STRESS CARDIOMYOPATHY AFTER DOWNHILL SKIING: A CASE REPORT

Therapeutic Area

Heart Failure

Case Presentation

A 61-year-old female presented after a day of anxiety-filled downhill skiing, with 2 syncopal episodes in the ski lodge. The patient had an electrocardiogram (ECG) showing deep T-wave inversions in anterior leads, QTc 600 msec, troponin of 0.299 ng/mL (normal <0.034 ng/mL), and BNP of 4,530 pg/mL (normal <221 pg/mL). The patient was given intravenous magnesium, furosemide, and an infusion of lidocaine for polymorphic ventricular tachycardia seen on telemetry. A transthoracic echocardiogram (TTE) revealed reduced ejection fraction (LVEF) of 30-35% with akinesis of the apex, hypokinesis of all mid-apical myocardial segments, suspicious for takotsubo cardiomyopathy (TTC). The patient underwent a diagnostic coronary angiography revealing no signs of ischemic disease. On day 3 of hospitalization, the patient's ECG normalized with resolution of prolonged QTc, repeat TTE showed recovered LVEF of 50-55%, and was discharged home with complete cardiovascular recovery.

Background

TTC, also called stress cardiomyopathy or broken heart syndrome, is characterized by chest pain, ECG changes, transient apical “ballooning” of the left ventricle with mid-ventricular akinesis seen on TTE, and absence of obstructive coronary artery disease or plaque rupture. TTC is typically preceded by intense psychological or physical stress, diagnosed in 2% of patients presenting with acute myocardial infarction and has a 6% incidence for female patients, ages 50 and older. TTC has an in-hospital mortality from 0–8% and is thought to occur due to the negative inotropy effect of high levels of epinephrine on the largest density of β-adrenoceptors in the apical ventricular myocardium. As epinephrine levels return to normal, left ventricular function and apical wall motion return to baseline within days to weeks. At 6-month follow-up, women with TTC showed a better survival rate (97% vs 86%) and less major events such as death, reinfarction, or rehospitalization than women with CAD (8% vs 31%).

Conclusions

Our case highlights an inciting event of TTC with combined physical and emotional stress. Stress management, emotional regulation, and treatment of mood disorders, represent a crucial point to prevent TTC, reduce medical costs, and improve the long-term quality of life of patients.