Stress-induced cardiomyopathy is associated with physical or emotional stress. These stressors frequently include death of relatives, domestic abuse, arguments, catastrophic medical diagnoses, devastating financial or gambling losses, and natural disasters.9
TCM may be caused by catecholamine-induced microvascular spasm or dysfunction, giving rise to myocardial stunning.10
In a large cohort of 121 patients with TCM, a significant stressful event was identified in 89% of the patients immediately before TCM presentation.11
In a case series, only 50% of the patients had an emotional stress before the diagnosis was confirmed.12
In the case presented herein, the death of our patient’s sister was the trigger for all her syndromes.
TCM occurs more commonly in women.7
In a study of 12 patients, all were female in the postmenopausal age,12
as was our patient.
Stress-induced cardiomyopathy commonly presents like an acute MI. The most common presenting cardiovascular symptom of TCM is retrosternal chest pain. Other clinical presentations include dyspnea, syncope, shock, and arrhythmia.13
In a systematic review of 286 patients with TCM, electrocardiographic abnormalities, especially ST-segment elevation in the anterior precordial leads, were the most common findings. Other reported abnormalities in the ECG are deep T wave inversion with QT interval prolongation and abnormal Q waves. In some cases, the ECG might be normal.10
In contrast to our case, cardiac biomarkers are often mildly elevated.10
Other syndromes associated with ST-segment changes and normal coronary angiography include cardiac syndrome X, Prinzmetal’s angina, myocarditis, and cocaine abuse. Our patient did not have chest discomfort and presented with presyncope, slight ST-segment elevation in leads V1 to V3, and elevated cardiac enzymes.
In this case report, we presented a patient with severe left ventricular systolic dysfunction (ejection fraction=30% in the first echocardiography), which was transient and resolved after one month (ejection fraction=60% in the second echocardiography).This pattern resembles the course of stress-induced cardiomyopathy. Stimulation of catecholamine release caused by emotional or physical stress may result in transient left ventricular systolic dysfunction via an increase in intracellular calcium and oxygen-free radicals, epicardial microvascular spasm, or direct injury to myocytes.14
Other disorders with transient left ventricular systolic dysfunction such as toxin-induced cardiomyopathy or peripartum cardiomyopathy could not explain the condition of this patient.
In our patient, echocardiography revealed apical, mid-anterior, mid-septal, and mid-inferior akinesia with reduced left ventricular systolic function, which are the characteristic features of TCM.9
The diagnosis of TCM needs coronary angiography to exclude obstructive coronary artery disease. In our patient, coronary angiography showed minimal coronary artery obstruction.
In a large cohort study of 136 patients with TCM, only 3 deaths were reported and 126 patients ultimately had a normal ejection fraction(≥ 50%).11
The in-hospital mortality rate of stress-induced cardiomyopathy is 0 to 8%.1
Long-term follow-up of TCM patients demonstrated that the survival of these patients was reduced compared to that in the general population.11
Given the transient nature of stress-induced cardiomyopathy, this disorder can be managed with supportive therapy. It is reasonable to treat these patients with standard drugs for left ventricular systolic dysfunction such as beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and diuretics as needed. When coronary atherosclerosis is evident, Aspirin is also recommended.5
This treatment can be continued until the recovery of heart failure. As this syndrome may recur, a beta blocker alone or in combination with an alpha blocker can be continued indefinitely in the absence of contraindications.