Transient Mid-Ventricular Ballooning Due to Bad Dream in a Postmenopausal Woman

Mid ventricular ballooning syndrome (MBS) was diagnosed in a 55-year-old woman who was admitted to emergency room due to acute chest pain. The trigger for the chest pain was reported as “bad dream” about her husband. MBS, a variant of Takotsubo Cardiomyopathy is more common in postmenopausal women and the triggers have been linked to stress involving the husband. Sudden catecholamine surge during nightmare augmented by estrogen deficiency in postmenopausal women may be the underlying mechanism. There are many unanswered questions related to the etiology of MBS. With supportive treatment, prognosis is excellent.


Introduction
Mid ventricular ballooning syndrome (MBS) is an atypical variant of Takotsubo cardiomyopathy (TCM) [1].The clinical presentation is similar to TCM.It is characterized by transient wall motion abnormalities of the mid-segment of the left ventricle with apical sparing.We report a new trigger to this clinical entity.

Case Report
A 55-year-old woman presented early in the morning with a past history of hypothyroidism and diabetes mellitus accompanied by her husband to the emergency department after a sudden onset substernal chest pressure radiating to the shoulder blades and shortness of breath.An electrocardiogram and cardiac enzymes suggested acute myocardial infarction.Coronary angiography was performed which showed minimal coronary artery disease without a hemodynamically significant stenosis.Left ventriculography was notable for a low normal ejection fraction of 35%, an akinetic anterior and hypokinetic mid-ventricular walls (Figure 1).These findings were consistent with mid-ventricular ballooning syndrome.
The echocardiogram showed abnormality consistent with the left ventriculogram.Upon further investigation the patient admitted to have had a dream involving her husband.The patient was later discharged home on metoprolol, lisinopril and aspirin.One month follow up echocardiogram showed normal LV ejection fraction without regional wall motion abnormalities.

Discussion
Variants of TCM are generally labelled atypical forms and are seen in 40% of TCM cases [1].MBS is one such variant.It is speculated that the difference in density of cardiac adrenoceptors and their susceptibility to sympathetic stimulation in the mid and apical portions might be the reason for variance in ventricular ballooning [2].It is more common among postmenopausal women [3].
Earlier it was believed that the reason for TCM was coronary artery spasm.However, recent studies have supported increased catecholamine levels during psychosomatic stress are believed to result in development of acute myocardial stunning and LV wall motion abnormalities.Increase in firing rate of unmyelinated cardiac c-fiber afferents produce widespread sympathetic inhibition, thus inducing ventricular ballooning [4].In addition, estrogen deficiency in postmenopausal women may cause increased sensitivity and responsiveness to catecholamine surges [2].A sudden emotional stress can induce continued brain activation, which could persist even after the typical cardiac wall motion abnormalities have disappeared [5].
Emotional stress causing TCM in certain group of individuals is highly controversial.Although, some predisposing factors have been identified.Parahuleva et al. have described a case of mid ventricular ballooning without emotional stress [6].New data has suggested an association between dream anxiety and acute myocardial infarction [7].Bad dreams have also caused coronary artery dissection and vasospasm [8].This is the first case report where MBS was caused by a nightmare.In addition, nightmares have been associated with higher sympathetic drive resulting in altered heart rate variability [9].The stressors in women relating to death or hospital admission of their spouses have resulted in TCM [10]- [12].It is interesting to note in our case dream relating to husband was the reason for MBS.TCM is diagnosed more frequent than before.It could be caused by a wide variety of emotional triggers.Further studies are needed to study the detailed mechanism of these triggers which will help us better understand and treat TCM and its variants.

Conclusion
Mid ventricular ballooning syndrome is a rare condition, but it has excellent prognosis.Sometimes, MBS may have miserable clinical outcome.Our case is interesting since the triggering mechanism, a nightmare, was not reported prior.