension/hypotension). This patient's history of emotional trigger, clinical presentation, and stable vital signs makes this less likely. (Choice D) An ST elevation MI usually presents with a critical lesion on angiography that is amenable to reperfusion therapy. Although this patient has ST elevation, the mildly elevated troponin and lack of obstructive lesions makes MI less likely. Educational objective: Stress cardiomyopathy (Takotsubo cardiomyopathy) presents with chest pain, ischemic appearing EKG changes, mild elevations of cardiac markers, transient cardiac dysfunction (usually apical with basilar compensation), and absence of obstructive coronary disease. It is most commonly seen in post-menopausal women after an intense emotional or physical stressor. Treatment is largely supportive with recovery of left ventricular function in 1-4 weeks in most cases. __________ References: Takotsubo cardiomyopathy: state-of-the-art review. (http://www.ncbi.nlm.nih.gov/pubmed/19152137)

A 73-Year-Old Woman Comes to the Emergency Department Because of Chest