A 48-year-old woman is brought to the emergency department due to chest discomfort. She describes a pressure-like sensation behind the sternum lasting several hours. Yesterday, the patient was brought to the emergency department after a front-end motor vehicle collision in which she was a restrained passenger. She was assessed to have minor injuries and was discharged home. Her husband, who sustained a head injury in the collision, is in the hospital. The patient has hyperlipidemia and her only medication is an estrogen-containing oral contraceptive. Blood pressure is 135/90 mm Hg and pulse is 102/min and regular. Oxygen saturation is 99% on room air. BMI is 31 kg/m². The lungs are clear on auscultation. ECG shows sinus tachycardia with 1-mm ST-segment elevation in leads V3 to V6. The QTc interval is 509 msec. Cardiac catheterization shows normal coronary arteries. Echocardiography is most likely to demonstrate which of the following?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c11d_d1ae_8f63_09c60ea04c66_MD0005_00 This patient likely has stress-induced (takotsubo) cardiomyopathy, which most commonly affects middle-aged or older women and is believed to result from a catecholamine surge brought on by acute physical or emotional stress (eg, traumatic event, illness of a loved one). 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. These wall motion abnormalities create a distinctive balloon shape on echocardiography that resembles an octopus trap (takotsubo means "octopus trap" in Japanese). balloon shape Stress-induced cardiomyopathy typically presents with chest pain that can mimic myocardial infarction. Some patients also have signs and symptoms of decompensated heart failure. ECG commonly shows evidence of ischemia (eg, ST-segment elevation, T-wave inversions) in the anterior precordial leads, and QTc prolongation may also be present. Serum troponin levels can be moderately elevated; however, coronary angiography reveals an absence of obstructive coronary artery disease. Treatment of stress-induced cardiomyopathy is supportive, and the condition usually resolves on its own within several weeks. (Choice A) Aortic dissection typically presents with tearing, rather than pressure-like, chest pain. It does not cause ST-segment elevation unless the dissection spreads to the coronary arteries, and it is less likely in the absence of a history of uncontrolled hypertension. (Choice C) Mitral chordae rupture may occur in patients with myxomatous degeneration of the mitral valve, leading to acute mitral valve regurgitation. Acute decompensated heart failure is expected; this patient's normal oxygen saturation and clear lungs are not consistent with this presentation. (Choice D) Pericardial effusion often occurs with acute pericarditis, which typically presents with sharp, rather than pleuritic, chest pain. In addition, diffuse, instead of localized, ST-segment elevation is typically expected on ECG. (Choice E) Right ventricular dilation and hypokinesis are seen with acute pulmonary embolism, for which the use of estrogen-containing contraception is a risk factor. However, significant pulmonary embolism is unlikely in the absence of hypoxemia and would not explain precordial ST-segment elevation on ECG. Educational objective: Stress-induced (takotsubo) cardiomyopathy most commonly affects middle-aged or older women and is believed to result from a catecholamine surge caused by acute physical or emotional stress. It is characterized by left ventricular mid and apical hypokinesis and basilar hyperkinesis and typically resolves on its own within several weeks. References: Takotsubo cardiomyopathy: pathophysiology, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25068020)

A 48-Year-Old Woman Is Brought to the Emergency Department Due