Takotsubo Cardiomyopathy in a 66-Year-Old Woman: A Case of Stress-Induced Cardiomyopathy Mimicking Acute Coronary Syndrome in the Presence of Cardiovascular Risk Factors

Abstract

Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy or "broken heart syndrome," is a transient cardiac syndrome characterized by acute left ventricular dysfunction, often mimicking acute coronary syndrome (ACS). TC is triggered by emotional or physical stress and presents with chest pain, electrocardiographic abnormalities, and elevated cardiac biomarkers, though typically without significant coronary artery obstruction. This case discussed a 66-year-old postmenopausal female who presented with progressive chest discomfort, borderline ST-segment elevation on an electrocardiogram, and mildly elevated cardiac biomarkers, initially raising suspicion for ACS. Urgent cardiac catheterization revealed mild coronary artery disease without significant obstruction, while left ventriculography showed hallmark apical ballooning and preserved basal contractility consistent with TC. Further evaluation revealed an ejection fraction of 24% and grade 2 diastolic dysfunction. Management included guideline-directed medical therapy for heart failure, anticoagulation for thrombus prevention, and comprehensive lifestyle modifications. This case underscores the diagnostic challenges in distinguishing TC from ACS and highlights the critical role of invasive coronary angiography and advanced imaging. The patient's presentation was consistent with TC, yet no single acute emotional or physical stressor was identified, suggesting a multifactorial etiology, potentially influenced by chronic hypertension and nicotine use. Postmenopausal women remain at high risk, likely due to hormonal changes affecting myocardial and vascular resilience. Timely recognition and diagnosis of TC are essential to optimize patient outcomes, as management differs significantly from ACS. This case emphasizes the importance of maintaining a high index of suspicion, particularly in postmenopausal women presenting with ACS-like symptoms, and the value of a multidisciplinary approach to treatment and follow-up.

Keywords: acute coronary syndrome; broken heart syndrome; heart failure with reduced ejection fraction; left ventriculography; takotsubo cardiomyopathy.

Figure 1. The patient’s EKG significant for borderline ST-segment elevation in the anterolateral leads (V2, V3, V5, V6) with reciprocal ST-segment depression in the inferior leads (V2, V3, AVF) and a prolonged QT interval.

Figure 2. A still image of the patient’s left ventriculogram, showing a basal segment that is contracted with associated dyskinesis of the apex.