Besides ABS and AMI, an important entity to consider in the differential diagnosis of transient wall motion abnormalities is regional myocarditis. Viral titers are helpful in excluding this condition. Furthermore, prolonged recovery is more commonly seen in myocarditis compared with ABS. Imaging studies are particularly helpful in this scenario.
Cardiac MRI demonstrates the wall motion abnormalities or apical ballooning typical for this condition and can differentiate ABS from myocarditis or MI. It is known that delayed myocardial enhancement is seen with myocardial fibrosis. Typically in ischemic cardiomyopathy, there is wall thinning with associated delayed enhancement that extends from the subendocardium to the epicardium (from 0%-90% of wall thickness) of a particular vascular territory. In myocarditis, the enhancement is usually seen in the involved intramyocardial (mesocardium) region, and the pattern is patchy. In ABS, the delayed enhancement is absent, because there is no fibrosis in the area of regional wall motion abnormalities, and wall thickness is usually normal.9,10
No evidence-based guidelines for treating ABS are currently available. Most patients are initially treated with antiplatelets/anticoagulant therapy, nitrates, and diuretics if the patient presents with heart failure. Patients should be admitted to an intensive care unit for close cardiac monitoring. Once ABS is diagnosed and significant coronary stenosis is excluded, patients should receive standard supportive care and optimal neurohormonal therapy. This should include beta blocker or combined alpha/beta blocker agents, an ACE-I or angiotensin receptor blocker, and diuretics if appropriate. Once left ventricular function (LVF) is recovered, therapy with inhibitors of the renin-angiotensin system may be discontinued, but patients should remain on long-term alpha or beta blocker therapy, because the sympathetic blockade provided by these agents may prevent recurrences of this disease.10
Prognosis is generally favorable, and most patients recover to normal LVF over weeks to months. It is important to assess the LVF 4 to 6 weeks after the patient is discharged to confirm the diagnosis of ABS. Recurrence may occur in up to 9% of cases.10 Long-term mortality is similar compared with the age-matched general population.
Apical ballooning syndrome is a relatively novel cardiomyopathy that has gained important attention among the cardiovascular community, mostly because its clinical presentation mimics that of an acute coronary syndrome. Awareness of this entity will result in a more focused diagnosis and appropriate treatment. Managing both cardiac and emotional components of this disease will have a permanent impact in the reversibility and secondary prevention of this cardiomyopathy.
Special thanks to the Radiology Service at the VA Caribbean Healthcare System, in particular Dr. Frances Aulet for interpretation of the cardiac MRI results and assistance with MRI images.
The authors report no actual or potential conflicts of interest with regard to this article.
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.