Case Presentation: A 78-year-old African American female with a history of coronary artery disease (CAD) with stent placement, hypertension, and hyperlipidemia developed chest pain after being admitted for pulmonary embolism secondary to recently diagnosed pancreatic cancer. She was treated appropriately, but developed severe chest pain on day six of her stay. The patient’s vital signs were stable and physical examination was pertinent for irregular cardiac rhythm. An electrocardiogram (ECG) was unchanged from her ECG on admission without ST or T changes and right heart strain, but her troponin levels were elevated. A transthoracic ECG (TTE) showed a 20% to 25% reduced ejection fraction (EF) compared to her TTE on admission with apical ballooning concerning for cardiomyopathy. Given her presentation, Takotsubo cardiomyopathy was suspected, so a left heart catheterization (LHC) was performed to rule out potential CAD. The LHC showed an EF of 15% with apical ballooning but no significant CAD. Based on these results, the patient was started on guideline-directed medical therapies for CAD and was discharged.

Discussion: Takotsubo Cardiomyopathy (TC), or broken heart syndrome, was first recognized in Japan. TC patients typically have left ventricular apical ballooning resulting in a distorted heart shape of a narrow neck and wide base. While the incidence of TC is unknown, it accounts for 1% to 2% of all suspected acute myocardial infarction (AMI) cases and 90% of TC cases are post-menopausal women. TC is most commonly triggered by stress.Catecholamines and underlying psychiatric conditions putatively play roles in TC pathogenesis. Neurologic or psychiatric disorders were present in 56% of TC patients compared to 26% in acute coronary syndrome (ACS) patients. Furthermore, TC patients often have more than twice the normal amount of serum catecholamine levels. Catecholamines cause coronary artery vasospasms that lead to supply-demand mismatch from increased cardiac workload and ultimately to post-ischemic myocardial stunning. Not all TC patients have high catecholamine levels. Therefore, a thorough evaluation of the patient’s history, risk factors, and lab workup must be performed if TC is suspected.TC and ACS presentations are similar; however, only 2% of patients initially suspected to have ACS are diagnosed with TC. Diagnostic criteria by the Mayo Clinic is widely used to diagnose TC. Common TC features include chest pain, dyspnea, signs of acute heart failure, elevated troponin and BNP levels, ST-segment elevation, and/or T-wave inversions. TC can also have atypical presentations similar to our patient (i.e., chest pain and elevated troponin levels without ECG changes), so cardiac evaluation with LHC must be performed. Once TC is diagnosed, treatment is supportive until resolution of symptoms, which can last for 2 weeks to 12 months, with 95% of patients achieving a full recovery.

Conclusions: We present a case of a patient diagnosed with TC who exhibited decreased EF with apical ballooning without evidence of ECG changes. When considering differentials for ACS in a patient without significant risk factors, especially patients with recent emotional challenges, consider TC, which can present atypically.

IMAGE 1: Figure 1. Takosubo cardiomyopathy on patient’s left ventriculography in (A) diastole and (B) systole showing left ventricular apical ballooning during systole

IMAGE 2: Figure 2. ECG on admission (A) vs. ECG captured following acute onset chest pain during hospitalization (B)