Emergency due to dizziness and fall to the floor at home, without loss of consciousness and without injuries secondary to the trauma.

History, current illness and physical examination
78-year-old female patient, allergic to penicillins, with a personal history of obesity, hypertension and dyslipidaemia, on treatment with hydrochlorothiazide 40 mg - olmersatan 25 mg, atorvastatin 20 mg and omeprazole 20 mg. Appendectomised. Baseline situation: NYHA function class I-II. She presented suddenly at 9:00 am, with dizziness and a fall to the floor at home, without loss of consciousness and without injuries secondary to the trauma. She was seen a few hours later by a relative, who found her very anxious due to her inability to get up from the floor after the fall. Emergency services were called and she was transferred to our Emergency Department. On arrival, Glasgow 15, BP 80/40 mmHg, HR 110 bpm, 02 saturation 80%, tachypnoea of 25 rpm. While in the observation room, she presented with self-limited tonic-clonic crises, after which she reported intense central thoracic pain, oppressive, radiating to the interscapular area and significant accompanying vegetative cortex.

Physical examination: Conscious and oriented. Poor general condition. Skin pallor. Central cyanosis. Carotids symmetrical and rhythmic. Jugular ingurgitation. CVM with bilateral crackles up to midfields. Rhythmic heart tones; systolic murmur III/IV in mitral focus, radiating to the axilla. Abdomen without pathological alterations. Palpable and symmetrical paedial pulses. Malleolar oedema II/IV.

Complementary tests
- CBC: Leukocytes 13.800 thousands/μl, PMN 70%, HB 12.2 gr/dl, OHT 36.3%, platelets 127 thousands/μl, prothrombin activity 98%, aTTP 27.5 ́ ́, fibrinogen 343 mg/dl, Glu 159 mg/dl, urea 39 mg/dl, Cr 1 mg/dl, Na 142 mmol/l, K 4.1 4.2 mmol/, Mg 1.8 mmol/L, Cl 116 mmol/L, CPK 810 Ui/L, CKMB 63 ng/ml, troponin I 17.98 ng/ml.
- Arterial blood gas: pH 7.38, pC02 27 mmHg, P02 110 mmHg, HC03 13 24.8 mmol/, EB -7.7, Sat02 98%, lactate 12mg/dl.
- Chest X-ray: Cardiothoracic index at the upper limit of normality, hilar thickening, fluid in cystic cracks and pinched costophrenic sinuses.
- ECG: RS at 90lpm, with generalised ST segment decline and ST rise of 1 mm in aVR.
- Urgent TTE: Left ventricle without significant hypertrophy or dilatation, with severely depressed systolic function (15%). Mid-apical hypokinesia, with preserved contractility at the level of the basal segments. Grade III mitral insufficiency. Mild aortic insufficiency and moderate pulmonary hypertension. No dynamic obstruction of the left ventricular outflow tract. No pericardial effusion. Dilated inferior vena cava with inspiratory collapse less than 50%.

Clinical course
In cardiogenic shock, the patient was transferred to the Coronary Care Unit (CCU), starting vasoactive support with noradrenaline (0.6 μg/kg/min) and dobutamine (10-12 μg/kg/min). Coronary angiography showed parietal irregularities, without angiographically significant lesions. Ventriculography showed severe ventricular dysfunction and typical Tako-tsubo morphology. During the procedure, an intra-aortic balloon pump (IABP) was implanted via the right femoral artery. In the first 24 hours of admission, the patient required non-invasive mechanical ventilation due to hypoxaemic respiratory failure related to acute pulmonary oedema. The patient's evolution was favourable, allowing the IABP to be withdrawn 48 hours after admission and ventilatory support to be provided gradually over the following days. The enzyme peak was: CPK 1430, CK-MB 60.2 and troponin I 19.06. Prior to discharge, TTE was repeated and showed recovery of systolic function (LVEF by Simpson biplane 45%) with persistence of discrete hypokinesia of the middle portions. After twelve days in the CCU, she was discharged to the cardiology ward.

Diagnosis
Tako-tsubo syndrome complicated by cardiogenic shock.
