Case Presentation: A 79-year-old female presented with substernal chest discomfort while having dinner radiating to her jaw lasting approximately 2 hours with associated lightheadedness. She reported psychological stressors in the weeks leading up to her admission including her neighbors threatening to kill her cat on multiple occasions. She was also stressed from being limited in her ability to leave her home due to the COVID-19 pandemic. Ten hours prior to her presentation, she had an outpatient echocardiogram that was unremarkable. In the ER She was given nitroglycerin with relief of her pain. Her Labs were significant for high sensitivity troponin of 56 ng/L. EKG showed an old left bundle branch block with no ischemic changes. Transthoracic Echocardiogram (TTE) showed reduced Left ventricular ejection fraction (LVEF) 25-30% with akinesis of the mid-apical anteroseptal, anterior, and anteroseptal myocardium. Patient was started on guideline-directed medical therapy for non-ST elevation myocardial infarction (NSTEMI). Heart catheterization showed normal coronaries with ballooning of the LV and no LV thrombus. The patient’s chest pain did not recur, and she was discharged. Repeat TTE approximately 1 month later showed LVEF of 50-55% with complete resolution of the apical ballooning.

Discussion: Takotsubo Cardiomyopathy (TCM) is an unusual form of acute left ventricular dysfunction. Patients, especially post-menopausal females, frequently present with STEMI-like episode. Echocardiographic findings alone cannot establish the diagnosis, as LAD territory infarction can cause apical hypokinesis.[1] The time frame is also interesting; our patient had a completely normal TTE a few hours prior to presentation. The time to resolution also remains unknown, as we do not know the exact left ventricular recovery mechanism, therefore close follow up with repeat TTE is important.[2]

Conclusions: TCM remains a medical mystery with very interesting time frame. Our case serves to alert us how fast TCM can develop.