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takotsubo cardiomyopathy ( tc ) , also called stress cardiomyopathy or apical ballooning syndrome , is a syndrome of reversible stress - induced cardiomyopathy associated with profound emotional or physical stress .
tc is characterized by transient left ventricular ( lv ) dysfunction with ischemia - like chest pain and ischemia - like electrocardiographic ( ecg ) changes and lack of any obstructive epicardial coronary artery disease observed at the time of emergent coronary angiography .
lv wall motion abnormalities usually involve apical and/or midventricular myocardial segments with wall motion abnormalities extending beyond a single epicardial coronary distribution .
although several pathological mechanisms have been proposed , the precise pathophysiology of tc is still not entirely understood .
we present a case with lung adenocarcinoma whose initial hospital admission was due to tc .
a 59 year - old man without any history of cardiovascular disease was admitted to emergency service with the complaint of chest and back pain .
ecg revealed sinus rhythm with a rate of 70/min , 2 - 3 mm st elevations in v2 and v6 [ figure 1 ] .
he was on antihypertensive medication and smokes 20 cigarettes per day for more than 20 years .
he was immediately taken into the cardiac catheterization laboratory with the diagnosis of acute anterior myocardial infarction .
transthoracic echocardiography demonstrated apical akinesia with a dynamic lv outflow tract obstruction ( peak resting gradient : 45 mmhg , peak gradient reaches to 177 mmhg and mean gradient to 81 mmhg with valsalva maneuver ) [ figure 3 ] .
st elevations returned towards baseline and his complaints were improved progressively with medical treatment , which included antiplatelet agents and anticoagulation , beta adrenergic receptor blocker and renin - angiotensin system blocker agents .
twelve - lead electrocardiography samples of patient obtained at admission ( a ) and 2 days later ( b ) coronary angiography and left ventriculography of the patient transthoracic echocardiography images of the patient demonstrating left ventricular systolic apical ballooning ( arrows ) and left ventricular outflow tract obstruction patient had a cachectic appearance and had complaints of backache and dysphagia with weight loss of 25 kg during the last 12 months .
endoscopic examination revealed esophageal obstruction due to external compression . computed tomography scan of the chest revealed a mass with 5 x 2.5 cm diameter at the level of right pulmonary upper lobe on the posterior segment , extending from retrotracheal to paravertebral space with bone invasion .
fine needle aspiration biopsy obtained from mass showed neoplastic cells and immunohistochemical analysis demonstrated that these cells were reactive with ck7 , ck20 , and ttf-1 antibodies .
he was diagnosed with lung adenocarcinoma and whole body positron emission tomography ( pet ) demonstrated hypermetabolic subcarinal and paraosephageal lymphadenopathies and lytic / sclerotic lesions on thoracic vertebral bodies ( t 3 - 4 - 5 ) and right sided ribs ( from 4 to 9 ) , which were accepted as metastases .
repeat transthoracic echocardiogram performed 10 days after admission revealed complete resolution of lv systolic dysfunction and disappearance of lv outflow gradient [ figure 4 ] .
tc usually mimics acute coronary syndrome and the most common abnormalities on the ecg are st elevations on the precordial on the precordial leads .
usually there is only a moderate rise in cardiac enzymes which is disproportionate with the size of the affected myocardium .
dynamic lv outflow tract ( lvot ) obstruction may occur in up to a fourth of tc subjects .
basal hypercontractility related venturi effect has been suggested as a cause of dynamic lvot obstruction .
tc is a transient syndrome and resolution of symptoms with complete echocardiographic and clinical recovery is expected within 2 to 3 weeks of presentation .
our patient had complete recovery of cardiac symptoms and echocardiography performed 10 days after presentation revealed complete resolution of both wall motion abnormalities and dynamic lvot obstruction .
several pathophysiological mechanisms have been suggested for tc among them coronary artery vasospasm , coronary microcirculation dysfunction , and catecholamine overload .
exposure to emotional or physical stress and increased sympathetic activity has been reported in most cases of tc .
excessive catecholamine production in patients with pheochromocytoma has also been shown to induce reversible lv dysfunction .
prognosis of tc seems favorable in the absence of significant underlying co - morbid conditions .
however , a high rate of concomitant malignancies were reported in a prospective tc registry and burgdorf- et al .
they evaluated 50 patients with tc and 50 age- and gender- matched control patients with acute anterior myocardial infarction ( mi ) .
they reported that 9 patients with tc ( 18% ) and 3 patients with mi ( 6% ) had a previous history of malignancy at the time of the index event . on follow - up
, 7 malignancies were newly diagnosed in the tc group , whereas no new case of malignancy was found in the control group .
these observations have suggested a possible association between malignancies and tc , which may be a result of paraneoplastic phenomena . a variety of malignancies were observed in patients with tc in their study , such as bronchial carcinoma , colorectal carcinoma , breast carcinoma , endometrial carcinoma , melanoma , bladder urothelial carcinoma , gastric carcinoma , and chronic lymphocytic leukemia . on the basis of these observations , burgdorf et al . suggested to perform cancer screening in patients with tc . to the best of our knowledge ,
our patient had bone metastases causing backache and had complaints of dysphagia with weight loss of 25 kg during the past 12 months , which might also have constituted sufficient physical stress for the development of tc .
we contribute this case report to the growing set of literature data regarding the presence of various concomitant malignancies in patients with tc .
takotsubo cardiomyopathy ( tc ) is a rare and usually physical or emotional stress - induced clinical disorder characterized by transient left ventricular dysfunction and apical segment ballooning . 
 much is still unknown regarding risk factors and clinical relationships . 
 recently , an association between tc and malignancies has been proposed . 
 we present a case of lung adenocarcinoma whose initial hospital admission was due to tc . 
 we contribute this case report to the growing set of literature on the association between tc and malignancies .