Acute chest pain in an anxious woman

Abstract

A 63 years old woman with past medical history of hypertension, osteoporosis, dyslipidaemia and anxiety, was admitted in the emergency room with acute chest pain after a family discussion, she presented oppressive retrosternal pain 7/10 of intensity, that irradiated to the left shoulder and the left arm, she was diaphoretic, her vital signs were normal and the physical examination was unremarkable, there were no abnormalities in the electrocardiogram and the blood tests showed normal haemogram as well the renal, liver and thyroid function, the troponin I was 6.9 μg/ml (normal value 0,04 μg/ml), a diagnosis of Non-ST Segment Elevation Myocardial Infarction (NSTEMI) was admitted, and an angiography was scheduled. In the meanwhile the chest pain relieved with nitroglycerine administration and anti-ischaemic treatment and the patient stayed haemodynamically stable. What is the diagnosis? Fig. 1 shows the ventriculography pattern of this patient that is typically known as Tako tsubo disease (TTD) or apical ballooning with a static apex and compensatory hipercontractility of the basal segments, without coronary abnormalities. The emotional stress has been related to this entity, causing a coronary vasospasm and the subsequent myocardial ischemia, due to these physiopathological facts, the clinical symptoms and laboratory findings of this illness look like the acute coronary syndromes. Some author had proposed the association between neoplasic diseases and TTD, mainly in patients that presented this condition without any stressing stimuli, they suggest that the catecholamines liberation by some tumours may be involved in the pathogenesis of those cases [[1]Sattler K. El-Battrawy I. Lang S. Zhou X. Schramm K. Tülümen E. et al.Prevalence of cancer in Takotsubo cardiomyopathy: short and long-term outcome.Int. J. Cardiol. 2017; https://doi.org/10.1016/j.ijcard.2017.02.093Abstract Full Text Full Text PDF Scopus (36) Google Scholar]. The prognosis of this condition is generally benign, although it may be complicated with malignant arrhythmias, cardiac rupture and cardiac tamponade [[1]Sattler K. El-Battrawy I. Lang S. Zhou X. Schramm K. Tülümen E. et al.Prevalence of cancer in Takotsubo cardiomyopathy: short and long-term outcome.Int. J. Cardiol. 2017; https://doi.org/10.1016/j.ijcard.2017.02.093Abstract Full Text Full Text PDF Scopus (36) Google Scholar]. Although the clinical and radiologic findings are typical, this illness only can be confirmed with after the myocardial function normalization in the follow up [[2]Giusca Sorin Eisele Tom Nunninger Peter Benedikt Münz G.K. Aborted sudden cardiac death in a female patient presenting with Takotsubo-like cardiomyopathy due to epicardial coronary vasospasm.Case Reports Cardiol. 2017; https://doi.org/10.1155/2017/7875240Crossref PubMed Google Scholar]. In this case the patient had completely recovered the cardiac function after 3 months of follow up under medical treatment with beta-blockers, ACE inhibitors as suggested in the literature [[2]Giusca Sorin Eisele Tom Nunninger Peter Benedikt Münz G.K. Aborted sudden cardiac death in a female patient presenting with Takotsubo-like cardiomyopathy due to epicardial coronary vasospasm.Case Reports Cardiol. 2017; https://doi.org/10.1155/2017/7875240Crossref PubMed Google Scholar]. Despite the available evidence many doubts remain about the appropriated follow up and prognosis of these patients [[3]Drakopoulou M.I. Gatzoulis M.A. Is Takotsubo syndrome a benign condition?.Hell. J. Cardiol. 2017; https://doi.org/10.1016/j.hjc.2017.03.009Crossref PubMed Scopus (2) Google Scholar]. The authors want to highlight this so called “benign” entity that can lead to fatal complications.