HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
Male, 74 years old. No known drug allergies. Ex-smoker of one pack a day until 12 years ago. Diagnosed with arterial hypertension, currently being treated with olmesartan 20 mg, with good control of blood pressure.
The patient consulted his primary care doctor for dyspnoea on moderate exertion.
In addition, he has recently noticed frequent episodes of dizziness and blurred vision when walking, of very short duration, which disappear immediately when he stops walking. She has had no loss of consciousness or other cardiovascular symptoms. An electrocardiogram (ECG) was performed which showed atrioventricular conduction disorder with second-degree Wenckebach type block, and she was referred to our clinic.
It was decided to extend the study with a 24-hour Holter, which showed bouts of 2:1 atrioventricular block (AVB) and nodal escape rhythm. In addition, transthoracic echocardiography was performed, which was found to be compatible with normality. During the test, complete AVB was observed, and he was admitted to cardiology with monitoring.
Blood pressure: 150/53 mmHg. Heart rate: 32 beats per minute. Oxygen saturation with ambient air: 98%. Good general condition, conscious, oriented, cooperative, eupneic and afebrile. Jugular venous pressure not elevated. Rhythmic cardiac auscultation with systolic murmur in mitral and aortic focus II/VI. Pulmonary auscultation with normal vesicular murmur, without added noises. Abdomen soft, depressible, non-painful to deep palpation, without masses or visceromegaly. Positive and symmetrical peripheral pulses in all four extremities.
Lower limbs without oedema or signs of deep vein thrombosis.

COMPLEMENTARY TESTS
ECG on admission: sinus activity at 60 beats per minute. Complete AVB with ventricular escape rhythm at 40 beats per minute, narrow QRS, without repolarisation alterations.
ECG with pain: sinus rhythm at 60 bpm. PR 220 ms. QRS stimulated by pacemaker.
Concave ST elevation from V2 to V6 and in inferior leads, with a maximum of 4 mm in V4.
ECG at discharge: sinus rhythm at 60 bpm. Normal PR. QRS stimulated by pacemaker.
ANALYSIS: haemoglobin 13.6 g/dl, haematocrit 40.1%, platelets 136,000/mm3, leukocytes 5,970/mm3 (normal formula). Coagulation: prothrombin rate 91%, INR 1.06, aPTT ratio 0.90. Biochemistry: glucose 91 mg/dl, urea 65 mg/dl, creatinine 1.16 mg/dl, sodium 138 mEq/l, potassium 5.1 mEq/l. Troponin I 3.37 ng/l, maximum peak 6.37 ng/ml (normal up to 0.06).
THORAX RADIOGRAPHY: normal. At discharge, generator in left infraclavicular region.
Electrodes in right atrium and ventricle.
Transthoracic echocardiogram on admission: LV normal size with mild concentric hypertrophy (IVS 13 mm, DTD 53 mm, PP 11 mm). Normal global systolic function, without alterations of segmental contractility. Normal filling pattern for age with E/E" ratio of 9. RV of normal size and systolic function. Dilatation of both atria, severe left atrial dilatation (LA volume 67 ml/m2). No significant valvular heart disease. Inferior vena cava of normal size with adequate inspiratory collapse. Great vessels of normal calibre.
Normal pericardium.
Transthoracic echocardiogram during admission: akinesia of all middle and apical segments, with preserved contractility in basal segments, which conditions a moderately depressed systolic function (biplane LVEF 35%).
Control transthoracic echocardiogram: normal systolic function (biplane LVEF 66%), with no alterations in segmental contractility.
CARDIAC CATHETERISM: coronary arteries without significant lesions. Left ventricle with medioapical akinesia and moderate systolic dysfunction.

CLINICAL EVOLUTION
The patient attended an outpatient echocardiogram, referred from the outpatient clinic. Given the finding of paroxysms of complete AVB, which explained the dizziness and dyspnoea on exertion for which he consulted, he was informed and urgently admitted to the hospital ward with electrocardiographic monitoring. He was very nervous and worried.
During his stay on the ward, he was found to be asymptomatic at rest, with complete AVB and heart rate below 30 bpm, so treatment was started with isoproterenol.
The following morning, a permanent bicameral pacemaker was implanted without complications.
That same afternoon, after implantation, the cardiologist on duty was notified due to severe oppressive central thoracic pain with associated vegetative cramping. An ECG was performed showing an anterolateral subepicardial lesion wave and an echocardiogram showing alterations in contractility in mid-apical segments with moderately depressed systolic function. Emergent coronary angiography was performed, showing coronary arteries without significant lesions and ventriculography compatible with tako-tsubo syndrome. After pain control, the patient showed good clinical evolution, with improvement of the alterations in segmental contractility and was discharged in a stable condition.
Three months after discharge he remained asymptomatic, with a good appearance of the surgical wound and complete normalisation of the segmental alterations and ventricular function.

DIAGNOSIS
Complete paroxysmal atrioventricular block. DDDR definitive pacemaker implantation.
Post-procedural tako-tsubo syndrome. Psychological stress due to unplanned hospital admission and administration of isoproterenol as possible inducers. Transient moderate LV systolic dysfunction, at the expense of mid and apical segment akinesia. Coronary arteries without significant lesions.
