Scared to death: fatal stress-related myocardial infarction in patients with patent coronary arteries. Patent Coronary Arteries and Fatal stress

Five cases of fatal myocardial infarction (MI) occurring shortly after an intense emotion are reported. Post-mortem examination allowed to diagnose MI, and to exclude coronary thrombosis. The MI events were then attributed to a coronary spasm, with the ultimate cause of death represented by arrhythmias in four cases and free wall rupture in the fifth one. Before dying, this last patient developed changes in left ventricular (LV) geometry suggestive of Takotsubo cardiomyopathy (TCM). TCM is characterized by apical ballooning, is commonly preceded by a major stress, and has a very good prognosis. This case series prompts the hypothesis that TCM represents the tip of the iceberg of stress cardiomyopathy, and also its mildest form. Indeed, patients developing a more intense and prolonged coronary spasm (and possibly those having a greater susceptibility to coronary ischemia or arrhythmias) would undergo extensive myocardial necrosis, and die for either arrhythmias or mechanical complications of MI before developing a full-blown TCM phenotype.