A 56-year-old woman comes to the emergency department with a two-day history of substernal chest pain and mild shortness of breath. She takes levothyroxine for hypothyroidism and alendronate for osteoporosis. She has been under a great deal of stress at her job lately because many of her co-workers were recently terminated. Her mother died from a stroke at the age of 65 and her father had a heart attack at the age of 67. She smokes a half-pack of cigarettes per day and drinks alcohol socially. She denies any illicit drug abuse.
Her blood pressure is 122/70 mm Hg and pulse is 100/min and regular. Her oxygen saturation is 98% on room air. Lungs are clear on auscultation.
An EKG shows deep T wave inversions in the anterior precordial leads. Her troponin I level is 2.2 ng/ml (normal

Question

A 56-year-old woman comes to the emergency department with a two-day history of substernal chest pain and mild shortness of breath.  She takes levothyroxine for hypothyroidism and alendronate for osteoporosis.  She has been under a great deal of stress at her job lately because many of her co-workers were recently terminated.  Her mother died from a stroke at the age of 65 and her father had a heart attack at the age of 67.  She smokes a half-pack of cigarettes per day and drinks alcohol socially.  She denies any illicit drug abuse.
Her blood pressure is 122/70 mm Hg and pulse is 100/min and regular.  Her oxygen saturation is 98% on room air.  Lungs are clear on auscultation.
An EKG shows deep T wave inversions in the anterior precordial leads.  Her troponin I level is 2.2 ng/ml (normal < 0.012).
The patient is taken to cardiac catheterization, which shows no evidence of coronary artery disease.  On left ventriculogram, the apex is non-contractile while the base is hypercontractile.  
Which of the following is the most likely prognosis for this patient?

Quizplus · Accepted Answer

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 most commonly occurs in post-menopausal women after an intense stressful, emotional, or physical situation. Postulated pathogenic mechanisms include excessive catecholamine stimulation, microcirculatory dysfunction, and multivessel coronary artery spasm. Diagnosis is based on clinical criteria and treatment is largely supportive with hydration, treatment of complications, and clinical monitoring as the stressful situation resolves. In most cases, patients recover left ventricular function within 8-12 weeks (Choices A, B, & C). Educational objective: Stress cardiomyopathy (Takotsubo cardiomyopathy) presents with chest pain, ischemic appearing EKG changes, mild elevations of cardiac markers, transient cardiac dysfunction (usually at the apex with basilar compensation), and absence of obstructive coronary disease. Treatment is largely supportive with recovery of left ventricular function in 8-12 weeks in most cases. __________ References: Takotsubo cardiomyopathy: state-of-the-art review. (http://www.ncbi.nlm.nih.gov/pubmed/19152137)

A 56-Year-Old Woman Comes to the Emergency Department with a Two-Day