Syncope in a patient presenting to the emergency room with chest pain, shock, and neurological disorders

Transient left ventricular dysfunction associated with apical ballooning at echocardiography or angiography has been described in many overlapping clinical settings: neurological disorders, such as subarachnoid haemorrhage and stroke, pheochromocytoma, and the recent takotsubo syndrome. We describe the case of an elderly woman presenting with syncope, chest pain, electrocardiographic abnormalities, mild enzymatic release, and transient left ventricular apical ballooning, mimicking an anterior wall acute coronary syndrome with shock, following a subarachnoid haemorrhage that could not be detected upon admission. The pathophysiological mechanisms of myocardial damage during catecholamine surge cannot be completely explained by epicardial coronary vasoconstriction or microvascular spasm and subsequent ischaemia; also direct catecholamine-mediated myocyte injury may play a role in myocardial stunning.