A 68-year-old woman develops acute chest pain and dyspnea hours after learning of her husband's death. ECG shows ST elevation in anterior leads, but coronary angiography reveals no obstructive stenosis. Troponin I is mildly elevated at 0.8 ng/mL. Ventriculography shows apical akinesis with basal hyperkinesis. LVEF is 38%. What is the most appropriate initial management?
- A Primary PCI with drug-eluting stent to the left anterior descending artery
- B Thrombolysis followed by anticoagulation
- C Supportive care with diuretics for congestion and monitoring for ventricular arrhythmias ✓
- D Urgent surgical ventricular restoration of the apex
Correct answer: C. Supportive care with diuretics for congestion and monitoring for ventricular arrhythmias
Explanation
This is Takotsubo (stress) cardiomyopathy: transient apical ballooning in a postmenopausal woman after emotional stress, with wall motion abnormality extending beyond a single coronary territory and normal coronaries. Management is supportive, treating heart failure and watching for arrhythmias, LVOT obstruction, and thrombus. PCI and thrombolysis are inappropriate because there is no culprit lesion. Surgical restoration has no role as recovery of function within weeks is expected.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.