Transient left ventricular apical ballooning and exercise induced hypertension during treadmill exercise testing: Is there a common hypersympathetic mechanism?

Objective. To describe two cases of Takotsubo like myocardial contractile pattern during exercise stress test secondary to hypertensive response. Background. Treadmill exercise testing is known to cause sympathetic stimulation, leading to increased levels of catecholamine, resulting in alteration in vascular tone. Hypertensive response during exercise testing can cause abnormal consequences, resulting in false positive results. Cases. We present the cases of two patients experiencing apical and basal akinesis during exercise stress echocardiography, in whom normal wall motion response was observed on subsequent pharmacologic stress testing. The first patient developed transient left ventricular (LV) apical akinesis during exercise stress echocardiography. Due to high suspicion that this abnormality might be secondary to hypertensive response, pharmacologic stress testing was performed after three days, which was completely normal and showed no such wall motion abnormality. Qualitative assessment of myocardial perfusion using contrast was also performed, which showed good myocardial blood flow, indicating low probability for significant obstructive coronary artery disease. The second patient developed LV basal akinesis as a result of hypertensive response during exercise testing. Coronary angiogram was not performed in either patient due to low suspicion for coronary artery disease, and subsequently negative stress studies. Results. Transient stress induced cardiomyopathy can develop secondary to hypertensive response during exercise stress testing. Conclusion. These cases provide supporting evidence to the hyper-sympathetic theory of left ventricular ballooning syndrome.