A distraught older woman entered the Emergency Department, hysterical and crying. Mrs. J told the nurse she just received word about a loss in her family. Upon finding out the horrible news, she had collapsed to the floor and was discovered by a family member.    

The emergency room nurse comforted the woman and held her hand and directed her to the waiting area for a seat. “This one can wait a bit, she thought, distraught, yes, but not dying.” As the nurse turned to leave, Mrs. J. complained of chest pain and dyspnea; upon second look she appeared pale and diaphoretic. The ER staff immediately escorted her into an exam room and placed her on a cardiac monitor and oxygen. Mrs. J had anterior ST-changes on her EKG, was hypotensive and tachycardic and her cardiac biomarkers from the lab came back elevated.

Mrs. J’s coronary arteries were found to be “clean” on angiogram. But her heart was obviously in distress. While in the cath lab under fluoroscopy, the cardiologists found marked systolic ballooning of the ventricular apex of the heart. Echocardiograms later reported the phenomenon as hyper contractility of the base of the heart. Mrs. J was actually suffering from a condition known as “broken heart syndrome” or Takotsubo cardiomyopathy. This abrupt onset of extensive dilation of the left ventricle most often occurs in post menopausal women following a traumatic event. Although its onset is sudden and dramatic, apical ballooning is transient and reversible, and its cause is not really known. It is thought to be a stunning of the myocardium due to excessive catecholamine release.

Mrs. J should not receive fibrinolytics on admission. A stat echo would have diagnosed the problem quickly and less invasively. Unfortunately, Mrs. J deteriorated quickly, developing severe left sided heart failure while in the cath lab. A balloon pump was inserted. She was placed in the ICU on a ventilator, and received sedation, inotropic support and anticoagulation for a few days. Mrs. J’s outcome was positive.

Because it mimics the signs and symptoms of an MI, emergency room and critical care room nurses may care for patients suffering with this interesting and uncommon phenomenon. Takotsubo cardiomyopathy, or transient left ventricular apical ballooning, is a rare abnormality, with common signs and symptoms.

ER nurses and ICU nurses must not be fooled if they are presented with an elderly female who has developed cardiac symptoms that coincide with psychological or physical stressors.