Broken heart syndrome

A 56-year-old Asian woman presented with severe shortness of breath and chest tightness for 4 days. Her past medical history included well-controlled type 2 diabetes mellitus and hypertension. She was a non-smoker. On examination, she was afebrile with a blood pressure of 160/90 mmHg, a pulse of 90 beats per minutes, and a respiratory rate of 30 breaths per minutes with a PaO 2 of 7.4 kPa on air. Auscultation of the chest revealed bi-basal crackles and expiratory rhonchi. Cardiac examination was normal. Chest radiograph showed pulmonary congestion with normal heart size. Electrocardiogram (Figure 1) showed deep T-wave inversions in the anterolateral and inferior leads. Her troponin T level was raised at 0.243 ng/ml (normal <0.03 ng/ml). The patient was treated as having an acute coronary syndrome with supplemental oxygen, low molecular weight heparin, aspirin and clopidogrel. She was referred to a tertiary cardiothoracic centre for percutaneous coronary intervention. Bedside echocardiography showed reduced ejection fraction. Angiogram showed normal coronary arteries (Figures 2 and 3), and left ventriculography showed extensive anterior and inferio-apical areas of dyskinesia (Figures 4 and 5), consistent with Tako–Tsubo syndrome. With supportive therapy (aspirin, nitrate and diuretics), she made a good recovery. Her left ventricular function was normal on follow-up echocardiography 6 weeks later.