Case report
A 67-year-old female in general good health, BMI 26.4, with a history of
hyperlipidemia, migraines, and hypothyroidism started to suffer from
headache during training at the gym with light weights - 10 lb, 12 lb. -
for arms, chest and legs. She felt nauseous and called her husband.
When he came to the gym, he asked her if she was well enough to drive.
She said yes, but couldn’t remember where she parked the car. Her
husband was concerned because she kept repeating herself, saying that
she did not feel good. She did not remember anything that happened for
the next 8 hours. She did not remember that her sister had died 3 months
ago and did not know what day or month or even year it was. The husband
took her to the hospital because he suspected myocardial infarction or
stroke.
During the 18 months before this event, she was taking care of her
sister who suffered from ovarian cancer. She was with her 3-4 times a
week until the last 8 weeks, when she was there each day. She was also
with her when she died. Afterwards she got the sister’s estate settled,
sold the home, and helped her daughters through all of this.
She was on a chronic medication with bupropion 200 mg/d, levothyroxine
75 µg/d, rosuvastatin 5 mg/d, butalbital 50 mg/d, acetaminophen 325 mg/d
and caffeine 40 mg/d.
In the emergency department her heart rate was 89/min, respiratory rate
20/min, blood pressure 206/107 mmHg and O2 saturation 98 %. Laboratory
tests showed an initially elevated high-sensitivity troponin of 138
ng/L, which increased to 1344 ng/ml (normal range: 0 - 54 ng/L).
Computed tomography (CT) of the head showed no acute intracranial
abnormality, CT angiography of head and neck showed no hemodynamically
significant stenosis, aneurysm, dilatation, or dissection within the
intracranial or extracranial arterial circulation. Magnetic resonance
imaging (MRI) of the brain showed no acute infarct.
She underwent cardiac catheterization with no evidence of coronary
artery disease. The left ventricular ejection fraction (LVEF) was 50%,
and anterolateral wall hypokinesia was seen. Cardiac MRI showed a
normal left ventricular cavity size and global systolic function with a
LVEF of 57%, and a mild hypokinesia involving the basal to mid anterior
wall. Additionally, faint edema and mild mid myocardial/epicardial
delayed enhancement involving the basal to mid anterior and septal
segments was seen, but there was no evidence of myocardial infarction.
Right ventricular cavity size and systolic function were normal.
Clinical investigation 20 hours after onset of symptoms found her seated
on the bed, awake and alert. She had no complaints, denied symptoms of
headache and vision changes. The memory was back to normal. She denied
symptoms of tingling, numbness, palpitations, weakness, dizziness, or
lightheadedness and walked with steady gait. Metoprolol 25 mg/d was
added to her medication. She was discharged after three days. Before,
during and after hospital admission she never felt anginal chest pain.
Because of low blood pressure, her cardiologist reduced metoprolol to
12.mg/d. After discharge from the hospital, she started grief counseling
and is doing much better mentally and physically. Four weeks after
discharge, the echocardiogram did not show any wall motion
abnormalities.