Exp Clin Cardiol Vol 16 No 2 2011 57 Apical ballooning syndrome following exercise treadmill testing RB Irwin Bsc MBChB (Hons) MRCP, MA Mamas MA DPhil BMBCh MRCP, M El-Omar BSc MBBS MRCP MD Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, United Kingdom Correspondence: Dr RB Irwin, Manchester Royal Infirmary, Oxford Road, Manchester M13 9W1, United Kingdom. Telephone 44-161-276-1234, fax 44-161-291-5634, e-mail rbirwin@hotmail.com Received for publication January 15, 2011. Accepted March 11, 2011 T ransient left ventricular apical ballooning syndrome (TLVABS) is an increasingly recognized cause of acute coronary syndrome (ACS). The clinical syndrome is also referred to by the terms ‘apical ballooning syndrome’, ‘broken-heart syndrome’ and ‘Takotsubo cardio- myopathy’. The term Takotsubo refers to a Japanese octopus trap, whose shape the left ventricle closely resembles in the acute phase. We present a case involving an elderly patient who developed clas- sical features of TLVABS following an exercise treadmill test (ETT). The present case identifies a rare but important complication of exercise treadmill testing in elderly patients. It also provides a framework for exploring the salient features of TLVABS including the currently pro- posed mechanisms, clinical features, investigations and management. Case Presentation An 81-year-old woman of anxious predisposition was referred by her local cardiologist for an outpatient ETT. She had been experiencing nonspecific chest discomfort for several months. Aside from advanced age, her only risk factor for coronary artery disease was hypertension. The patient admitted to extreme anxiety before commencing the test, primarily because of the perceived physical demands. The ETT was performed according to a standard Bruce protocol, but was terminated after only 40 s due to poor mobility and fatigue. The patient had reached 89% of her maximal age-predicted heart rate, with no acute electrocardiographic (ECG) changes. Approximately 15 min after cessation of exercise, she experienced sudden-onset severe retro- sternal chest pain associated with diaphoresis and nausea. An ECG at that stage revealed widespread ST segment elevation, most pro- nounced in the anterolateral leads, with diminution of R wave voltage in leads V1 to V4 (Figure 1). Shortly following the onset of her chest pain, the patient experi- enced a period of expressive dysphasia with no other focal neurological deficit. An urgent computed tomography brain scan revealed no evi- dence of cerebral hemorrhage or established infarction. The patient was given morphine, and loading doses of acetylsalicylic acid (300 mg) clinicAl cArdiology: cAse report ©2011 Pulsus Group Inc. All rights reserved rB irwin, Ma Mamas, M el-omar. apical ballooning syndrome following exercise treadmill testing. exp Clin Cardiol 2011;16(2):57-61. Transient left ventricular apical ballooning syndrome is an increasingly recognized cause of acute coronary syndrome, particularly in postmeno- pausal women, and is the subject of increasing interest to both clinicians and researchers. Emotional and physical stressors are often implicated in its development and, while excess sympathetic drive appears to act as a pri- mary trigger, the exact mechanism remains controversial. The clinical presentation is characterized by transient, often severe, left ventricular dysfunction affecting the mid and apical myocardium. By defi- nition, no significant coronary artery lesions are present, although this may not be recognized at initial presentation. While recovery of function with evidence of limited myocardial necrosis is common, significant complica- tions may manifest in the acute phase. A case involving an elderly patient who developed classical features of the syndrome following an exercise treadmill test is presented. To the authors’ knowledge, the present case is the only such report that meets the recently proposed diagnostic criteria. The present case serves to highlight a rare but important complication of exercise testing in an elderly patient. Recent large systematic reviews have provided valuable insights into the clinical features of this condition. The current article examines the data from these studies and others to provide a comprehensive clinical overview. Key Words: Apical ballooning syndrome; Exercise; Takotsubo Figure 1) Electrocardiogram trace during pain showing widespread ST elevation in the anterolateral and inferior leads