STRESS CARDIOMYOPATHY AFTER DOWNHILL SKIING: A CASE REPORT

Abstract

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.