Chest pain after emotional and physical upset

doi:10.1136/bmj.a107

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P Parulekar, senior house officer,
M Z O Khawaja, specialist registrar,
E T McWilliams, consultant

¹Department of Cardiology, Conquest Hospital, St Leonards-on-Sea TN37 7RD

drzeeshan{at}doctors.org.uk

Case history

A 61 year old white woman attended her local accident and emergency department with severe central chest pain. After being chased by two large terrier dogs. The pain was not relieved by nitroglycerine spray given in the ambulance. An electrocardiogram showed anterolateral ST segment depression, with an elevated troponin T of 1.25 μg/l. She had no cardiovascular risk factors. Non-ST elevation myocardial infarction was diagnosed, and the patient was treated accordingly.

Coronary angiography showed normal coronary arteries, but the left ventriculogram showed a large area of apical hypokinesis with moderate impairment of left ventricular systolic function.

The patient was readmitted several weeks later with further chest pain. An electrocardiogram showed no new changes with no rise in the cardiac troponin. An echocardiogram showed that her left ventricular systolic function had almost returned to normal.

Questions

1. What is the diagnosis?
2. Which patients are most at risk?
3. How should these patients be treated?
4. What are the characteristic findings?

Answers

Short answers

1. The diagnosis is tako-tsubo cardiomyopathy, also known as left ventricular apical ballooning and “broken heart syndrome.”
2. It has been traditionally associated with emotional or physical upset in postmenopausal women.
3. Patients should be treated as for acute myocardial infarction. Many develop symptoms of acute left ventricular failure and should be treated as per current guidelines (nitrates, diuretics, etc).
4. Characteristic findings are:
- Chest pain or dyspnoea
- Electrocardiographic changes suggestive of acute myocardial infarction or elevated cardiac troponin
- Triggered by emotional or physical stress
- Normal coronary angiogram
- Characteristic left ventricular apical “ballooning”