Title: Hiking can break your heart: Hiking induced stress cardiomyopathy
Authors: Amineta Sy, OMS3
Introduction
Stress cardiomyopathy, also called apical ballooning syndrome, takotsubo cardiomyopathy and broken heart syndrome is a transient systolic dysfunction of the heart following intense sympathetic discharge. It typically affects women over 50, and majority of cases have been described following the death of loved one hence the name broken heart syndrome. However, in our case the patient trigger factor was hiking. This case report has for goal to highlight the commonness of stress cardiomyopathy and consider intense exercise as a factor.
Case description
73-year-old female with a past medical history of hyperlipidemia, hypertension, GERD, iron deficiency anemia and recurrent SBO who presented with neck pain and was admitted for STEMI. Patient had sudden onset left neck and shoulder pain while hiking. She vomited at the top of the mountain. Patient had been incoherently withdrawn. She collapsed at home. She was sent to ED after having a suspicious EKG reading at the urgent care. Patient was given 324 mg of aspirin. CT of the head was negative, echo showed EF 40-45%, apical akinesis, mild mitral, tricuspid, and aortic regurgitation. The coronary angiogram showed no significant coronary lesions. Patient symptoms significantly improved hours later, a second echo showed normal size and wall thickness and EF 55-60%. There was still some residual hypokinesis. After 2 doses of 0.5 mg midazolam injections and 2 doses of 25mcg of fentanyl injections and lopamidol 76% injection 50 ml, her symptoms resolved. She was released Day 2 with instructions to continue her metoprolol, amlodipine, and Lipitor. Patient was diagnosed with stress cardiomyopathy and instructed to follow up with her PCP.
Discussion
Stress cardiomyopathy is a diagnostic of exclusion. Our patient presented symptoms of coronary artery disease and due to her past medical history and age, it was imperative to rule out MI and stroke hence the decision to do an EKG, echo, coronary angiogram, and a head CT. Due to misdiagnosis of MI being more common in women, stress cardiomyopathy should only be considered after ruling out more urgent and dangerous condition. Most cases of stress cardiomyopathy have been attributed to emotional stress; this case however shows that intense exercise such as hiking is a crucial trigger factor to consider as well. Although transient, 10% of patients experience cardiac and neurological complications within a year. Therefore, it is essential for patients to follow up with their primary care provider.
I am one of the judges for your intriguing case report. You describe it as a diagnosis of exclusion, there were a number of criteria listed by the mayo clinic in making the diagnosis, but from what you know about it, what would you tell someone are the 3 to 5 most important criteria for making this diagnosis?
The 3 most important criteria would be the first three:
1. Transient left ventricular systolic dysfunction
2. Absence of coronary disease or angiographic evidence of a plaque rupture
3.New ECG abnormalities
Thank you for sharing an interesting case study. According to the Smidt Heart Institute, the incidence of Takotsubo cardiomyopathy among middle-aged and older women is steadily rising. From your experience with this case report, what would you recommend for future research with this population and condition, especially related to physical activity?
From my experience with this case I would recommend that intense exercise be considered one of the main factor that can cause stress cardiomyopathy and therefore educate patients on symptoms and off course only consider stress cardiomyopathy after ruling out more life threatening condition such as myocardial infraction.
Judge: What other predisposing factors did this woman have? Can you hypothesize why intense exercise had this effect in this patient?
The main factors this patient has, are her history of hypertension, her gender and her advanced age.
Patient is an avid hiker however due to Covid 19 restriction this was her first hiking in month.
It is hypothesized that intense exercise causes an important discharge of catecholamine via the sympathetic pathway, therefore putting the same strain on the heart as intense emotion which is typically a main cause of stress cardiomyopathy.
Thank you for your presentation. Do you know how far the patient hiked that day before becoming symptomatic?
The patient did no specifically describes how many miles she hiked. She is however an avid hiker but because of the Covid19 restrictions this was her first hike in months