Title : Atypical takotsubo cardiomyopathy presenting as st-elevation myocardial infarction
Abstract:
A 64-year-old woman with a history of diverticulosis and duodenal ulcer presented with classic signs and symptoms of ST-elevation myocardial infarction (STEMI), including chest pain typical of cardiac origin, ST elevations on ECG, and raised cardiac biomarkers. She was a former smoker with a family history of heart disease but lacked other common cardiovascular risk factors like hypertension, diabetes, or high cholesterol. She also reported recent emotional stress related to a friend’s cancer diagnosis. Initially, her presentation was considered a routine STEMI. However, on admission (day 0), coronary angiography showed no obstructive coronary artery disease. Left ventricular angiography revealed mid-ventricular ballooning with a normal apex. An echocardiogram on day 1 showed normal left ventricular size but impaired systolic function with an ejection fraction (EF) around 45% and regional wall motion abnormalities.
Cardiac MRI on day 5 demonstrated normal cardiac size and function but hypokinesia in mid- to apical anteroseptal and anterior walls with a normal apex, along with mild oedema, patchy late gadolinium enhancement, and elevated T1 values. These findings suggested atypical Takotsubo cardiomyopathy (TTC) with apical sparing or regional myocarditis. Improvement in EF from 45% to 63% over several days, absence of viral symptoms, and no pericardial effusion supported reversible ventricular dysfunction consistent with TTC.
She improved significantly in hospital, with normalization of left ventricular function.Treatment included beta-blockers, and ramipril was planned once blood pressure stabilized.She was followed locally and resumed normal activities.
This case highlights the need to consider stress-induced cardiomyopathy in acute coronary syndrome presentations with normal coronaries, recognizing that TTC can present atypically without typical apical ballooning.
