A 76-year-old African American woman presented to a local hospital with complaints of left-sided chest heaviness accompanied by shortness of breath and fatigue. Her symptoms, which she said were exacerbated by the hot weather, started the previous afternoon when she encountered a large snake on her front porch. She used a shovel to kill the snake, which required a significant amount of exertion. On a trip to the Laundromat after the incident, the symptoms worsened. The patient denied loss of consciousness but felt physically weak.
The patient was a nonsmoker, and she did not use alcohol(Drug information on alcohol). Her past medical history was remarkable for coronary artery disease of the proximal circumflex artery, which was treated successfully with a Taxus drug-eluting stent 5 years previously. She also had hyperlipidemia, type 2 diabetes mellitus, hypertension, and depression. The surgical history was remarkable for a hysterectomy, cholecystectomy, and humeral fracture reduction, from which she had recovered uneventfully.
Memantine and sertraline(Drug information on sertraline) had been prescribed by her primary care physician. She was also taking clopidogrel(Drug information on clopidogrel), daily aspirin(Drug information on aspirin), and antihypertensive and antihyperglycemic medications.
When the patient arrived at the hospital, a troponin T test was done; the second test revealed an elevated troponin T level, at which time a cardiology consultation was requested. The patient’s blood pressure was 131/74 mm Hg; heart rate, 61/min; and respirations, 18/min. She was afebrile. No jugular venous distention was noted, and carotids were 2+ bilaterally without bruits.
The trachea was midline. On auscultation, the heart rate and rhythm were regular, with no clicks, heaves, thrills, or rubs. S1 and S2 were normal. The patient’s lungs were clear, and no masses were detected in her abdomen. There was no clubbing, cyanosis, or edema in the extremities. Findings from the neurologic examination were grossly intact.
Results of laboratory tests revealed normal levels of blood urea(Drug information on urea) nitrogen, creatinine, low-density lipoprotein cholesterol, magnesium, and phosphorus. However, the patient’s blood glucose level was 196 mg/dL, and her glomerular filtration rate was 48 mL/min. Her troponin T level had been 0.03 ng/mL at presentation; it subsequently rose to 0.21 ng/mL, and finally 0.23 ng/mL. An ECG revealed very minimal ST-segment elevations in leads I, aVL, and V3 through V6 with minimal reciprocal T-wave inversions in leads III and aVF (Figure 1).
On the basis of the history, physical examination findings, laboratory test results, and cardiac studies, a non–ST-segment elevation myocardial infarction caused by a lesion in the left anterior descending or circumflex artery was suspected. The patient was admitted for an echocardiogram and left heart catheterization to fully assess wall motion and coronary anatomy, respectively.
The echocardiogram revealed an akinetic anterior and inferior apex. Mild mitral regurgitation and trace tricuspid regurgitation were also noted; the left ventricular ejection fraction was 45%. Catheterization revealed nonobstructive coronary artery disease, with a 20% tubular stenosis of the mid–right coronary artery and a discrete 30% stenosis of the proximal left anterior descending artery. The circumflex artery and the stent that had been placed previously were patent. Cardiac arteriography with left ventriculogram indicated a large apical aneurysm (ballooning) (Figure 2). These findings led to a diagnosis of stress-induced takotsubo cardiomyopathy. Because the patient had a prolonged QTc, she was monitored for dysrhythmia.
A follow-up ECG demonstrated a resolution of ST-segment elevations, but new T-wave inversions in leads I, aVL, and V3 through V6 were seen (Figure 3). The patient was discharged and directed to continue her usual course of medications. It was recommended that her primary care physician initiate insulin therapy because her current antihyperglycemic regimen no longer appeared to provide adequate control. Her hemoglobin A1C level remained at 9.7% suggesting an average glucose level of 230 mg/dL. The patient was advised to avoid any strenuous activity until her follow-up within 1 to 2 weeks.
Discussion on next page.