Post-partum Syncope And Chest Pain - Exercise Training

HISTORY: A 35-year-old G3P3 female with a history of migraines and orthostatic lightheadedness presented to the ED five days post-partum with three days of palpitations and chest pain. She experienced two syncopal episodes at weeks 36 and 37 of pregnancy but had an uncomplicated delivery. PHYSICAL EXAMINATION: Heart rate 44 BPM. Blood pressure 119/79 mmHg. Regular rate and rhythm, normal S1 and S2. No murmur, edema, or jugular venous distension. DIFFERENTIAL DIAGNOSIS: 1. Acute coronary syndrome 2. Post-partum cardiomyopathy 3. Takotsubo syndrome 4. Spontaneous coronary artery dissection 5. Pulmonary embolism 6. Myocarditis TEST AND RESULTS: 1. ECG: Downsloping 3mm ST depression in inferior and anterolateral leads with ST elevation in AVR 2. Labs:NT-Pro BNP 453 (≤140 pg/mL); Troponins 403 baseline, 836 2-hr, 625 6-hr (≤10 ng/L) 3. TTE: Left ventricular ejection fraction 37%; akinesis of basal septum and hyperkinesis of the apex 4. Coronary Angiogram: Normal coronary arteries FINAL WORKING DIAGNOSIS: Post-Partum Basal Variant Takotsubo Syndrome TREATMENT AND OUTCOMES: 1. Beta-blockers and ACE inhibitors were deferred after discharge as the patient was breastfeeding her newborn. 2. Four months after discharge, TTE showed LVEF of 56% and normal biventricular systolic function; NT-Pro BNP normalized to <50 pg/mL. Patient reported dyspnea upon exertion and was referred to CR due to concerns about safely returning to exercise. 3. CPET was negative for ischemia but showed blunted BP response and dizziness with increased intensity. V̇O2peak was below average (78% predicted) despite maximal cardiometabolic effort, likely due to impaired cardiac output. 4. In CR she experienced ongoing exertional lightheadedness, orthostatic syncope, and a blunted BP response. A tilt-table test showed an increase in HR (62 BPM supine baseline to 105 BPM 7-minute tilt) without significant changes in BP, consistent with postural tachycardia syndrome. 5. She transitioned to a recumbent exercise interval training regimen in CR which led to normal BP response and resolution of symptoms. 6MWT improved from 438m at baseline to 576m after 19 CR sessions.