A 65-year-old woman is brought to the emergency department due to chest pain. The patient has had intermittent, pressure-like, mid-sternal chest pain since this morning. She has also had mild nausea. Medical history is significant for hypertension. The patient recently underwent screening colonoscopy, and yesterday she was told she has early-stage colon cancer. Her mother died of a stroke at age 70. She has no medication allergies. Blood pressure is 145/90 mm Hg, and pulse is 101/min and regular. Oxygen saturation is 99% on room air. The chest is clear on auscultation, and no heart murmurs are heard. ECG reveals sinus tachycardia with deep, symmetric T wave inversion in leads V2-V4. The patient is taken to the cardiac catheterization lab and coronary angiography shows no obstructive coronary artery disease. Which of the following is the most likely diagnosis?

Question

A 65-year-old woman is brought to the emergency department due to chest pain.  The patient has had intermittent, pressure-like, mid-sternal chest pain since this morning.  She has also had mild nausea.  Medical history is significant for hypertension.  The patient recently underwent screening colonoscopy, and yesterday she was told she has early-stage colon cancer.  Her mother died of a stroke at age 70.  She has no medication allergies.  Blood pressure is 145/90 mm Hg, and pulse is 101/min and regular.  Oxygen saturation is 99% on room air.  The chest is clear on auscultation, and no heart murmurs are heard.  ECG reveals sinus tachycardia with deep, symmetric T wave inversion in leads V2-V4.  The patient is taken to the cardiac catheterization lab and coronary angiography shows no obstructive coronary artery disease.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d369_dd99_bc81_8d24c7841cc2_MD0003_00 This patient likely has stress-induced (takotsubo) cardiomyopathy, also known as broken heart syndrome. The condition most commonly affects postmenopausal women and is believed to result from a catecholamine surge brought on by acute physical or emotional stress (eg, recent cancer diagnosis). There may be microvascular spasm with consequent ischemia and myocardial stunning that leads to impaired contraction. The resulting left ventricular dysfunction is characteristically segmental, with mid- and apical hypokinesis and basilar hyperkinesis. This leads to a distinctive balloon shape on echocardiography that resembles an octopus trap (takotsubo means "octopus trap" in Japanese). balloon shape Patients with stress-induced cardiomyopathy typically have chest pain that can mimic myocardial infarction, and they may develop symptoms of decompensated heart failure (eg, dyspnea, lower extremity swelling). ECG commonly shows evidence of ischemia (eg, ST elevation, T wave inversions) in the anterior precordial leads, and serum troponin can be moderately elevated. However, coronary angiography reveals an absence of obstructive coronary artery disease. Treatment is supportive, and the condition usually resolves on its own within several weeks. (Choice A) Acute pericarditis typically causes sharp, pleuritic chest pain and is less likely in the absence of a characteristic pericardial friction rub or diffuse ST elevation on ECG. (Choice B) Aortic dissection commonly presents with chest pain in a patient with a history of hypertension; however, the pain is expected to be constant rather than intermittent and is typically described as tearing rather than pressure-like. (Choice C) Hypertrophic cardiomyopathy is unlikely in the absence of a systolic murmur. (Choice D) Esophageal spasm commonly presents with intermittent, retrosternal chest pain. However, the pain is accompanied by dysphagia, and this diagnosis would not explain ischemic changes on ECG. (Choice E) Panic disorder involves periodic episodes of anxiety that can manifest with chest pain and shortness of breath. It would not explain ischemic ECG changes, and this patient's recent emotional stressor raises greater suspicion for stress-induced cardiomyopathy. (Choice F) Acute pulmonary embolism typically presents with sudden-onset chest pain and shortness of breath, and an underlying malignancy increases the risk. However, significant pulmonary embolism is unlikely in the absence of hypoxemia. Educational objective: Stress-induced (takotsubo) cardiomyopathy most commonly affects postmenopausal women and is believed to result from a catecholamine surge brought on by acute physical or emotional stress. It is characterized by left ventricular mid- and apical segment hypokinesis and basilar segment hyperkinesis and typically resolves on its own within several weeks. References: Takotsubo cardiomyopathy. (http://www.ncbi.nlm.nih.gov/pubmed/29081904)

A 65-Year-Old Woman Is Brought to the Emergency Department Due