A 47-year-old woman with a history of ischemic stroke and dyslipidemia presented with severe gastrointestinal (GI) symptoms that lasted for a week. The abdominal CT was normal, but due to persistent complaints, she was admitted for clinical monitoring.
Intravenous β-blockers were administered for a sinus tachycardia. Soon after esmolol, acute cardiac failure ensued with prompt progression to cardiogenic shock. Owing to acute respiratory failure, the patient was mechanically ventilated and inotropes were started. Electrocardiogram showed no signs of myocardial ischemia (Fig. 1), with a slight prolongation of the QTc interval (479 ms). A mild troponin I elevation was detected (8.2 μg/l) and the nt-pro BNP levels were 12 706 pg/ml.
The transthoracic echocardiogram (TTE) was performed after the clinical diagnosis of acute heart failure, which revealed a non-dilated left ventricle (LV) with severe systolic dysfunction. Apical segments had a preserved contractility, contrary to the mid-basal ones, which was not supportive of a coronary event. Moderate functional mitral regurgitation (MR) was identified (Figs 2, 3 and Videos 1, 2).
A coronary angiogram revealed no significant disease and a LV angiogram confirmed severe systolic dysfunction, with MR. Similar to the TTE, a wall motion pattern of preserved apical contractility was recognized (Fig. 4 and Video 3).
The subsequent clinical evolution was excellent. The TTE, performed 72 h after admission, showed a normal LV systolic function with no wall motion abnormalities and no MR (Videos 4 and 5). The nt-pro BNP decreased to 6917 pg/ml. Improvements were also registered two weeks later through cardiac MRI evaluation, and no myocardial edema, fibrosis, or infarction was identified (Fig. 5 and Video 6).
We hypothesize that the cause of the non-apical ballooning syndrome was a combination of esmolol and a preceding stress, due to a GI illness with sympathetic stimulation.
Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
The authors thank: Diogo Torres MD, Hospital Santa Maria, Lisbon, for performing the cardiac catheterization; and Hugo Marques MD, Hospital da Luz, Lisbon, for performing the cardiac MRI.