Takotsubo cardiomyopathy (left ventricular ballooning syndrome) induced during dobutamine stress echocardiography

A 75-year-old woman presented with left ventricular apical ballooningsyndrome mimicking acute anterior myocardial infarction. Shehad a long history of chest tightness and was undergoing a contraststress echocardiogram because of frequent re-admissions withchest pain, all with normal ECGs and troponins. A standard dobutamine/atropine protocol had been used. The patient developed central crushing chest pain, marked STelevation, transient slowing of heart rate and left ventricularapical ballooning. She was admitted to the coronary care unitand received thrombolysis. Echocardiography showed no mitralregurgitation, normal pulmonary artery systolic pressure andno intraventricular gradient. Immediate troponin T was significantlyraised and peaked at 6 h. The patient underwent coronary angiographythe next day. This showed systolic left ventricular apical ballooningand no coronary lesions or vasospasm. A further contrast echo2 weeks later showed complete resolution of the wall motionabnormalities. Left ventricular apical ballooning or takotsubo syndrome canlead to cardiogenic shock but has a favourable prognosis comparedto myocardial infarction. This patient was noted to be unusuallyanxious about having a stress echocardiogram and mental stressmight be a precipitating factor, furthermore, this responseduring dobutamine stress echocardiography favours a catecholaminerelated disease mechanism.