Apical Ballooning Syndrome: A Cardiac Syndrome Mimicking Acute Myocardial Infarction

Abstract

Introduction: Apical ballooning syndrome, Takotsubo cardiomyopathy, or broken heart syndrome, is a rare but currently well recognized clinical entity. It occurs after severe emotional or physical stress, most often in postmenopausal women, and mimics the symptoms and signs of acute coronary syndrome, in the absence of significant coronary injury. This cardiomyopathy is rapidly and completely reversible. The exact pathophysiological mechanism of the condition remains debated; several hypotheses have been put forward, the most credible of which seems to be a sudden hyperadrenergic reaction related to stress. Objective: To report the case of a patient with clinical features of possible myocardial infarction but diagnosed as Takotsubo cardiomyopathy. Case Report: The patient was a 64-year-old woman with no cardiovascular risk factors other than age and menopause, and no particular pathological history. She was admitted on Day 3 with infarct-like chest pain, which appeared following an episode of emotional stress, associated with NYHA stage III dyspnea. On admission, the patient was pain free. The clinical examination found a conscious patient, hemodynamically and respiratory stable, apyretic. The cardiovascular examination was unremarkable. The ECG was in sinus rhythm, showing a QS aspect in the anterosepto-apical area associated with negative T waves in the inferolateral area. The biological workup showed an inflammatory syndrome, with positive troponin at 650ng/l. The thoracic echocardiography showed an aspect of hypokinetic cardiopathy at the dilated stage with severe LV dysfunction (LVEF at 38%), a thin and flexible mitral valve with restriction of the small mitral valve with moderate mitral insufficiency (SOR at 20 cm2 and RV at 19 ml), a dilated left atrium. Coronary angiography showed angiographically healthy coronary arteries, and an MRI was performed, confirming the diagnosis of Takutsbo cardiomyopathy. Discussion and Conclusion: Takotsubo cardiomyopathy is an increasingly recognized clinical entity, characterized by apical left ventricular dysfunction with chest pain, electrocardiographic changes, minimal biomarker changes, and no coronary lesions. In most cases, an episode of emotional or physical stress precedes the event. Its pathophysiological mechanism remains unknown, but high circulating catecholamines seem to be the triggering factor and the most plausible explanation for this primary acquired cardiomyopathy. It is important to be aware of this diagnosis in patients presenting with ACS because its evolution is most often spontaneously favorable.