Transient left ventricular apical ballooning mimicking acute coronary syndrome in four patients from central Europe.

The syndrome of "apical ballooning" consists of an acute onset of transient extensive akinesia of the apical portion of the left ventricle, without significant stenosis on the coronary angiogram. The syndrome is accompanied by chest symptoms, electocardiographic changes, and limited release of cardiac markers disproportionate to the extent of akinesia. So far, the vast majority of cases with this syndrome have been reported among Japanese population and only a few cases among Caucasian population. We describe "apical ballooning" in four Caucasian patients, three women and one man, who presented at a tertiary referral center over a period of eight months. Their age ranged between 64 and 84 years. Three of them presented with chest symptoms. All four patients had electrocardiographic changes and increased concentration of troponin T. One patient developed hemodynamic instability, but none died or showed recurrence of symptoms during the follow-up of 1-8 months. In all patients, a preceding triggering factor was identified, such as emotional or physical stress. In all patients left ventriculography showed extensive akinesia of the apex of the left ventricle ("apical ballooning") in the absence of a significant coronary artery stenosis. Left ventricular systolic function recovered completely within three days to three weeks. Emotional or physical stress or other preceding triggering factors might play a key role in this cardiomyopathy, but the precise etiology remains unknown. Despite severe initial presentation, conservative medical management leads to good long term outcome.