F Cangella Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , A Medolla Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , G De Fazio Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , C Iuliano Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , N Curcio Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , L Salemme Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , G Mottola Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy , Marco Agrusta Cardiology Department, 'Montevergine' Cardilogy Clinic, Mercogliano, Italy and Casa di Cura Montevergine, Via Mario Malzoni, 1, 83013 Mercogliano (Av.), Italy

Echocardiographic data
All patients underwent comprehensive transthoracic echocardiography examination at rest, upon discharge and at a median period of 40 months follow-up. End-systolic, end-diastolic volumes, ejection fraction and wall motion score index (each segment scored from 1 = normal/hyperkinetic, to 4 = dyskinetic, in a 16 segment model of the left ventricle) were calculated following the recommendations of the American Society of Echocardiography [5]. The left ventricular volumes and ejection fraction were measured by modified biplane Simpson's method and adjusted for body surface area. The systolic pulmonary artery pressure has been derived from maximal velocity of tricuspid Doppler tracing adding the value of the right atrial pressure. The right atrial pressure was estimated on the basis of inspiratory collapse index of the inferior vena cava. Diastolic function was determined from the pattern of mitral and pulmonary venous flow velocity by pulsed Doppler echocardiography, complemented by mitral annular velocity by tissue Doppler imaging, when needed [5]. Diastolic dysfunction was staged as being "absent" (grade 0), "mild" (grade 1, impaired relaxation), "moderate" (grade 2, pseudo-normalized filling pattern), and "severe" (grade 3, restrictive filling pattern). All echocardiographic examinations were performed using commercially available instruments with a cardiac probe (2.5–3.5 MHz): Acuson Sequoia (Mountain View, Ca), Esaote Mylab (Genoa, Italy).

Statistical analysis
Values are expressed as mean ± standard deviation (SD) unless indicated otherwise. Groups were compared by parametric or non-parametric tests (t-tests and Wilcoxon-Mann-Whitney tests, respectively). More than 2 groups were compared using the analysis of variance. Post-hoc tests were performed (if significant differences were proved globally) with the help of Newman-Keuls test. A p < 0.05 was considered as statistically significant.

Results

Demographic and clinical features of the study patients are reported in Table 1. All patients reported a physical and/or an emotional distress in the hours immediately before admission consisting of death of a relative in 4, strong financial loss in 1 and heated argument with daughter in 1. The presenting symptoms were chest pain in 6, dyspnea in 2, lipotimia in 1 and severe dyspnea with acute heart failure in 1 patient. The initial electrocardiogram showed sinus rhythm in all patients with ABS, with a median heart rate of 105 beats per minute; 3 patients had ST-segment elevation of at least 1 mm, and 3 patients had diffuse T-wave inversion; 3 patients had a prolonged QT interval corrected for heart rate (QTc). Q waves did not appear in any of the observed patients. On admission, echocardiogram showed an apical dysfunction in all of the patients. Over time, there was a normalization of regional wall motion (Figure 1), a reduction of left ventricular end-systolic volume and improvement of diastolic function (Table 2).