Case Presentation: A 63-year-old female with past medical history of hypertension, hyperlipidemia, and tobacco use presented to the emergency room with one hour of substernal chest pain radiating to the left arm associated with nausea and dizziness. On examination temperature 98.4°F, blood pressure 160/93, heart rate 93, respiratory rate 19, saturating 98% on room air; remainder of exam was benign. Labs revealed troponin 62,114 and WBC 12.8. Electrocardiogram (ECG) demonstrated ST-segment elevations in the inferior and antero-lateral leads. An echocardiogram revealed moderately hypokinetic left ventricular walls with an ejection fraction (EF) of 45%. A subsequent cardiac catheterization demonstrated occlusive thrombi in the left anterior descending artery and the first obtuse marginal branch of the left circumflex artery and an EF 30-39%; the marginal artery received balloon angioplasty. The next day, a transesophageal echocardiogram showed an improved EF (55%) and no evidence of a patent foramen ovale (PFO) or left atrial appendage thrombus. The remainder of the hospitalization was unremarkable, and she was discharged home.
Discussion: Takotsubo cardiomyopathy (TC) commonly affects postmenopausal women and is marked by transient regional wall motion abnormalities without coronary artery disease, often with ECG changes or elevated cardiac biomarkers. Approximately 15% of TC cases present with CAD. Pathogenesis is believed to involve elevated catecholamine levels due to physiological stress. Risk factors include sympathetic overdrive from intense stress, decreased estrogen in postmenopausal women, and microvascular dysfunction. Clinical symptoms include chest pain, dyspnea, or syncope and can progress to heart failure, cardiac arrest, or cardiogenic shock. Although rare, TC can be associated with embolic phenomena, such as aorto-iliac occlusions linked to left ventricular thrombus or coronary thromboembolism in atrial fibrillation. In our case, simultaneous embolization to distal arteries without left ventricular thrombus, PFO, or atrial fibrillation is unusual, suggesting that TC may have precipitated thrombus formation and embolization. The rapid EF improvement from 30-39% to 55% within one day strongly suggests TC, as such a quick recovery is unlikely in an ischemic event.
Conclusions: When admitting patients presenting with symptoms of acute coronary syndrome, physicians should keep in mind that embolization causing myocardial infarction – although rare – can be a result of Takotsubo cardiomyopathy.