There are many causes of shortness of breath, but this kind, from congestive heart failure, brought several cardiac possibilities to mind:

Our 89-year-old patient's new pacemaker may have malfunctioned.

He could have had a heart attack. This can occur without any chest pain, presenting with sudden shortness of breath.

His normally functioning pacemaker might be causing his heart to beat out of sync, which can result in what is called pacing-induced cardiomyopathy.

The stress of his recent surgery caused the problem.

Before the patient left my office on the initial visit, his pacemaker was checked and found to be functioning normally, so that checked off the possibility of a malfunctioning device.

An out-of-sync heartbeat from a normally functioning pacemaker was ruled out because the timing was off. This side effect usually does not occur until months after a pacemaker is inserted.

A heart attack was still a possibility. But ultimately, I determined stress-induced cardiomyopathy was the reason he was so sick.

Its symptoms - chest pain and shortness of breath - are initially indistinguishable from a heart attack. But his echocardiogram shed some light on the cause.

Stress-induced cardiomyopathy is also called takotsubo, after a Japanese pot with a round body and small neck used to trap octopus. It is so named because of the unique appearance of the heart on an echocardiogram. My patient's echocardiogram looked just like a Japanese octopus pot.

Although an uncommon complication after a pacemaker, Dr. Google let me know that several prior cases have been reported.

The condition is also known as "broken-heart syndrome." The precise cause is not known, but it is typically a reaction to stress brought on from the loss of a loved one, sudden illness, or natural disasters such as hurricanes or earthquakes. Apparently, we can now add getting a new pacemaker to this list.

He became better quickly with medication. Two weeks after his initial visit, he was feeling back to normal and his leg swelling was gone. A repeat echocardiogram done a month after the initial diagnosis showed complete normalization of his heart function. He went home with his son with a big smile on his face. - David Becker