Shortness of Breath and Palpitations After a Funeral: Depression or Something Worse?

Case:

A 78-year-old woman with a history of diabetes, hypertension, and dyslipidemia presented to a local hospital emergency department with a complaint of shortness of breath 2 days after a funeral for her spouse of 55 years. In the emergency department, she reported experiencing chest pressure, severe dyspnea, palpitations, and lightheadedness for several days after the stressful event. Her social history was significant, as her spouse had died 2 weeks earlier.

On physical examination, she had bibasilar crackles and a displaced point of maximal impulse. Oxygen saturations were 89% to 92%. Chest radiograph showed severe pulmonary edema, and electrocardiogram demonstrated significant anterolateral ST-T wave abnormalities suggestive of subendocardial ischemia. Troponins were markedly elevated. Echocardiogram was ordered and the patient was admitted to the cardiac catheterization lab.

What is the most likely diagnosis?

a. Myocardial infarction

b. Coronary dissection

c. Takotsubo cardiomyopathy

d. Pulmonary embolism

Discussion:

Echocardiogram showed overall moderately impaired left ventricular systolic function with anteroapical ballooning of the left ventricle. Ejection fraction was between 35% and 40%.

The patient underwent cardiac catheterization, which revealed no significant obstructive lesions, but a left ventriculogram demonstrated moderate anterolateral and apical hypokinesia, consistent with findings identified on echocardiogram. The patient improved with conservative medical management, and a follow-up echocardiogram 3 months later revealed normal wall motion with an ejection fraction of 65%.

Transient left ventricular apical ballooning syndrome, or Takotsubo cardiomyopathy, is a condition that is often mistaken for acute coronary syndrome (ACS) and is thought to involve 1% to 2% of patients presenting with ACS.¹ Similar to this patient, most patients diagnosed with Takotsubo are postmenopausal women in their sixth and seventh decades who often present after an acute and significant emotional stressor.²

The diagnosis is suspected in the setting of new electrocardiographic abnormalities such as ST-segment elevation or T-wave inversion, as well as transient akinesis or dyskinesis of the left ventricular apical and midventricular segments, giving rise to the balloon-like abnormalities seen on echocardiogram. These abnormalities extend beyond a single epicardial vascular region in the absence of angiographic evidence of plaque rupture or obstructive coronary artery disease.^2,3

References

1. Tsai TT, Nallamothu BK, Prasad A, Saint S, Bates ER. Clinical problem-solving. A change of heart. N Engl J Med. 2009;361(10):1010-1016. doi:10.1056/NEJMcps0903023
2. Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141(11):858-865. doi:10.7326/0003-4819-141-11-200412070-00010
3. Primetshofer D, Agladze R, Kratzer H, Reisinger J, Siostrzonek P. Tako-Tsubo syndrome: an important differential diagnosis in patients with acute chest pain. Wien Klin Wochenschr. 2010;122(1-2):37-44. doi:10.1007/s00508-009-1275-7