Abstract 3565: Diagnostic Value of Transthoracic Echocardiography in Differentiating Transient Left Ventricular Apical Ballooning From Anterior Myocardial Infarction
Background: Transient left ventricular (LV) apical ballooning (AB) is characterized by chest pain, ECG changes and LV apical akinesia mimicking anterior myocardial infarction (AMI) in the absence of coronary artery disease. Since diagnosis is usually made by angiography, the echocardiographic features are less well known.
Methods and Results: Among 1922 patients with an acute coronary syndrome undergoing coronary angiography over a 6-year period, 34 AB patients (1.8%) were identified (30 f, 4 m, age 73±10). Prevalence of AB was 4.7% in females and 0.3% in males. AB patients were compared to 25 consecutive AMI patients with similar findings on LV angiography. There was no difference regarding age, symptoms or ejection fraction. A triggering event was present in 32/34 AB vs 1/25 AMI patients (p<0.001) consisting of emotional (n=21) ± physical stress (n=22). In AB levels of CK (187±93 vs 1903 ±1651 U/l) and troponin I (6.534.2 vs 2313249 ng/ml) were significantly lower than in AMI. ST-segment elevation (32/34 vs 24/25) and T-wave inversion (34/34 vs 24/25) was similar in both groups. Q waves, present in 11/34 AB patients only in the acute phase, resolved during follow-up but persisted in 23/25 AMI patients (p<0.01). Compared to AMI with a more asymmetric wall motion abnormality, all AB patients undergoing echocardiography showed akinesia of the entire LV apical area including septal, anterior, inferior and lateral segments. A transient LV pressure gradient (10 – 45 mm Hg) was present only in 4 AB patients and resolved within 4 days under betablocker therapy. Normalization of LV function occurred in 1/25 AMI vs 34/34 AB patients (p<0.001) following a sequence of akinesia, hypokinesia and early relaxation. Three AB but no AMI patient developed an apical thrombus and stroke (n=2) despite continuous therapeutic anticoagulation. ECG normalization occurred in 1/25 AMI vs 34/34 AB patients always later (88±111 days) than echocardiographically documented resolution of LV dysfunction (23±20 days).
Conclusion: By demonstrating akinesia of the entire apical area echocardiography aids in differentiating apical ballooning from AMI. Serial studies are essential for diagnosis of AB and detection of complications such as intraventricular pressure gradients and LV thrombus.