Case Presentation: A 72-year-old man with untreated generalized anxiety disorder, coronary artery disease, and a remote non-ST elevation myocardial infarction presents with non-exertional chest pressure for one day. The patient had multiple prior hospitalizations for similar symptoms with associated chronic anxiety, though with consistently negative cardiac work-ups.
On presentation, he was hemodynamically stable with electrocardiogram notable for new T-wave inversions in the precordial leads and a prolonged QTc interval. Serial troponin levels were negative. A transthoracic echocardiogram revealed a reduced ejection fraction (EF) of 20% with mid and apical anterior wall akinesis and inferolateral wall akinesis. This was compared to a normal EF with normal systolic function 10 months prior. Due to concern for ischemic cardiomyopathy, cardiac catheterization was performed which revealed non-obstructive coronary artery disease.

Based on the above findings, the patient was diagnosed with Takotsubo cardiomyopathy, likely triggered by untreated generalized anxiety disorder. The patient remained notably anxious, but declined psychiatric treatment and was ultimately discharged home on aspirin and a high intensity statin.

Discussion: Takotsubo cardiomyopathy (TC) is defined by transient regional left ventricular wall motion dysfunction beyond the territory of a single coronary artery, new ECG abnormalities or mild troponin elevation, and lack of angiographic evidence of obstructive coronary disease or acute plaque rupture. It is thought to be due to catecholamine or adrenergic toxicity causing temporary paralysis of the heart, typically the left apical ventricular chamber. TC is commonly seen in post-menopausal women and is associated with intense emotional or physical stress. It is rarely considered related to chronic psychiatric comorbidity, as in our patient; however, studies have shown that up to 50% of patients with TC have acute or chronic neurologic or psychiatric disorders. Further, reviews have shown that approximately one-third of patients with TC have a pre-existing psychiatric condition, mainly anxiety and mood disorders. This association is likely due to coronary innervation by brain stem neurons mediating coronary vasoconstriction, thereby linking chronic psychiatric and cardiac disease.

Conclusions: Though TC is frequently triggered by physical or emotional stress, there is a strong association between TC and pre-existing chronic psychiatric comorbidity. Therefore, psychiatric disease must be considered in the differential diagnosis for TC. Additionally, by identifying and treating psychiatric disease as a potential cardiac risk factor, clinicians may reduce a patient’s risk of developing TC.