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.