CASE REPORT BY DR FAWZY MEGAHED

A 71-year-old woman with essential hypertension and type 2 diabetes mellitus presented with 12 hours of retro sternal chest discomfort. Except for sinus tachycardia vital signs were normal.

Physical examination was remarkable only for right upper quadrant tenderness. Chest roentgenogram showed mild pulmonary edema.

Electrocardiogram demonstrated sinus rhythm, with 2-mm horizontal ST depressions in leads V2-V5, suggestive of posterior myocardial infarction and corroborated by bedside echocardiography revealing infero posterior wall akinesis (Figure). Troponin I was elevated at 4.48 ng/L.

She underwent coronary angiography, which showed no evidence of coronary artery disease, and a left ventricular end-diastolic pressure of 14 mm Hg. Abdominal computed tomography subsequently was suggestive of acute cholecystitis.

Three days later, symptoms had resolved and a repeat echocardiogram showed normal systolic function and complete resolution of wall motion abnormalities. Subsequently, the patient was discharged with plans for outpatient cholecystectomy

However, she was re-hospitalized 3 weeks later with abdominal pain and dyspnea. Echocardiogram demonstrated extensive apical hypokinesis

Symptoms and wall motion abnormality resolved 2 days later, and she was discharged home. She was re-admitted for elective laparoscopic cholecystectomy 4 weeks later and discharged the next day without complication.

That evening she developed dyspnea and was admitted to the intensive care unit with profound hypoxemia and pulmonary edema. Symptoms resolved rapidly after one dose of intravenous furosemide. Echocardiogram revealed elevated left-sided filling pressures but no segmental wall motion abnormalities, and normal systolic function. Subsequently, she has remained asymptomatic for 3 months

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Stress-related cardiomyopathy is often triggered by emotional stress or other underlying medical conditions, including one case of cholecystitis

Most reported cases of stress-related cardiomyopathy are precipitated by acute emotional stress, often among post menopausal women.

Postulated mechanisms for stress-related cardiomyopathy include catecholaminergic surges producing cardiovascular spasm, microvascular dysfunction, myocardial stunning, and free-radical-mediated myocyte injury.

Stress-related cardiomyopathy should be suspected when the electrocardiographic and echocardiographic abnormalities are out of proportion to the degree of cardiac biomarker elevation.

Apical ballooning (typical variant) or mid ventricular hypokinesis (atypical variant or apical sparing variant) are most frequently noted. Coronary angiography demonstrates either normal vessels or nonobstructive coronary atherosclerosis.

a case of stress-related cardiomyopathy associated with acute cholecystitis. Focal basilar inferoposterior wall involvement and gallbladder disease as a precipitant are both rare manifestations of stress-related cardiomyopathy

Physicians should be aware of this unusual presentation of stress-related myocardial dysfunction, or migratory takotsubo cardiomyopathy.

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