We present a case of reversible stress cardiomyopathy in a surgical patient, described here as a forme fruste due to its atypical features. It is important to recognize such unusual presentation of stress cardiomyopathy that mimics acute coronary syndrome. Stress cardiomyopathy commonly presents as acute coronary syndrome and is characterized by typical or atypical variants of regional wall motion abnormalities. We report a 60-year-old Caucasian male with reversible stress cardiomyopathy following a sternal fracture fixation. Although the patient had several typical features of stress cardiomyopathy including physical stress, ST-segment elevation, elevated cardiac biomarkers and normal epicardial coronaries, there were few features that were atypical, including unusual age, gender, absence of regional wall motion abnormalities, high lateral ST elevation, and high troponin-ejection fraction product. In conclusion, this could represent a forme fruste of stress cardiomyopathy.
Stress cardiomyopathy is a well-established entity and commonly presents as acute coronary syndrome (ACS). The condition, also known as apical ballooning syndrome, was first reported in Japan in the early 90s. It commonly affects elderly females and accounts for 1.7 to 2.2% of those presenting with symptoms of ACS. We report a forme fruste of stress cardiomyopathy without regional wall motion abnormality and high troponin-ejection fraction product.
A 60-year-old Caucasian male with a past history of heart failure with preserved ejection fraction, hypertension, deep venous thrombosis, pulmonary embolism (PE), inferior vena cava filter placement, long-term anticoagulation, and obstructive sleep apnea was admitted following a traumatic sternal fracture sustained 6 months ago that resulted in a malunion. He underwent an elective sternal fixation. Preoperative electrocardiogram (EKG) was within normal limits. Laboratory studies including complete blood count and chemistries were within normal limits. Postoperative course was complicated by incision site hematoma on postoperative day 6, requiring aspiration. On the following day, patient developed sudden onset of crushing, severe, substernal pain radiating to left arm and neck. Electrocardiogram (EKG) revealed ST-segment elevation of 1.5 mm in leads I and aVL (Figure
(a) EKG during chest pain-ST elevation in leads I and aVL. (b) Normal EKG after two days.
(a) Coronary angiogram showing right coronary artery. (b) Coronary angiogram showing left coronary artery.
Stress cardiomyopathy, also known as reversible LV dysfunction, broken heart syndrome, or ampulla cardiomyopathy, is characterized by transient systolic dysfunction in the absence of obstructive coronary artery disease [
Our patient’s presentation was compatible with stress cardiomyopathy diagnostic criteria. This includes the presence of a stressful situation (fracture fixation), the typical clinical features including chest pain and dyspnea, ST-segment elevation in EKG, and troponin elevation with normal epicardial coronaries. But he had quite a few atypical features that did not fit in the diagnostic criteria. Our patient was a middle-aged male, whereas stress cardiomyopathy is commonly diagnosed in elderly females. The peak troponin in stress cardiomyopathy is usually less when compared to that in patients with STEMI. In addition, troponin-ejection fraction product (TEFP) obtained by multiplying peak troponin by ejection fraction obtained by echocardiography in our case was 156,000 and it does not fall in the range for stress cardiomyopathy. TEFP value ≥250 had a sensitivity of 95%, a specificity of 87%, a negative predictive value of 94%, a positive predictive value of 88%, and an overall accuracy of 91% to differentiate ST-segment elevation myocardial infarction from stress cardiomyopathy [
The authors declare that they have no conflict of interests regarding the publication of this paper.