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

A 75-year-old woman presented with left ventricular apical ballooning syndrome mimicking acute anterior myocardial infarction. She had a long history of chest tightness and was undergoing a contrast stress echocardiogram because of frequent re-admissions with chest pain, all with normal ECGs and troponins. A standard dobutamine/atropine protocol had been used. The patient developed central crushing chest pain, marked ST elevation, transient slowing of heart rate and left ventricular apical ballooning. She was admitted to the coronary care unit and received thrombolysis. Echocardiography showed no mitral regurgitation, normal pulmonary artery systolic pressure and no intraventricular gradient. Immediate troponin T was significantly raised and peaked at 6 h. The patient underwent coronary angiography the next day. This showed systolic left ventricular apical ballooning and no coronary lesions or vasospasm. A further contrast echo 2 weeks later showed complete resolution of the wall motion abnormalities. Left ventricular apical ballooning or takotsubo syndrome can lead to cardiogenic shock but has a favourable prognosis compared to myocardial infarction. This patient was noted to be unusually anxious about having a stress echocardiogram and mental stress might be a precipitating factor, furthermore, this response during dobutamine stress echocardiography favours a catecholamine related disease mechanism.