a 72-year old woman presented with a two hour history of chest pain and mild respiratory distress . she reported a dull ache across the anterior chest unrelated to exertion , with some radiation to the left shoulder .
she had no significant past medical history and no prior history of similar chest pain .
physical examination revealed a heart rate of 76 , blood pressure 130/65 mmhg , and a respiratory rate of 20/minute .
cardiovascular examination revealed normal jugular venous pressure , soft heart sounds , no gallop rhythm , and no murmur .
the 12-lead electrocardiogram showed minor st - segment elevation and inverted t - waves in leads v3-v6 .
serum creatinine phosphokinase was elevated at 330 u / l ( normal range : 45 - 130 u / l ) and serum troponin i at 3.6 ( normal < 0.01 ) . chest - x - ray was unremarkable . coronary angiogram on admission showed no significant coronary artery disease .
left ventriculogram revealed apical dyskinesis and basal hyperkinesis , a picture consistent with ttc ( figure 1 ) .
she was discharged on metoprolol 25 mg twice a day , ramipril 5 mg daily , and warfarin .
a repeated cardiac catheterization three months later revealed normal left ventricle function with complete resolution of apical dyskinesis ( figure 2 ) .
( b ) left ventriculogram in systole showing apical dyskinesis ( ballooning ) and basal hyperkinesis .
( b ) left ventriculogram in systole showing normal systolic function and complete resolution of apical dyskinesis ( ballooning ) .
tako - tsubo cardiomyopathy is a potentially lifethreatening cardiac syndrome characterized bytransient left ventricular dysfunction , without angiographically significant coronary artery stenosis .
the disease takes its name from the typical left apical ballooning observed on end systolic left ventriculogram , which has the appearance of a tako - tsubo , a term for an ancient device used in japan to trap octopuses in the sea .
other names , stress cardiomyopathy , tako - tsubo cardiomyopathy , left ventricular apical ballooning syndrome , and broken heart syndrome are used interchangeably .
it is estimated that about 2% of patients presenting with suspected acute coronary syndromes may actually have ttc .
although initially reported only in japan , it has been reported in patients with diverse ethnic background from all over the world [ 26 ] .
the most frequent presentation is chest pain ( 66% ) , followed by dyspnea ( 16% ) .
these include an acute and excessive rise of catecholamine levels , calcium overload with direct myocyte damage , estrogen depletion , multiple vessel epicardial coronary spasm or diffuse microvascular spasm [ 810 ] . increased sympathetic tone with elevated levels of plasma catecholamines and stress neuropeptides may play an important role in the pathogenesis of myocardial stunning following emotional and physical stress .
electrocardiography ( ecg ) can be normal , or can have nonspecific st- and t - wave abnormalities . the most common ecg abnormality ( in 70% of cases )
is st - segment elevation in the anterior precordial leads [ 4 , 11 ] .
there is less inferior reciprocal st - depression than is typically seen with an anterior st - segment elevation myocardial infarction .
ten percent of patients develop q - waves ( most frequently in leads v2-v4 ) . within 24 to 48 hours of the acute presentation
, the ecg frequently shows deeply inverted t - waves and a markedly prolonged qtinterval in both precordial and limb leads .
the qtinterval prolongation often normalizes within two days , but the t - wave abnormalities can take weeks or even months to normalize [ 6 , 11 ] .
most patients with ttc have mildly elevated cardiac enzymes ( including creatine phosphokinase , troponin i , and t levels ) at the time of presentation .
these enzyme elevations , however , are much lower than those typically observed with acute myocardial infarction [ 4 , 6 ] .
perhaps the most specific diagnostic feature of this syndrome is the unusual left ventricular contractile pattern in the absence of significant coronary artery disease .
the left ventriculogram frequently shows akinesis or dyskinesis of the apical and midventricular segments with hyperkinesis of the basal segments ( figure 1 ) .
the standard supportive care for congestive heart failure with diuretics and vasodilators remains largely empirical . for
hemodynamically stable patients , diuretics are used to treat pulmonary congestion , and angiotensin - converting enzyme ( ace ) inhibitors and beta - blockers are frequently used during the period of lv recovery .
there is no consensus on how long to continue these medications ; it is probably safe to stop them once lv function has completely recovered . unless there is a contraindication , systemic anticoagulation
hemodynamically unstable patients , the treatment includes inotropic therapy , vasopressor support , and intra - aortic balloon counterpulsation .
recent data implicate massive catecholamine release as the pathogenesis of stress - induced myocardial stunning . therefore
, it has been recommended to avoid the administration of exogenous catecholamines and beta - agonists whenever possible and to rely on mechanical circulatory support , e.g. , intra - aortic balloon counterpulsation .
whichever form of hemodynamic support is chosen , most patients only require it for a short time and typically demonstrate rapid clinical recovery .
in most patients , the left ventricular function returns to normal within two weeks . the ecg abnormalities usually disappear completely within six months .
complications like shock , followed by heart failure , lv thrombus formation , dynamic lv outflow tract obstruction , acute mitral valve regurgitation , and ventricular arrhythmias are seen in 18% of cases ( 13 , 14 ) .
interestingly , physical stress has higher mortality rates when compared to patients presenting with emotional stress .
its clinical presentation mimics the presentation of acute stelevation myocardial infarction without concomitant epicardial coronary artery disease . despite the initial dramatic presentation of this disease
 tako - tsubo cardiomyopathy ( transient left ventricular apical ballooning ) is a reversible form of cardiomyopathy of unknown etiology . 
 tako - tsubo cardiomyopathy ( ttc ) is typically precipitated by sudden emotional or physical stress , and is associated with excessive sympathetic stimulation and catecholamine release . 
 its clinical presentation is similar to that of acute coronary syndrome . 
 the diagnosis of ttc must be considered in all patients who develop a transient left ventricular apical ( or mid ventricular ) ballooning in the absence of obstructive coronary artery disease . although the prevalence of ttc remains unknown , approximately 2% of all patients presenting with a presumed diagnosis of acute myocardial infarction 
 have been found to have this syndrome . 
 an illustrative case report and literature review is provided . 
Case presentation
Discussion
Diagnosis
Treatment
Prognosis
Conclusion