2009 Southern Regional Meeting Abstracts

Case Report: Tako-tsubo cardiomyopathy is a relatively newly described syndrome first reported by Japanese authors in the 1990s. It typically presents as ST-elevation myocardial infarction without evidence of obstructive coronary artery disease in post-menopausal women with apical akinesis or dyskinesis appearing as apical ballooning.
Case: An 84-year-old white female patient with no previous history of CAD presented with left-sided chest pain radiating to the back, nausea and vomiting, blood pressure of 89/46 and a severe mitral regurgitation murmur radiating to the axilla. The initial EKG showed antero-lateral ST-segment elevation myocardial infarction with Q waves. Troponin at the time of admission was 7. Left heart catheterization done immediately showed minimal CAD, global hypokinesis with anterior wall akinesis and apical ballooning, ejection fraction of 10 to 15% and severe mitral regurgitation with annular dilatation. She was placed on an intra-aortic balloon pump (IABP) and heparin drip for her severe mitral regurgitation, low cardiac output and hypotension. By the middle of that day, the patient stabilized and the IABP was removed. An echocardiogram done later that same day showed resolution of the cardiomyopathy with ejection fraction improving to 55-60% with only minimal mitral regurgitation. The patient was discharged a few days later as her clinical condition had improved considerably.
Discussion: This case illustrates several unusual features compared to the typical case of Tako-tsubo cardiomyopathy which is also known as the “broken heart syndrome”. First, our patient was considerably older than most patients with the syndrome (84yo compared to 50-75yo). Secondly, there was no obvious emotional stress around the time of the event which is more typical. Thirdly, while Tako-tsubo cardiomyopathy is generally transient and resolves over days to weeks, our patient showed dramatic reversal of the cardiomyopathy in a few hours instead of the usual longer recovery period. This occurred despite the presence of severe MR at the outset which usually portends a worse outcome. Clinicians should keep Tako-tsubo cardiomyopathy in their differential diagnosis of elderly women with AMI despite the presence of atypical features.